Burden and anticipatory grief in caregivers of family members with Alzheimer's disease and other dementias

OBJECTIVES

This study aimed to analyze the different factors that intervene in the task of caring for relatives of people with Alzheimer's and other dementias. A first objective focused on assessing the relation between burden and anticipatory grief, considering the possibility of social support and the risk of psychopathology. A second objective aimed to examine whether caregiver burden modulates the relationships between anticipatory grief and psychopathology. A cross-sectional design was employed.

METHODS

The sample consists of 129 participants who care for a family member with Alzheimer's and other dementias. A protocol based on a battery of tests has been applied and a mediation analysis was carried out.

RESULTS

The results show a positive relationship between burden and anticipatory grief. Social support could have an indirect relationship with anticipatory grief, based on its effect on the level of psychopathology and caregiver burden. Finally, a modulation model reflects that the relationship between anticipatory grief and psychopathology is strong, the latter having a greater effect as a result variable than as a risk variable. However, it seems that the relationship between grief and psychopathology is better explained directly than not through the modulating effect of the caregiver burden.

SIGNIFICANCE OF RESULTS

The results obtained encourage us to think that an approach focused on intervening in the anticipatory grief may be an opportunity to reduce or buffer other caregiving outcomes, especially those related to the perception of caregiver burden and psychopathology.

Anticipatory Grief in Dementia: An Ethnographic Study of Loss and Connection

In this article, I address the experiences of family members of people with dementia, as they expressed the sensation of gradually losing the person with dementia. Based on ethnographic fieldwork in nursing homes in the Netherlands, and contributing to the anthropology of grief, I explore the co-existence of experiences of anticipatory grief and manifestations of care to maintain meaningful relations. I show how my interlocutors adapted to changing circumstances as the disease progressed, and in so doing found new ways to relate, as well as prepared for future losses and the expected end of life. I argue that anticipatory grief is temporal and relational, encompassing both present and future losses, and involving a continuous negotiation between the loss and the continuing relationship. I underscore the entanglement of loss and connection, showing how both exist parallel to, and may emerge from one another, and demonstrating how an anthropological approach to anticipatory grief can reveal the nuanced and equivocal character of experiences of illness and at the end of life.

[Anticipatory grief in family caregivers of persons with dementia. Psychosocial correlates and impact on caregiver's health: A literature review]

INTRODUCTION

Taking care of a relative with dementia may be linked to negative consequences for the caregiver. One of the processes that can be experienced is anticipatory grief, that is defined as the feelings of pain and loss that appear in the caregiver before the death of the person cared for.

OBJECTIVES

The review aimed to conceptualize anticipatory grief in this population, to study the related psychosocial variables, and to know the repercussions for the health of the caregiver.

METHOD

A systematic search was made under the directives of PRISMA statement in the ProQuest, PubMed, Web of Science (WOS), and Scopus databases, including studies published in the last 10 years (2013-2023).

RESULTS

A total of 160 articles were obtained, 15 being finally selected. It is observed that anticipatory grief is defined as an ambiguous process since it appeared before the death of the sick family member. Being a female caregiver, spouse of a family member with dementia, having a closer relationship with him and/or having an important responsibility in care, are associated with a greater chance of experiencing anticipatory grief. In relation to the person cared for, if he or she is in a severe phase of the disease, is younger, and/or presents problematic behaviours, there is also greater anticipatory grief in the family caregiver. Anticipatory grief has a significant impact on caregivers' physical, psychological, and social health, being associated with greater burden, depressive symptomatology, and social isolation.

CONCLUSIONS

Anticipatory grief turns out to be a relevant concept in the context of dementia, being necessary to include it in intervention programs for this population.

Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time

BACKGROUND

Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time.

OBJECTIVE

Assess caregivers' EOL care goal for PWSDs and change in these goals over time.

METHODS

Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point.

RESULTS

At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals.

CONCLUSION

Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.

Effects of family-based dignity intervention and expressive writing on anticipatory grief in family caregivers of patients with cancer: a randomized controlled trial

Family caregivers of dying cancer patients may suffer from grief experiences and bereavement complications. Previous studies have proposed some psycho-emotional interventions for the management of these complications. However, little attention has been given to family-based dignity intervention and expressive writing. This study was conducted to examine the effects of family-based dignity intervention and expressive writing, combined and alone, on anticipatory grief in family caregivers of dying cancer patients. This was a randomized controlled trial, in which 200 family caregivers of dying cancer patients were randomly assigned to four intervention groups: family-based dignity intervention (n = 50), expressive writing intervention (n = 50), combined family-based single dignity intervention and expressive writing (n = 50), and control group (n = 50). In three times (baseline, 1 week, and 2 weeks after the interventions), anticipatory grief was assessed by a 13-item anticipatory grief scale (AGS). Finally, we found a significant reducing effect of family-based dignity intervention on AGS (-8.12 ± 1.53 vs. -1.57 ± 1.52, P = 0.01) and its subscales including behavioral (-5.92 ± 0.97 vs. -2.17 ± 0.96, P = 0.04) and emotional (-2.38 ± 0.78 vs. 0.68 ± 0.77, P = 0.03) subscales compared to the control group. However, no significant effect was seen for expressive writing intervention and combined interventions of expressive writing and family-based dignity intervention. In conclusion, family-based dignity intervention may be a safe intervention for relieving anticipatory grief among family caregivers of dying cancer patients. Additional clinical trials are needed to confirm our findings. Registration number: IRCT20210111050010N1. Trial registration date:2021-02-06.

Exploratory factor analysis of the caregiver grief inventory in a large UK sample of dementia carers

OBJECTIVES

Anticipatory grief (AG) is the process of experiencing loss prior to the death of a significant person. Coping with this multifaceted experience in the context of dementia caregiving is a relatively novel, yet significant area in caregiving literature. The Marwit-Meuser Caregiver Grief Inventory (MM-CGI) and its abbreviated MM-CGI-Short-Form (MM-CGI-SF) is the most widely used scale measuring AG. However, limited research has employed robust analytical strategies to assess its dimensional structure. This study employed contemporary factor analytical techniques to assess the dimensional structure of the MM-CGI/SF.

METHOD

Caregivers of persons with dementia (n = 508) completed a survey containing MM-CGI/SF and other associated psychological measures. Exploratory factor analysis was employed to compare eight alternative factor analytical models to determine the optimal model. Internal-consistency reliability was assessed by Cronbach's α and construct validity was assessed by Spearman's correlation-coefficient.

RESULTS

The best fitting model was the MM-CGI-SF three factor model (Personal Sacrifice and Burden, Heartfelt Sadness and Longing and Worry and Felt Isolation). The MM-CGI-SF three factor model demonstrated internal consistency reliability and factor correlations with associated psychological measures indicated construct validity.

CONCLUSION

The MM-CGI-SF three factor model demonstrated adequate fit and utility, however, the Worry and Felt Isolation subscale needs further replication and revision to assess its dimensionality. The MM-CGI-SF is the more useful tool due to its brevity and better model fit.

Effects of family-based dignity intervention and expressive writing on anticipatory grief of family caregivers of patients with cancer: a study protocol for a four-arm randomized controlled trial and a qualitative process evaluation

BACKGROUND

Family caregivers of dying cancer patients are affected by grief experiences and bereavement complications. Several approaches such as psycho-emotional care and an increase in spirituality have been suggested to diminish these complications. However, the knowledge about the effects of family-based dignity intervention and expressive writing on anticipatory grief in family caregivers of dying cancer patients is limited. This is a study protocol describing a hospital-based mixed-methods study on the effects of family-based dignity intervention and expressive writing on anticipatory grief in family caregivers of dying cancer patients.

METHODS

This mixed-methods study will be done in an embedded explanatory design with two quantitative and qualitative phases. In the first phase (quantitative), a randomized clinical trial will be done, in which 200 family caregivers of dying cancer patients will be randomly assigned to one of the four groups: family-based single dignity intervention (group 1), expressive writing intervention (group 2), combined family-based single dignity intervention and expressive writing (group 3), and control (group 4). At baseline, 1 week and 2 weeks after the interventions, anticipatory grief will be assessed by a 13-item anticipatory grief scale. After the quantitative phase, the qualitative phase will be conducted through the conventional content analysis approach of Granheim and Lundman, in which an individual semi-structured interview will be taken from participants in the first phase to collect data on their experiences on interventions. Finally, data from the quantitative and qualitative phases will be analyzed and discussed.

DISCUSSION

Family caregivers of dying cancer patients usually experience depression, anxiety, and psychological distress due to isolation and inadequate social support. Psychological interventions such as dignity and expressive writing interventions may help caregivers to obtain a better understanding of themselves and to increase their abilities to cope with caregiving difficulties. Therefore, there is a need for a comprehensive study confirming the effects of mentioned interventions on family caregivers of dying cancer patients.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials ( www.irct.ir ) identifier: IRCT20210111050010N1. Date of trial registration: Feb 6, 2021. This is the first version of this protocol.

Pre-loss grief and preparedness for death among caregivers of terminally ill cancer patients: A systematic review

BACKGROUND

Cancer is one of the most common causes of death. The period of time between receiving a terminal diagnosis of cancer and the death of a loved one has been operationalized as pre-loss grief and, more recently, as preparedness for death. Originally, grief before loss was thought to have positive effects on the bereavement outcome, but some studies have revealed contradictory findings. This systematic review investigates definitions and measurement tools of pre-loss grief and preparedness for death, as well as the associations of both constructs with caregiver characteristics, pre-loss psychological aspects and post-loss adjustment among caregivers of people living with terminal cancer.

METHODS

PubMed/Medline, PsycINFO and Web of Science were searched for studies published up until October 2020. Quantitative empirical studies from peer reviewed journals were included if a measurement tool for pre-loss grief or preparedness for death was used and if they focused on adult caregivers of adult people with cancer in an end-of-life trajectory and were excluded when they were not written in English or were descriptive/qualitative studies. Quality assessment of all studies was performed.

RESULTS

Most studies used convenience samples and had a mean number of 725 participants. Overall, 16,326 participants in 35 articles were included and narratively synthesized. High levels of pre-loss grief, as well as low levels of perceived preparedness for death, were associated with poor post-loss adjustment (e.g., prolonged grief, depressive symptoms, etc.).

CONCLUSIONS

Caregivers with high levels of pre-loss grief and low levels of preparedness for the death of their loved one would benefit from targeted support for post-loss adjustment. Results are limited by an inconsistent operationalization of both constructs.

Anticipatory Grief among Chinese Family Caregivers of Patients with Advanced Cancer: A Cross-Sectional Study

Objective

The objective of this study was to explore the interrelationship between anticipatory grief (AG), caregiver burden, communication, preparation for death, and coping style.

Methods

A convenience sample of 256 Chinese family caregivers of patients with advanced cancer were recruited from an academic cancer hospital between April 2018 and May 2019. This cross-sectional survey included the AG Scale, caregiver burden (Caregiver Reaction Assessment), communication (Caregivers' Communication with Patients about Illness and Death Scale), preparation for death, and coping style (Simplified Coping Style Questionnaire). Structural equation modeling tested the interrelation between them.

Results

The final model fitted the data acceptably (χ² = 25.79, degrees of freedom = 17, P = 0.08, root mean square error of approximation = 0.05, goodness-of-fit index [GFI] = 0.98, adjusted GFI [AGFI] = 0.95, parsimony GFI [PGFI] = 0.46, normed fit index = 0.94, comparative fit index = 0.98). Poor communication contributed to less preparation for death and caregiver burden, which further aggravate AG. Communication was positively associated with AG. In addition, communication and positive coping style interacted to further influence caregiver burden.

Conclusions

Preliminary results supported the model and showed that poor communication, less preparation for death, and caregiver burden contributed to AG while positive coping alleviated AG. Findings suggest the need for further studies to explore effective intervention for communication, preparation for death, burden, and coping style of caregivers to ultimately alleviate AG.

Theoretical and philosophical assumptions behind the concept of anticipatory grief

Anticipatory grief is a concept commonly used by researchers and clinicians when talking about the experience before the death of a loved one. This article offers a critical perspective on the disciplinary, theoretical and philosophical foundations of three distinct and frequently used conceptualisations of anticipatory grief: Lindemann's, Rando's and one derived from sociology. Lindemann's perspective conceived anticipatory grief as an inevitable component of the grieving experience in the situation of impending death. Rando's perspective views anticipatory grief as a multidimensional experience that facilitates post-mortem mourning. The third perspective, offered by sociologists, defines anticipatory grief as an experience highly influenced by the social context of the individual. This review explains how these different perspectives influence research and concludes with a reflection for potential future research.

Palliative care needs in Parkinson's disease: focus on anticipatory grief in family carers

BACKGROUND

A diagnosis of Parkinson's disease (PD) has a significant psychological impact on both the person diagnosed and their loved ones, and can have a negative effect on family relationships. Caring for someone with a long-term progressing illness may cause anticipatory grief, i.e., experienced before a bereavement. This has been widely studied in illnesses such as dementia and cancer, but less so in relation to PD. The study aims were: (I) to demonstrate the occurrence of anticipatory grief experienced by carers of people with PD; (II) to explore how this grief relates to caregiver burden and caregiver depression and demographic variables.

METHODS

Family carers of people with moderate to advanced PD (Hoehn & Yahr stages 3-5) were invited to complete a survey, including demographic questions and three questionnaires: Zarit Burden Interview (ZBI); 16-item Geriatric Depression Scale (GDS); and Anticipatory Grief Scale (AGS).

RESULTS

Anticipatory grief was common among carers of people with PD [mean AGS score =70.41; standard deviation (SD) =16.93; sample range, 38-102]. Though distinct concepts, carers with higher burden and depression scores also experienced more anticipatory grief symptoms. Carers experiencing higher anticipatory grief tended to be caring for someone of a younger age, displaying more non-motor symptoms, at a more advanced disease stage, and who considered either themselves and/or their loved one as depressed.

CONCLUSIONS

Carers of people with advanced PD experienced anticipatory grief, as well as depression and a high caregiver burden. To improve carer outcomes, our focus should include the period both before and after the death of a loved one, and carers should receive regular psychological assessment and support.

Euthanasia from the Veterinary Client's Perspective: Psychosocial Contributors to Euthanasia Decision Making

End-of-life decision making for a companion animal relies on the veterinarian acting as educator and counselor. However, little research has been conducted to understand client variables in this context. The current study examined potential client-related contributors to steps taken toward a euthanasia decision. Caregiver burden, anticipatory grief, depression, stress, and income all correlated positively with this outcome. However, when client factors were examined in a regression model controlling for animal quality of life, only caregiver burden and income emerged as significant predictors. All 3 caregiver burden factors: general strain, affective/relational discomfort, and guilt/uncertainty were significantly related to consideration of euthanasia.

Experiences of spouses of patients with cancer from the notification of palliative chemotherapy discontinuation to bereavement: A qualitative study

PURPOSE

Many patients with advanced cancer choose palliative chemotherapy. Considering its purpose of palliation and not treatment, it is important to consider the life of family caregivers. Family caregivers who experience bereavement undergo extreme stress, which is particularly high among patients' spouses. The present study aims to clarify the experiences of the spouses of patients at the hospitals in Japan after the notification of palliative chemotherapy discontinuation until bereavement.

METHOD

We interviewed the spouses of 13 patients who received palliative chemotherapy using a semistructured interview guide. Each spouse was interviewed twice. The interviews were transcribed verbatim, and key concepts were identified using a grounded theory analytic approach.

RESULTS

After the hospital's recommendation for palliative chemotherapy discontinuation, the spouses had "bewilderment over having to discontinue palliative chemotherapy" and experienced "difficulty in facing bereavement." The spouses having "difficulty to give up hope for the patient's survival," felt "bafflement over caregiving at the terminal stage," which would be their responsibility in the future. Further, they had "hesitation in being honest to the patient" and were engaged in "knowing how to live with the patient until bereavement."

CONCLUSION

Nurses need to encourage the patients and spouses to honestly express how they feel from the early stages of palliative chemotherapy. Furthermore, nurses should help spouses with how they face bereavement. This result may help prevent anticipatory grief, which may lead to excessive stress and emotional distress on the family caregivers.

Psychometric evaluation of the anticipatory grief scale in a sample of family caregivers in the context of palliative care

Introduction

In palliative care, family caregivers are often faced with experiences of grief in anticipation of the loss of a close person. An instrument designed to measure this form of grief is the Anticipatory Grief Scale, which includes 27 items and has been used in several studies in various contexts. However, the instrument has not been validated.

Aim

The aim was to evaluate the psychometric properties, focusing on the factor structure, of the Anticipatory Grief Scale in a sample of family caregivers in palliative care.

Methods

The study had a cross-sectional design. Data were collected from an intervention study in palliative home care that took place between 2013 and 2014. In total, 270 family caregivers in palliative care completed a baseline questionnaire, including the Anticipatory Grief Scale. The factor structure of the scale was evaluated using exploratory factor analysis.

Results

The initial factor analysis suggested a four-factor solution, but, due to weak communalities, extensive crossloadings, and item inconsistencies, the model was problematic. Further analysis supported that the scale should be reduced to 13 items and two factors. The two subscales captured the behavioral and emotional reactions of grief in family caregivers in palliative care and were named Behavioral reactions and Emotional reactions. This modified version will hereafter be named AGS-13.

Conclusions

This validation study of the Anticipatory Grief Scale resulted in a revised two-factor model, AGS-13, that appears to be promising for use in palliative care but needs to be tested further.

Immigrants Coping with Transnational Deaths and Bereavement: The Influence of Migratory Loss and Anticipatory Grief

This study examines immigrants' experiences of bereavement and coping with the deaths of family members in a transnational context. Data were collected through in-depth personal interviews with middle-aged and older immigrants from different countries of origin, who have been living in the United States for a majority of their adult lives. Thematic analysis of participants' narratives showed that immigrants' geographic distance from family complicated caregiving circumstances and rituals surrounding burial, and impacted the grieving process. At the same time, this distance also served as an emotional barrier and provided protection from prolonged grief. Immigrants' U.S.-based family and work responsibilities served as buffers from prolonged grief. Over time, immigrants became Americanized in their attitudes toward coping with death and favored a fast return to productive activities. Finally, immigrants' experience of migratory loss and anticipatory grief early in immigration, along with their personal growth and resilience developed over time, impacted their bereavement experiences later in life. Considering the limitations and the exploratory nature of the present study, further research is needed to investigate the specifics of coping with loss and bereavement among immigrants.

Anticipatory grief of spousal and adult children caregivers of people with dementia

BACKGROUND

Anticipatory grief (AG) among caregivers of people with dementia is common and has been found to be related to negative health outcomes. Previous studies showed different patterns of AG between spousal and adult children caregivers of people with dementia (PWD) at different stages; however, the levels of such grief are not yet compared. The findings in Western studies are very limited, and inconsistencies have also been found in Asian studies.

METHODS

One hundred and eight primary caregivers (54 spousal and 54 adult children) of community-dwelling PWD were recruited from elderly community services sectors in Hong Kong, China through quota sampling. The demographics, AG (measured by the Marwit-Meuser Caregiver Grief Inventory-short form), subjective caregiver burden, and well-being of the participants were assessed. A Functional Assessment Staging Test was used to grade the stages of dementia of the PWD. In this study, those in stages 4 and 5 were regarded as being at an earlier stage, and those in stages 6 and 7 at a later stage of dementia. The Mann-Whitney U-test and the Chi-square test were used to compare the variables between spousal and adult children caregivers, and the Kruskal-Wallis test was used to compare the outcomes among the sub-groups (spousal caregivers caring for relatives with earlier/later stage dementia; and adult children caregivers caring for relatives with earlier/later stage dementia). A post-hoc analysis was also conducted to identify differences between the sub-groups. Pearson's correlation was performed to investigate the bivariate relationships among AG, subjective caregiver burden, and well-being.

RESULTS

The results showed that spousal caregivers caring for relatives in a later stage of dementia experienced the highest level of AG and subjective caregiving burden, as compared with spousal caregivers caring for relatives in an earlier stage of dementia and adult children caregivers. Well-being was significantly negatively correlated with AG and subjective caregiver burden, while AG was also significantly correlated with subjective caregiver burden.

CONCLUSION

This study found that spousal caregivers of relatives in a later stage of dementia have significantly higher levels of AG, warranting special attention and extra support from palliative professionals.

Practice Concepts and Innovations for Pediatric End-of-Life Care by the Interdisciplinary Care Team

In recent years, clinical approaches to anticipatory grief and inclusivity amongst the medical team and family members have grown. In thinking about the end-of-life concerns within the pediatric care setting, practice concepts, and innovations inform how physicians and members of the interdisciplinary care team choose to approach conversations with parents and family members, as well as the particular level of involvement parents should have in decisions regarding the end of their child's life.

The characteristics and experiences of anticipatory mourning in caregivers of teenagers and young adults

This article reports a systematic review of literature undertaken to identify characteristics and experiences of anticipatory mourning in caregivers of teenagers and young adults with life-limiting or life-threatening conditions. A comprehensive literature search was conducted using the key words 'anticipatory', 'mourning', 'grief', and synonyms. This review focused on six studies that met inclusion criteria and reported characteristics of anticipatory mourning in caregivers of teenagers and young adults. Characteristics and experiences were sorted into four main themes: symptoms; a sense of loss; caregiver behaviour; and the unique experience of caring for, or losing, a teenager or young adult. The review suggests that there are characteristics and experiences of anticipatory mourning that are unique to caregivers of this age group. The review also suggests that consideration of anticipatory mourning is important in offering holistic care to young adults and their caregivers, and points to the need for further research in this area.