Insights into designing educational materials for persons living with dementia: a focus group study

BACKGROUND

Persons living with dementia (PLWD) may experience communication difficulties that impact their ability to process written and pictorial information. Patient-facing education may help promote discontinuation of potentially inappropriate medications for older adults without dementia, but it is unclear how to adapt this approach for PLWD. Our objective was to solicit feedback from PLWD and their care partners to gain insights into the design of PLWD-facing deprescribing intervention materials and PLWD-facing education material more broadly.

METHODS

We conducted 3 successive focus groups with PLWD aged ≥ 50 (n = 12) and their care partners (n = 10) between December 2022 and February 2023. Focus groups were recorded and transcripts were analyzed for overarching themes.

RESULTS

We identified 5 key themes: [1] Use images and language consistent with how PLWD perceive themselves; [2] Avoid content that might heighten fear or anxiety; [3] Use straightforward delivery with simple language and images; [4] Direct recipients to additional information; make the next step easy; and [5] Deliver material directly to the PLWD.

CONCLUSION

PLWD-facing educational material should be addressed directly to PLWD, using plain, non-threatening and accessible language with clean, straightforward formatting.

Caregiving in the COVID-19 pandemic: Family adaptations following an intensive care unit hospitalisation

AIM AND OBJECTIVE

To identify how family caregivers adapt to the caregiving role following a relative's COVID-19-related intensive care unit (ICU) hospitalisation.

BACKGROUND

Family caregiving is often associated with poor health amongst caregivers which may limit their capacity to effectively support patients. Though severe COVID-19 infection has necessitated increasing numbers of persons who require caregiver support, little is known about these caregivers, the persons they are caring for, or the strategies used to effectively adjust to the caregiving role.

DESIGN

A qualitative descriptive study design was adopted, and findings are reported using COREQ.

METHODS

A secondary analysis of transcripts from semi-structured interviews conducted with recently discharged ICU patients who had COVID-19 (n = 16) and their family caregivers (n = 16) was completed using thematic analysis. MAXQDA 2020 and Miro were used to organise data and complete coding. Analysis involved a structured process of open and closed coding to identify and confirm themes that elucidated adaptation to family caregiving.

RESULTS

Six themes highlight how family caregivers adapt to the caregiving role following an ICU COVID-19-related hospitalisation including (1) engaging the support of family and friends, (2) increased responsibilities to accommodate caregiving, (3) managing emotions, (4) managing infection control, (5) addressing patient independence and (6) engaging support services. These themes were found to be congruent with the Roy adaptation model.

CONCLUSIONS

Family caregiving is a stressful transition following a patient's acute hospitalisation. Effective adaptation requires flexibility and sufficient support, beginning with the care team who can adequately prepare the family for the anticipated challenges of recovery.

RELEVANCE TO CLINICAL PRACTICE

Clinical teams may improve post-hospitalisation care outcomes of patients by preparing families to effectively adjust to the caregiver role-particularly in identifying sufficient support resources.

PATIENT OR PUBLIC CONTRIBUTION

Participation of patients/caregivers in this study was limited to the data provided through participant interviews.

Barriers to and Facilitators of Family Caregiving of Patients With COVID-19 Early in the Pandemic

BACKGROUND

In 2020, many family members were thrust into the role of caregiving for a relative with COVID-19 with little preparation, training, or understanding of the disease and its symptoms.

OBJECTIVES

To explore the barriers to and facilitators of caregiving experienced by family caregivers of patients with COVID-19 who had been in intensive care in the pandemic's earliest months.

METHODS

In-depth qualitative interviews were conducted by web conference with 16 adults recovering at home after intubation for COVID-19 in an intensive care unit at a major academic medical center and their primary caregivers from March to August 2020 (N = 32). Thematic qualitative analysis was done using Watkins' rigorous and accelerated data reduction technique with MAXQDA software.

RESULTS

Seven themes emerged regarding factors that facilitated or posed barriers to care: other health conditions that increased complexity of care, interactions and experiences in the health care system, COVID-19's proliferation into other areas of life, the psychological well-being of the patient-caregiver dyad, experience of support from the dyad's network, the role of caregiving in the dyad, and contextual circumstances of the dyad. The themes often included both barriers and facilitators, depending on the experience of the dyad (eg, feeling encouraged vs fatigued by their support network).

CONCLUSIONS

Understanding how patients with COVID-19 and their caregivers experience illness management across the recovery journey can help clarify the COVID-19 care-giving process and identify intervention targets to improve overall health and well-being of the care dyad.

Functional Decline Over Time and Change in Family and Other Unpaid Care Provided to Community-Dwelling Older Adults Living With and Without Dementia

OBJECTIVES

To provide a longitudinal analysis of how functional decline over time among older adults affects provision of family and unpaid care, overall and stratified by dementia status.

METHODS

Longitudinal cohorts of community-dwelling adults ≥65 years between 2015 and 2017 from the National Health and Aging Trends Study (NHATS; n = 5,103) and their caregivers from the National Study of Caregiving (n = 862 caregivers for 595 NHATS care recipients). A panel data fixed-effects model was used to examine how increases in mobility, self-care, and household activity-related impairment between 2015 and 2017 affected family and unpaid care (care recipient reported: total number of family and unpaid caregivers, total hours of care received; caregiver reported: hours of care provided, caregiving-related emotional, and physical difficulties).

RESULTS

Among community-dwelling older adults overall, impairment in 1 additional self-care activity led to 0.12 more caregivers and 19 additional total monthly hours of care. Among those with dementia, impairment in 1 additional self-care activity led to 0.14 more caregivers and 28 additional total monthly hours of care; among those without dementia, this was 0.11 caregivers and 15 total monthly hours of care. For dementia caregivers, impairment in 1 additional self-care activity among their care recipients led to 8% higher probability of caregiving-related emotional difficulty.

DISCUSSION

There is a mismatch between the large additional hours of care received by older adults who experience functional decline (particularly self-care activities) and the relatively small accompanying increase in family and unpaid caregivers. Targeted functional supports, particularly for self-care activities, may benefit both older adults and their caregivers.

Gatekeepers: The Association of Caregiving Network Characteristics With Emergency Department Use by Persons Living With Dementia

OBJECTIVES

Caregivers are typically enmeshed in networks of family and friends who assist with care, yet this network is largely neglected in research. In light of the fact that caregivers are key medical decision makers and play a critical role in how persons living with dementia (PLwDs) interface with the health care system, this study explores how features of the caregiver network relate to PLwD emergency department (ED) use.

METHODS

Using 2015 National Health and Aging Trends Study data linked with fee-for-service Medicare claims, we examine ED use in a nationally representative sample of community-dwelling persons aged 65 and older with dementia and at least 1 caregiver. We consider aspects of the caregiver network including membership (e.g., daughter in network), network size, hours of care received, and the presence of generalists and specialists (i.e., broad vs narrow functional assistance) as predictors of ED encounters among PLwD.

RESULTS

PLwDs were 81.5 years old on average, 50% were female, and 33% were non-White. Care networks including nonimmediate family members involved in task sharing for mobility and self-care difficulties and those with more generalists had significantly higher odds of an ED visit. Networks that only consisted of specialist caregivers had significantly lower odds of an ED visit.

DISCUSSION

Greater complexity of care networks increases risk of presenting to the ED for care. Better understanding how caregiving networks help PLwD interact with the health care system can inform intervention design and targeting in order to help care networks improve care coordination, management, and shared decision making.

Validation of a Measure of Role Overload and Gains for End-of-Life Dementia Caregivers

OBJECTIVES

Caregiving stress process models suggest that heterogeneous contexts differentially contribute to caregivers' experiences of role overload and gains. End-of-life (EOL) caregivers, especially EOL dementia caregivers, facing unique challenges and care tasks, may experience role overload and gains in different ways than other caregivers. This study evaluates measurement invariance of role overload and gains between EOL caregivers and non-EOL caregivers and between EOL dementia and EOL non-dementia caregivers.

METHODS

We utilized role gains and overload data from 1,859 family caregivers who participated in Round 7 of the National Study of Caregiving. We ran confirmatory factor analyses to investigate the factorial structure across all caregivers and then examined the structure's configural, metric, and scalar invariance between (a) EOL caregivers and non-EOL caregivers and (b) EOL dementia and EOL non-dementia caregivers.

RESULTS

Across the entire sample, the two-factor overload and gains model had good fit (χ 2(19) = 121.37, p < .0001; RMSEA = .053, 90% CI = [.044, .062]; CFI = .954; TLI = .932). Tests of invariance comparing EOL caregivers to non-EOL caregivers and EOL dementia caregivers to EOL non-dementia caregivers maintained configural, metric, and partial scalar invariance. Latent mean comparisons revealed that EOL caregivers had higher role overload (p = .0002), but no different role gains (p = .45), than non-EOL caregivers. Likewise, EOL dementia caregivers had higher role overload (p = .05), but no different role gains (p = .42), than EOL non-dementia caregivers.

DISCUSSION

Results offer both a deeper theoretical understanding of end-of-life dementia caregivers' experiences of role overload and gains, and a practical tool to measure those experiences.

A national profile of sandwich generation caregivers providing care to both older adults and children

BACKGROUND

Many U.S. caregivers provide care to the generation above and below simultaneously, described as "sandwich" generation caregivers. We seek to provide the first national estimates characterizing sandwich generation caregivers and the older adults for whom they care.

METHODS

We used the 2015 National Study of Caregiving (NSOC) and National Health and Aging Trends Study (NHATS) to compare individual (demographic, socio-economic, health, and caregiving characteristics) and caregiving-related experience (financial and emotional difficulties, caregiver role overload and gains, supportive services, employment and participation restrictions) between sandwich and non-sandwich generation caregivers. The analysis included adult child caregivers with or without any minor child under 18 years (n = 194 and 912 NSOC respondents, respectively) providing care to n = 436 and 1217 older adult NHATS respondents.

RESULTS

Of all adult child caregivers, 24.3% also cared for a minor child (i.e., sandwich generation caregivers), representing 2.5 million individuals. Sandwich generation caregivers provided similar care hours to older care recipients as non-sandwich caregivers (77.4 vs. 71.6 h a month, p = 0.60), though more of them worked for pay (69.4% vs. 53.9%, p = 0.002). Both sandwich generation caregivers (21.0% vs. 11.1%, p = 0.005) and their care recipients (30.1% vs. 20.9%, p = 0.006) were more likely to be Medicaid enrollees than their non-sandwich caregiving counterparts. More sandwich generation caregivers reported substantial financial (23.5% vs. 12.2%, p < 0.001) and emotional difficulties (44.1% vs. 32.2%, p = 0.02) than non-sandwich caregivers; they also reported higher caregiver role overload (score: 2.9 vs. 2.4, p = 0.04). Their supportive services use was similarly low as non-sandwich caregivers except for seeking financial help (24.8% vs. 14.7%, p = 0.008).

CONCLUSIONS

Besides caring for minor child(ren), sandwich generation caregivers provided similarly intense care to care recipients as non-sandwich caregivers and had higher labor force participation; they experienced more caregiving-related financial and emotional difficulties and role overload. Policymakers may consider supportive services that address their unique needs and roles.

Daily sleep, well-being, and adult day services use among dementia care dyads

OBJECTIVES

The study aimed to describe daily sleep characteristics for dementia care dyads in the context of adult day services (ADS) use and examine the associations with sleep quality and daytime functioning (fatigue, affect, and behavior problems).

METHODS

Caregivers (CG; N = 173) reported daily bedtime, wake time, and sleep quality for themselves and the persons living with dementia (PLWD) across 8 consecutive days (N = 1359), where PLWD attended ADS at least 2 days of the week. On each day, caregivers also reported their own fatigue and affect and PLWD's daytime behavior problems and nighttime sleep problems. Considering the context of ADS use, we compared mean differences in bedtime, wake time, and total time in bed on nights before versus after ADS use. We estimated multilevel models to examine daily sleep-well-being associations.

RESULTS

On nights before an upcoming ADS day, care dyads went to bed and woke up earlier, and spent less time in bed. Further, PLWD had better sleep quality the night before an upcoming ADS day. Using ADS during the day buffered the negative impact of PLWD's sleep problems in the previous night, reducing daytime negative affect for caregivers. For caregivers, using ADS yesterday attenuated the association between shorter than typical time in bed and daytime fatigue; it also attenuated the association between PLWD's nighttime sleep problems and lowered daytime positive affect.

CONCLUSIONS

Regular ADS use may promote earlier sleep timing and protect against the adverse impact of sleep disturbances on daytime functioning for dementia care dyads.

Neighborhood Characteristics and Caregiver Depressive Symptoms in the National Study of Caregiving

Objectives: We examined the association between neighborhood characteristics and depressive symptoms in a population-based sample of dementia caregivers. Methods: Data came from the 2017 National Health and Aging Trends Study (NHATS) and National Study of Caregiving. The sample included 956 caregivers of those with dementia. Linear regression was used to examine associations between neighborhood physical disorder neighborhood social cohesion, and depressive symptoms, and to test the moderating effect of social support on these relations. Results: Results suggested that having friends and family (1) to talk to buffered the effect of high NPD and low cohesion on depressive symptoms, (2) to help with daily activities buffered the effect of low cohesion on depressive symptoms, and finally, and (3) to help with care had a protective effect on depressive symptoms if social cohesion was high. Discussion: Neighborhood contextual characteristics and social support interact to affect caregiver depressive symptoms in complex ways.

Care Challenges Due to COVID-19 and Mental Health Among Caregivers of U.S. Adults With a Chronic or Disabling Condition

Background and Objectives

The coronavirus disease 2019 (COVID-19) pandemic poses new challenges for caregivers of adults with chronic or disabling conditions. This study uses nationally representative data to examine the prevalence of pandemic care challenges and supports and their associations with caregiver mental health and interpersonal well-being.

Research Design and Methods

Participants include 311 caregivers aged 50–80 in the United States who were providing care for an adult with a chronic or disabling condition from the June 2020 National Poll on Healthy Aging. Five care challenges (e.g., confusion on public health guidelines) and 2 supports (e.g., physician offered information on care during COVID-19) are treated as predictors of caregiver mental health (care-related stress, self-reported mental health, and depressive symptoms) and interpersonal well-being (interpersonal conflicts, lack of companionship, and isolation).

Results

Each care challenge/support was endorsed by 13%–23% of caregivers. In adjusted models, difficulty getting needed medical care was associated with greater caregiver stress, depressive symptoms, and lower interpersonal well-being. All care challenges universally predicted greater caregiver stress. Caregiving supports were not independently associated with caregiver’ mental health and interpersonal well-being.

Discussion and Implications

Care challenges were associated with caregivers’ mental health and interpersonal well-being during the early months of the pandemic. Some of these challenges may be attributed to changing public health guidelines and practices as the pandemic unfolded, whereas others are relevant to all care contexts (e.g., less support from family). Tools and supports for caregivers must consider both changing policies and care needs.

Accentuate the Positive: The Association Between Informal and Formal Supports and Caregiving Gains

Background: To promote resilience among caregivers for persons living with dementia (PLWDs), we examine how formal and informal supports are linked to caregiving gains, and whether gender moderates the association between supports and gains. Method: Using the National Health and Aging Trends Study and associated National Study of Caregiving, sources of informal (emotional support, practical support, and help with the PLWD) and formal support (respite care, training program, support group) are considered as predictors of caregiving gains, with gender as a moderator of these associations. The sample included 707 caregivers for 502 PLWDs. Results: Greater caregiving gains were significantly associated with emotional support from friends/family (β = 0.14, SE = 0.09, p = .03). Furthermore, attending a caregiver training program was only associated with increased caregiving gains among men (β = 0.11, SE = 0.08, p = .02). Conclusion: Emotional support from family/friends appears particularly consequential for caregiving gains, and male caregivers may benefit most from programs that emphasize skill building.

Frailty Phenotype and Cause-Specific Mortality in the United States

BACKGROUND

Frailty is a common condition among older adults increasing risk of adverse outcomes including mortality; however, little is known about the incidence or risk of specific causes of death among frail individuals.

METHODS

Data came from the Health and Retirement Study (HRS; 2004-2012), linked to underlying cause-of-death information from the National Death Index (NDI). Community-dwelling HRS participants aged 65 and older who completed a general health interview and physical measurements (n = 10,490) were included in analysis. Frailty was measured using phenotypic model criteria-exhaustion, low weight, low energy expenditure, slow gait, and weakness. Underlying causes of death were determined using International Classification of Diseases, Version 10 codes. We used Cox proportional hazards and competing risks regression models to calculate and compare incidence of cause-specific mortality by frailty status.

RESULTS

During follow-up, prefrail and frail older adults had significantly greater hazard of all-cause mortality compared to individuals without symptoms (adjusted hazard ratio [HR] prefrail: 1.85, 95% CI: 1.51, 2.25; HR frail: 2.75, 95% CI: 2.14, 3.53). Frailty was associated with 2.96 (95% CI: 2.17, 4.03), 2.82 (95% CI: 2.02, 3.94), 3.48 (95% CI: 2.17, 5.59), and 2.87 (95% CI: 1.47, 5.59) times greater hazard of death from heart disease, cancer, respiratory illness, and dementia, respectively.

CONCLUSIONS

Significantly greater risk of mortality from several different causes should be considered alongside the potential costs of screening and intervention for frailty in subspecialty and general geriatric clinical practice. Findings may help investigators estimate the potential impact of frailty reduction approaches on mortality.

Characterizing dementia caregiver style in managing care challenges: Cognitive and behavioral components

BACKGROUND

Caring for a person living with dementia can take a physical and emotional toll, but understudied is the process by which family caregivers actually provide care. Caregiver management styles may vary and affect care decision-making, experiences, receptivity to and participation in interventions, and outcomes for the caregiver and person living with dementia.

METHODS

Participants included 100 primary family caregivers for persons with dementia who were on average 64 years old and had been providing care for 55 months, 74% women, and 18% nonwhite. Participants were interviewed in Michigan and Ohio regarding their cognitive and behavioral management of a recent care challenge and values guiding their decision-making. The rigorous and accelerated data reduction technique was used to analyze qualitative data leading to the identification of caregiving styles. Styles were compared across sample characteristics using chi-square and ANOVA tests.

FINDINGS

Five distinct styles emerged: "Externalizers" (superficial understanding, self-focused, and frequent expressions of anger or frustration), "Individualists" (provide care by going alone, emotionally removed, and lack management strategies), "Learners" (recognize need to change their approach but are stuck and emotionally turbulent), "Nurturers" (positive affect and empathy toward care and reflect natural mastery), and "Adapters" (arsenal of acquired management strategies and adapt to challenges). Style groups differed significantly in terms of age and use of formal care supports.

DISCUSSION

We identified five distinct styles by which caregivers addressed care challenges using a robust qualitative methodology. Styles may be important to identify in order to better tailor interventions to needs and abilities.

Vision impairment and depression among older adults in low- and middle-income countries

OBJECTIVES

To investigate the association between visual impairment (VI) and depression in low- and middle-income countries (LMICs) and the mediating role of disability and social participation.

METHODS/DESIGN

The World Health Organization Study on global AGEing and adult health (SAGE) provided data on objective and subjective visual function, depression, disability (WHODAS-12), and social participation for nationally representative samples of adults 50 years and older in China, India, Ghana, Mexico, Russia, and South Africa. Multivariable logistic and linear models were used to test the association between VI and depression and the indirect pathways through disability and social participation. Analyses were adjusted for sociodemographics, medical comorbidities, and complex survey design features.

RESULTS

Visual acuity was worse in respondents with depression compared to those without depression in China (0.32 vs 0.23 logMAR; P < .001), Ghana (0.26 vs 0.18 logMAR; P < .001), and India (0.36 vs 0.30 logMAR; P < .001); self-reported vision was also significantly worse in these three countries, but not in Mexico, Russia, or South Africa. Greater disability significantly mediated the association of both objective and self-reported VI with depression in China and India. Social participation significantly mediated the association between subjective vision and depression in Ghana.

CONCLUSIONS

There is variability in the association between VI and depression across LMICs and in the mediating role of disability and social participation. Culture-specific instruments may be needed to better characterize the association between VI and depression and further research is needed to assess causality.

Stressors and Resources Related to Medication Management: Associations With Spousal Caregivers' Role Overload

BACKGROUND AND OBJECTIVES

Managing medications can be stressful for spousal caregivers, but little is known about particular aspects of medication management that are most consequential for caregiving outcomes. We examined care stressors and resources related to medication management, their associations with role overload among spousal caregivers, and whether these links vary by care recipients' number of chronic health conditions and dementia status.

RESEARCH DESIGN AND METHODS

This cross-sectional study included 377 spousal caregivers of adults aged 65 and older from the 2011 National Health and Aging Trends Study and National Study of Caregiving. Linear regressions were estimated to evaluate how medication-related stressors (ordering medication, keeping track of medications, giving injections) and resources (medication reminder systems, shared medication management within the spousal dyad) are associated with caregivers' role overload. Care recipients' number of chronic health conditions and dementia status were considered as moderators. Models controlled for caregivers' sociodemographic characteristics, chronic health conditions, and other care tasks.

RESULTS

Caregivers who administered injections reported more role overload, whereas those who worked with care recipients to jointly manage medications reported less role overload. Keeping track of medications was linked to caregivers' greater role overload when care recipients had 5 or more chronic health conditions. Finally, care recipients' use of medication reminder systems was linked to less role overload for caregivers of a partner with dementia.

DISCUSSION AND IMPLICATIONS

Devising strategies to assist spousal caregivers in the more onerous components of medication management and promote resources that mitigate medication-related stress may improve caregiver well-being.

Till Death Do Us Part: Intersecting Health and Spousal Dementia Caregiving on Caregiver Mortality

OBJECTIVE

We consider whether it is the healthiest dementia caregivers who experience a mortality benefit and whether a protective association is consistent for leading causes of mortality.

METHOD

Using the Health and Retirement study (2000-2012), Cox survival models predict time to death for dementia caregivers, including an interaction between dementia caregiver status and self-rated health. The nationally representative sample consisted of 10,650 married adults aged 51 or older (917 dementia caregivers).

RESULTS

A significant interaction between dementia caregiver status and self-rated health suggested that relative to noncaregivers, dementia caregivers had reduced mortality, with this effect particularly strong at lower levels of self-rated health. The protective effect of dementia caregiver status was consistent across death by heart disease, cancer, and cerebrovascular disease.

DISCUSSION

These findings add to a growing body of literature suggesting that caregiving may provide a mortality benefit and a reason to maintain health.

Early Cognitive Decline and its Impact on Spouse's Loneliness

Background

Loneliness is common in dementia caregivers as cognitive impairment (CI) alters marital and social relationships. Unexplored is how an individual's loneliness is affected at earlier, more ambiguous, periods of their spouse's CI.

Methods

Using the Health and Retirement Study, our study participants included 2,206 coupled individuals with normal cognitive function at the 2006/8 baseline. Loneliness outcomes at baseline, 4-year and 8-year follow-up are assessed by the status of transition to cognitive impairment no dementia (TCIND) (2010/12 & 2014/16) using linear mixed models.

Results

Individual's loneliness was stable when their spouse's cognition remained normal, but increased with the spouse's TCIND. The increase in loneliness did not vary by gender.

Conclusions

Loneliness, a key risk factor for reduced life quality and increased depression, increases even at early stages of a partner's CIND. This work suggests the potential impact of early intervention and social support for partners of individuals with CIND.

Comparing Estimates of Fall-Related Mortality Incidence Among Older Adults in the United States

BACKGROUND

Falls are the leading cause of injury-related mortality among older adults in the United States, but incidence and risk factors for fall-related mortality remain poorly understood. This study compared fall-related mortality incidence rate estimates from a nationally representative cohort with those from a national vital record database and identified correlates of fall-related mortality.

METHODS

Cause-of-death data from the National Death Index (NDI; 1999-2011) were linked with eight waves from the Health and Retirement Study (HRS), a representative cohort of U.S. older adults (N = 20,639). Weighted fall-related mortality incidence rates were calculated and compared with estimates from the Centers for Disease Control and Prevention (CDC) vital record data. Fall-related deaths were identified using International Classification of Diseases (Version 10) codes. Person-time at risk was calculated from HRS entry until death or censoring. Cox proportional hazards models were used to identify individual-level factors associated with fall-related deaths.

RESULTS

The overall incidence rate of fall-related mortality was greater in HRS-NDI data (51.6 deaths per 100,000; 95% confidence interval: 42.04, 63.37) compared with CDC data (42.00 deaths per 100,000; 95% confidence interval: 41.80, 42.19). Estimated differences between the two data sources were greater for men and adults aged 85 years and older. Greater age, male gender, and self-reported fall history were identified as independent risk factors for fall-related mortality.

CONCLUSION

Incidence rates based on aggregate vital records may substantially underestimate the occurrence of and risk for fall-related mortality differentially in men, minorities, and relatively younger adults. Cohort-based estimates of individual fall-related mortality risk are important supplements to vital record estimates.

"It's Been a Hard Day's Night": Sleep Problems in Caregivers for Older Adults

PURPOSE OF REVIEW

This paper critically evaluates literature from the last three years on sleep in caregivers for older adults. Research is evaluated in four main areas: factors related to caregivers having sleep problems, sleep health in various types of caregivers, how caregivers' sleep and health inter-relate, and interventions to improve sleep.

RECENT FINDINGS

A range of both care recipients' and caregivers' characteristics have been associated with caregiver sleep quality measured subjectively and objectively. Care recipient factors associated with caregiver sleep quality include fall risk and sleep quality, while caregiver factors include stress, duration, intensity, provision of medical/nursing care tasks, and even particular serotonin genotypes (e.g. short allele carriers for 5-HTTLPR). While the greatest focus has been on dementia caregivers, recent work suggests groups such as end-of-life caregivers, former caregivers, and caregivers with multiple care roles (e.g. child, older adult, paid care) have sleep disturbances that vary by their unique contexts. Caregiver's sleep, particularly subjective assessments, relates to their mood and physiological well-being; and evidence suggests that sleep may be an important mediator linking care stressors with mental health. Factors such as mindfulness and sense of coherence may protect caregivers from sleep disturbances.

Multiple Chronic Conditions in Spousal Caregivers of Older Adults With Functional Disability: Associations With Caregiving Difficulties and Gains

OBJECTIVES

Multiple chronic conditions (MCCs) are common and have harmful consequences in later life. Along with managing their own health, many aging adults care for an impaired partner. Spousal caregiving may be more stressful when caregivers have MCCs, particularly those involving complex management. Yet, little is known about combinations of conditions that are most consequential for caregiving outcomes.

METHOD

Using a U.S. sample of 359 spousal caregivers and care recipients from the 2011 National Aging Trends Study and National Study of Caregiving, we examined three categories of MCCs based on similarity of management strategies (concordant only, discordant only, and both concordant and discordant) and their associations with caregiving difficulties and gains. We also considered gender differences.

RESULTS

Relative to caregivers without MCCs, caregivers with discordant MCCs reported fewer gains, whereas caregivers with both concordant and discordant MCCs reported greater emotional and physical difficulties. Wives with discordant MCCs only reported a trend for greater physical difficulties. Caregivers with concordant MCCs did not report more difficulties or gains.

DISCUSSION

Spousal caregivers with MCCs involving discordant management strategies appear to be at risk for adverse care-related outcomes and may benefit from support in maintaining their own health as well as their caregiving responsibilities.

STYLE AND SUBSTANCE: A QUALITATIVE CHARACTERIZATION OF DEMENTIA CAREGIVING MANAGEMENT STYLES

Caring for a person living with dementia (PLWD) can take a physical and emotional toll, but understudied is the process of how family caregivers actually provide care (caregiver management styles). We interviewed 100 primary family caregivers regarding management of a recently experienced care challenge and values held which might impact care management decisions. Watkins’ (2017) rigorous and accelerated data reduction (RADaR) technique was used to analyze qualitative data through open/focused coding, determining commonalities of style components/themes, and finally defining caregiving management styles. Style for a given caregiver emerged from enacted care strategies, caregiver’s internal stances which informed their use of strategies, and broader engagement (or lack thereof) with the PLWD’s lived experience/reality. Styles emerging from the analysis will be described including the direct, rigid “Just do it” style, and the flexible, empathic “Teamwork” style. Individualizing caregiver interventions and supports based on caregiver management style is an important future direction.

The association of insomnia and depressive symptoms with all-cause mortality among middle-aged and old adults

OBJECTIVES

Insomnia and depressive symptoms are commonly reported by adults and have independently been found to be associated with mortality, though contrasting findings are reported. Given the high comorbidity and interrelatedness between these symptoms, we tested whether insomnia symptoms explain risk of death independent of depressive symptoms. We examined insomnia symptoms and depressive symptoms, in addition to other health and demographic covariates, as predictors of all-cause mortality.

METHODS

The sample included 15 418 adults aged 51 and older drawn from a nationally representative, population-based study of adults in the United States, the Health and Retirement Study. Cox survival models were used to analyze time to death between the 2002 and 2014 study waves (5 waves). Controlling for health and demographic covariates, in 3 separate models, depressive symptoms and insomnia symptoms were independently and then together considered as risk factors for all-cause mortality (drawn from the National Death Index).

RESULTS

After adjustment for covariates, insomnia symptoms (HR = 1.10, CI:1.07-1.13) and depressive symptoms (HR = 1.14, CI:1.12-1.16) each were associated with a greater hazard of death. When considered together, however, depressive symptoms fully accounted for the association between insomnia symptoms and mortality.

CONCLUSION

Though their effects are small relative to health and demographic characteristics, both insomnia symptoms and depressive symptoms were associated with a greater hazard of death. Yet depressive symptoms accounted for the insomnia association when both were considered in the model. Screening for depression and providing validated treatments may reduce mortality risk in old adults with depressive symptoms.

Medical Care Tasks among Spousal Dementia Caregivers: Links to Care-Related Sleep Disturbances

OBJECTIVE

Medical care tasks are commonly provided by spouses caring for persons living with dementia (PLWDs). These tasks reflect complex care demands that may interfere with sleep, yet their implications for caregivers' sleep outcomes are unknown. The authors evaluated the association between caregivers' medical/nursing tasks (keeping track of medications; managing tasks such as ostomy care, intravenous lines, or blood testing; giving shots/injections; and caring for skin wounds/sores) and care-related sleep disturbances.

METHODS

A retrospective analysis of cross-sectional data from the 2011 National Health and Aging Trends Study and National Study of Caregiving was conducted. Spousal caregivers and PLWDs/proxies were interviewed by telephone at home. The U.S. sample included 104 community-dwelling spousal caregivers and PLWDs. Caregivers reported on their sociodemographic and health characteristics, caregiving stressors, negative caregiving relationship quality, and sleep disturbances. PLWDs (or proxies) reported on their health conditions and sleep problems.

RESULTS

Caregivers who performed a higher number of medical/nursing tasks reported significantly more frequent care-related sleep disturbances, controlling for sociodemographic and health characteristics, caregiving stressors, negative caregiving relationship quality, and PLWDs' sleep problems and health conditions. Post hoc tests showed that wound care was independently associated with more frequent care-related sleep disturbances after accounting for the other medical/nursing tasks and covariates.

CONCLUSION

Spousal caregivers of PLWDs who perform medical/nursing tasks may be at heightened risk for sleep disturbances and associated adverse health consequences. Interventions to promote the well-being of both care partners may benefit from directly addressing caregivers' needs and concerns about their provision of medical/nursing care.

Bright Light as a Preventive Intervention for Depression in Late-Life: A Pilot Study on Feasibility, Acceptability, and Symptom Improvement

OBJECTIVES

We examined the feasibility and acceptability of a portable bright light intervention and its impact on sleep disturbance and depressive symptoms in older adults.

METHODS

One-arm prevention intervention pilot study of the Re-Timer (Re-Timer Pty Ltd, Adelaide, Australia) bright light device (worn 30 minutes daily for 2 weeks) in 1 older adults (age 65 + years) with subsyndromal symptoms of depression and poor sleep quality. Participants were assessed on intervention acceptability and adherence, depressive symptoms (Patient Health Questionnaire- 9), and sleep (Pittsburgh Sleep Quality Index, Insomnia Severity Index, actigraphy and daily diary reports).

RESULTS

The Re-Timer device was rated positively by participants, and, on average, participants only missed 1 day of utilization. Although depressive symptoms declined and self-reported sleep improved, improvement was seen largely before the start of intervention.

CONCLUSIONS

An effective preventive intervention that is targeted towards a high risk group of older adults has the potential to reduce distress and costly health service use.

Falls and Hospitalizations Among Persons With Dementia and Associated Caregiver Emotional Difficulties

Background and Objectives

Falls and hospitalizations are adverse health events commonly experienced by persons with dementia (PWDs). These events often require urgent care from a family caregiver and may increase caregiver stress. We examine falls and hospitalizations among PWDs as predictors of caregivers' reported care-related emotional difficulty, in addition to care-related stressors.

Research Design and Methods

Cross-sectional telephone survey of 652 informal caregivers for PWDs. A multinomial logistic regression examined falls (last month) and hospitalizations (prior year) experienced by PWDs as predictors of caregivers' care-related emotional difficulty, accounting for demographic characteristics and primary and secondary caregiving stressors.

Results

Over 20% of caregivers reported high levels of care-related emotional difficulty. Controlling for demographic characteristics and primary and secondary caregiving stressors, the PWD's prior month fall was significantly associated with greater care-related emotional difficulty; the PWD's hospitalizations were not associated with care-related emotional difficulty.

Discussion and Implications

Approximately 30% of PWDs had experienced a past year hospitalization and prior month fall, and one in five caregivers reported high emotional difficulty related to care. Although secondary strains and resources of caregiving were strong predictors of care-related emotional difficulty, PWDs' falls represent a significant stressor that increases odds of caregiver emotional difficulty over and above other strains. Consequently, a fall experienced by a PWD may represent a key time for clinicians to assess caregiver well-being.

Medical Care Activities Among Spouses of Older Adults With Functional Disability: Implications for Caregiving Difficulties and Gains

OBJECTIVES

Spouses of older adults with functional disability often provide help with their partner's medical care. Yet little is known about the implications of these activities for spouses' caregiving experiences. We examined how spouses' medical care activities are linked to both positive and negative aspects of caregiving (difficulties and gains), and whether these associations vary by their age, gender, or education.

DESIGN

Retrospective analysis of data from the 2011 National Health and Aging Trends Study and National Study of Caregiving cross-sectional studies.

SETTING

Caregivers and care recipients/proxies were interviewed by telephone at home.

PARTICIPANTS

Nationally representative U.S. sample of 345 spousal caregivers and their community-dwelling care recipients aged 65 years and older.

MEASUREMENTS

Caregivers' self-reported sociodemographics, care activities, health conditions, well-being, and support resources. Care recipients (or proxies) reported on their health conditions and dementia status.

RESULTS

A higher number of health system interaction tasks (e.g., making appointments) were significantly associated with greater emotional caregiving difficulties, whereas a higher number of medical/nursing tasks (e.g., giving shots/injections) were significantly linked to greater caregiving gains. A higher number of medical/nursing tasks were also significantly associated with greater physical difficulties for caregiving wives and spouses with less education.

CONCLUSIONS

Medical care activities may have both positive and negative consequences for spousal caregivers, which depend partly on sociodemographics. This study underscores the importance of ensuring that spouses have the resources and support needed to provide complex care to their partners.

Sleep duration and the cortisol awakening response in dementia caregivers utilizing adult day services

OBJECTIVE

Sleep complaints are common among caregivers and are associated with detriments in mental and physical health. Cortisol, a biomarker of the stress process, may link sleep with subsequent health changes in caregivers. The current study examines whether sleep duration is directly associated with the cortisol awakening response (CAR), or whether it is moderated by Adult Day Services (ADS) use, an intervention found previously to influence daily CAR by reducing stressor exposure.

METHOD

Associations were examined in caregivers (N = 158) of individuals with dementia (IWD) on days when IWDs attended ADS and days when IWDs did not attend ADS. Data were gathered over 8 consecutive days. Caregivers were primarily female (87.3%) with a mean age of 61.59. A multilevel growth curve model tested the association of an interaction of today's ADS use and last night's sleep duration with today's CAR as the outcome.

RESULTS

The interaction between ADS use and within-person sleep duration was significant such that when an individual sleeps longer than their average but does not use ADS, they have a smaller or blunted CAR. On the other hand when an individual sleeps longer than their average and uses ADS, they have a higher but nonsignificant CAR. Sleeping shorter than usual was associated with a dynamic rise regardless of ADS use.

CONCLUSIONS

Findings indicate that ADS use moderates the association between sleep duration and CAR such that longer than average sleep is associated with blunted, dysregulated cortisol patterns only on non-ADS days.

Depressive Mood, Anger, and Daily Cortisol of Caregivers on High- and Low-Stress Days

OBJECTIVES

This study examines the association of daily cortisol with depressive mood and anger.

METHOD

Depressive mood, anger and 2 markers of cortisol, area under the curve (AUC), and cortisol awakening response (CAR) were examined for caregivers (N = 164) of individuals with dementia (IWDs) across 8 days, some of which IWDs attended an adult day service (ADS) program. Caregivers were primarily female (86.7%) with a mean age of 61.99. First, multilevel models were run with CAR and AUC each as separate covariates of anger and depressive mood. A second set of models examined contextual factors of caregivers (i.e., care-related stressors and amount of ADS use) were added to the models for anger and depressive mood (Model 2).

RESULTS

On days where caregivers had AUCs below their average they expressed higher anger scores. However in Model 2, anger was associated with more care-related stressors, but not ADS use or daily cortisol. Caregivers who on average had smaller CARs were more likely to be depressed. In Model 2, depressed mood was associated with more care-related stressors and a low average CAR.

DISCUSSION

We found that hypocortisol patterns, reflective of chronic stress experienced by caregivers, are associated with negative mood.

Stress and burden among caregivers of patients with Lewy body dementia

PURPOSE

Patients with Lewy body dementia (LBD) may present a unique set of symptoms and challenges to family caregivers compared with other types of dementia. Prominent difficulties include motor impairment, activities of daily living (ADLs) disability, recurrent behavioral and emotional problems (BEPs), and diagnostic difficulties. These problems are likely to affect caregivers' subjective burden.

DESIGN AND METHODS

The present study used data from an Internet survey conducted by the Lewy Body Dementia Association. Respondents were 611 people who indicated that they were currently involved in the care of their relative with LBD. Subjective burden was assessed with a 12-item short version of the Zarit Burden Interview.

RESULTS

A factor analysis revealed 3 dimensions of burden: role strain, personal strain, and worry about performance. Multiple regressions were used to examine predictors of these dimensions. BEPs, ADL disability, isolation, caregiver age, and patient gender were significant predictors of specific factors. Falls, formal service use, difficulty finding a physician, and evaluation of the physician had no significant associations with burden.

IMPLICATIONS

These findings highlight burden experiences by caregivers of patients with LBD and the impact of BEPs, ADL assistance, and awareness about LBD on subjective burden.