Caregiver and noncaregiver attitudes toward dementia screening

OBJECTIVES: To compare attitudes toward dementia screening of older adults with and without an experience of dementia caregiving. DESIGN: A cross‐sectional study. SETTING: Primary care clinics in Indianapolis, Indiana. PARTICIPANTS: Eighty‐one participants with dementia caregiving experience (CG) and a random sample of 125 participants without dementia caregiving experience (NCG). MEASUREMENTS: Attitudes of dementia screening, including acceptance of dementia screening and its perceived harms and benefits, as determined according to the Perceptions Regarding Investigational Screening for Memory in Primary Care questionnaire. RESULTS: After adjusting for age, race, sex, and education, CGs had a lower dementia screening acceptance mean score (53.9 vs 60.6; P=.03) and a higher perceived suffering score (61.6 vs 55.9, P=.04) than NCGs, but there were no differences in perceived benefits of dementia screening (72.8 vs 69.0; P=.50), perceived stigma (32.9 vs 37.5; P=.12), and perceived negative effect on independence (47.6 vs 54.0; P=.20). The top three barriers to screening identified by both groups were emotional suffering by the family (86% of CGs and 75% of NCGs), loss of driving privileges (75% of CGs and 78% of NCGs), and becoming depressed (64% of CGs and 43% of NCGs). CONCLUSION: The experience of being a dementia caregiver may influence one's own attitude about accepting dementia screening for oneself.     

The cost-effectiveness of a behavior intervention with caregivers of patients with Alzheimer's disease

OBJECTIVES: To examine the cost-effectiveness of a randomized, clinical trial of a home-based intervention for caregivers of people with dementia.
DESIGN: This cost-effectiveness analysis examined Resources for Enhancing Alzheimer's Caregivers Health (REACH II), a multisite, randomized, clinical trial, from June 2002 through December 2004, funded by the National Institute on Aging and the National Institute of Nursing Research, of a behavioral intervention to decrease caregivers' stress and improve management of care recipient behavioral problems.
SETTING: Community-dwelling dementia caregiving dyads from the Memphis REACH II site.
PARTICIPANTS: Of Memphis' random sample of 55 intervention and 57 control black and white dyads, 46 in each arm completed without death or discontinuation. Family caregivers were aged 21 and older, lived with the care recipient, and had provided 4 or more hours of care per day for 6 months or longer. Care recipients were cognitively and functionally impaired.
INTERVENTION(S): Twelve individual sessions (9 home sessions and 3 telephone sessions) supplemented by five telephone support-group sessions. Control caregivers received two "check in" phone calls.
MEASUREMENTS: Incremental cost-effectiveness ratio (ICER), the additional cost to bring about one additional unit of benefit (hours per day of providing care).
RESULTS: At 6 months, there was a significant difference between intervention caregivers and control caregivers in hours providing care ( P =.01). The ICER showed that intervention caregivers had 1 extra hour per day not spent in caregiving, at a cost of $5 per day.
CONCLUSION: The intervention provided that most scarce of caregiver commodities—time. The emotional and physical costs of dementia caregiving are enormous, and this intervention was able to alleviate some of that cost.     

Caregiving in the Philippines: a quantitative survey on adult-child caregivers' perceptions of burden, stressors, and social support

This study aims to describe the present caregiving situation of Filipino adult-child caregivers (CGs) particularly aiming to identify the predictors of CG burden and to assess the effect of social support on stressors and perception of burden. A cross-sectional survey employing face-to-face interviews with 193 adult-child CGs in Davao City, Philippines, measured the perception of burden using the Cost of Care Index (CCI) by Kosberg and Cairl. Results indicated the majority were daughter CGs living with their elderly parents, who were receiving high levels of informal social support. A moderate to high level of burden perception (mean+/-S.D. score of 47.0+/-9.1) was found among respondents. CGs with higher educational attainment showed low burden perception. However, higher family income and higher State-Trait Anxiety Inventory (STAI) anxiety scores were associated with higher burden perception. Also, longer caregiving hours, a male care recipient (CR), and the presence of CR's memory and behavior problems predicted higher CG burden. The interaction between stressors and perceived burden showed that social support provided a buffering effect for CGs experiencing higher burden perception. This suggests that respite and support resources including community-based counseling and education programs to assist CGs in dealing with stress may positively contribute to reduce burden.     

Screening for Abuse and Neglect of People with Dementia

OBJECTIVE: To investigate characteristics of people with dementia and their caregivers (CGs) that are associated with mistreatment in order to inform clinicians about screening for mistreatment. DESIGN: A convenience sample of CG–care recipient (CR) dyads were assessed for literature‐supported factors associated with mistreatment, and evidence of mistreatment for the prior year was collected. An expert panel considered the evidence and decided on occurrences of psychological abuse, physical abuse, and neglect based on criteria adopted before data collection. SETTING: Participants' homes. PARTICIPANTS: One hundred twenty‐nine persons with dementia and their CGs. MEASUREMENTS: CG and CR characteristics (demographic, health, and psychosocial variables), relationship characteristics, and three elder abuse and neglect detection instruments. RESULTS: Mistreatment was detected in 47.3%. Variables associated with different kinds and combinations of mistreatment types included the CG's anxiety, depressive symptoms, social contacts, perceived burden, emotional status, and role limitations due to emotional problems and the CR's psychological aggression and physical assault behaviors. The combination of CR's physical assault and psychological aggression provided the best sensitivity (75.4%) and specificity (70.6%) for elder mistreatment as defined by the expert panel. This finding has potential to be useful as a clinical screen for detecting mistreatment. CONCLUSIONS: The findings suggest important characteristics of older adults with dementia and their CGs that have potential for use in a clinical screening tool for elder mistreatment. Potential screening questions to be asked of CGs of people with dementia are suggested.     

Development of the Risk Appraisal Measure: A Brief Screen to Identify Risk Areas and Guide Interventions for Dementia Caregivers

OBJECTIVES: To develop and validate a brief screening measure for use in research, healthcare, and community settings to systematically assess well-being and identify needed areas of support for caregivers of patients with dementia.
DESIGN: This study used data from Resources for Enhancing Alzheimer's Caregiver Health (REACH II), a multisite randomized clinical trial of a behavioral intervention designed to improve the quality of life of caregivers in multiple domains.
SETTING: REACH II.
PARTICIPANTS: Two hundred twelve Hispanic, 211 black, and 219 white family caregivers providing in-home care to patients with dementia.
MEASUREMENT: Based on conceptual and psychometric analyses, a 16-item measure was developed that assesses six domains linked to caregiver risk and amenable to intervention: depression, burden, self-care and health behaviors, social support, safety, and patient problem behaviors. The reliability and validity of the instrument was evaluated with 642 dementia caregiver dyads from the REACH II program.
RESULTS: The measure was found to have acceptable internal consistency for a multidimensional scale and similar measurement properties for each of the racial and ethnic groups. Concurrent validity was also demonstrated for the measure.
CONCLUSION: The REACH Risk Appraisal Measure developed in this study shows promise as an assessment tool that can be used in research, clinical, and community settings to guide, prioritize, and target needed areas of support for caregivers of patients with dementia.     

Caregiver characteristics are associated with neuropsychiatric symptoms of dementia

OBJECTIVES: To determine whether caregiver characteristics are independently associated with neuropsychiatric symptoms of dementia (NPS) after accounting for patient characteristics. DESIGN: Cross-sectional analysis of data from the Medicare Alzheimer's Disease Demonstration and Evaluation study. SETTING: Community-dwelling residents in eight U.S. cities. PARTICIPANTS: Five thousand seven hundred eighty-eight patients with dementia and their caregivers. MEASUREMENTS: Caregivers were asked about the presence of 12 NPS in patients with dementia. Caregiver predictors included age, sex, education, income, marital status, relationship to the patient, whether they lived with patient, number of hours per week spent caregiving, self-reported health, dependency in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), depression, and burden. Multivariate linear regression was used to determine which caregiver characteristics were independently associated with reports of more NPS in patients after controlling for the patient's age, sex, dementia severity, level of ADL dependency, and dementia type. RESULTS: Caregivers were on average 64 years old, 72% female, and 49% were the spouse of the patient (32% wives, 17% husbands). The mean burden score of caregivers was 15 (range 0-32, with higher scores indicating more burden), and 32% had significant depressive symptoms. Patients were on average 79 years old, 60% were female, and most had moderate to severe dementia. The mean number of NPS+/-standard deviation was 4.8+/-2.8. After adjusting for patient characteristics, caregivers who were younger, less educated, more depressed, more burdened, or spent more hours per week giving care reported more NPS in care recipients (all P< or =.005). CONCLUSION: Certain caregiver characteristics are associated with NPS, independent of patient characteristics, including dementia severity. Clinicians should consider the dynamics between patients and caregivers when managing NPS. Understanding how different caregiver characteristics influence NPS may help tailor caregiver education and interventions.     

Recruitment of Older Adult Patient-Caregiver Dyads for an Online Caregiver Resource Program: Lessons Learned

Hip fracture is a significant health problem for older adults and generally requires surgery followed by intensive rehabilitation. Informal caregivers (CGs) can provide vital assistance to older adults recovering from hip fracture. Caregiving is a dyadic process that affects both CGs and care recipients (CRs). In a feasibility study, we assessed the effects of using a theory-based online hip fracture resource program for CGs on both CGs and CRs. In this article, we discuss our recruitment process and the lessons learned. Participants were recruited from six acute hospitals, and CGs used the online resource program for 8?weeks. A total of 256 hip fracture patients were screened, and 164 CRs were ineligible. CG screening was initiated when CRs were determined to be eligible. Among 41 eligible dyads, 36 dyads were recruited. Several challenges to the recruitment of these dyads for online studies were identified, including a low number of eligible dyads in certain hospitals and difficulty recruiting both the CR and the CG during the short hospital stay. Field nurses often had to make multiple trips to the hospital to meet with both the CR and the CG. Thus, when a subject unit is a dyad recruited from acute settings, the resources required for the recruitment may be more than doubled. These challenges could be successfully alleviated with careful planning, competent field staff members, collaboration with hospital staff members, and efficient field operations.     

Does Caring for a Spouse with Dementia Promote Cognitive Decline? A Hypothesis and Proposed Mechanisms

OBJECTIVE: To discuss why spouse caregivers (CGs) of people with dementia may be at higher risk for cognitive problems and decline than demographically similar people not caring for a spouse with dementia (noncaregivers; NCGs). DESIGN: Literature review. SETTING: Community. PARTICIPANTS: Older adults caring for a family member (primarily spouses) with dementia. MEASUREMENTS: Cognitive, psychosocial, physiological, and behavioral. RESULTS: This article reports a review of the literature examining relationships between CG status and cognitive problems in the context of a theoretical model of chronic stress. The model suggests that spouse CGs may be at higher risk of cognitive impairment or dementia than NCG spouses in response to several mediators, including psychosocial (e.g., depression, loneliness, social isolation, sleep problems), behavioral (e.g., exercise, diet), and physiological (e.g., metabolic syndrome and inflammation) variables. CONCLUSION: This research has important implications because it considers modifiable risk factors for dementia that, if unchecked, may compromise the lives of CGs and their ability to function. It is hoped that an understanding of such stress‐mediator‐cognitive processes will help clinicians, researchers, policy‐makers, and stakeholders mitigate what may be characterized as an “ironic tragedy”—dementia in both members of the caregiving dyad—if left unchecked.     

The value of telephone support groups among ethnically diverse caregivers of persons with dementia

PURPOSE: Dementia caregiving is a rapidly growing public health problem. Logistical problems prevent many caregivers from utilizing available interventions. This article provides a demonstration of the usefulness of technology for conducting telephone-based support groups in ethnically diverse dementia caregivers. DESIGN AND METHODS: Participants were 41 White American and Cuban American dementia caregivers participating at the Miami site of the Resources for Enhancing Alzheimer's Caregiver Health (known as REACH) program. Support groups were conducted over the telephone in English and Spanish as appropriate. RESULTS: Eighty-one percent of the participants found the group "valuable," largely because of the social and emotional support and useful information obtained from other group members. The majority of caregivers also reported that their participation had increased their knowledge and skills as caregivers. IMPLICATIONS: The findings demonstrate that telecommunications technology can overcome the often formidable logistical problems faced by both English- and Spanish-speaking caregivers, and it can provide benefits similar to those obtained in face-to-face support groups.     

Health Status Among 28,000 Women Veterans

BACKGROUND: Male veterans receiving Veterans Health Administration (VA) care have worse health than men in the general population. Less is known about health status in women veteran VA patients, a rapidly growing population.
OBJECTIVE: To characterize health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support upon health status.
DESIGN AND PATIENTS: Data came from the national 1999 Large Health Survey of Veteran Enrollees (response rate 63%) and included 28,048 women and 651,811 men who used VA in the prior 3 years.
MEASUREMENTS: Dimensions of health status from validated Veterans Short Form-36 instrument; social support (married, living arrangement, have someone to take patient to the doctor).
RESULTS: In each age stratum (18 to 44, 45 to 64, and ≥65 years), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were clinically comparable by gender, except that for those aged ≥65, mean MCS was better for women than men (49.3 vs 45.9, P <.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of social support than men; in patients aged <65, being married or living with someone benefited MCS more in men than in women.
CONCLUSIONS: Women veteran VA patients have as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services. Their ill health occurs in the context of poor social support, and varies by age.     

Caregiver burden and fatigue in caregivers of people with dementia: Measuring human herpesvirus (HHV)-6 and -7 DNA levels in saliva

PurposeWe examined chronic fatigue, which has not been investigated in detail, in family caregivers for people with dementia.Methods and materialsForty-four community-dwelling family caregivers (the caregiver group: CG) and 50 elderly control participants (the non-caregiver group: NCG) participated in this study. We measured salivary human herpesvirus (HHV)-6 and -7 DNA levels and the Chalder fatigue scale (CFS) to assess levels of fatigue; we also measured the Center for Epidemiologic Studies-Depression Scale, Physical Activity Scale for the Elderly, Zarit Caregiver Burden Interview, Mini-Mental State Examination, Assessment of Motor and Process Skills, and Dementia Behavior Disturbance Scale.ResultsFor CG, the salivary HHV-6 DNA levels and CFS scores were significantly higher than those in NCG. The salivary HHV-6 DNA levels in CG were significantly correlated with depressive symptoms, the cognitive function of the patients, and the activities of daily living/instrumental activities of daily living (ADL/IADL) abilities of the patients. The CFS scores in CG significantly correlated with caregiver burden, depression symptoms, leisure physical activity, the number of other family caregivers, and the hours spent for caregiving per week, as well as with behavior disturbances and ADL/IADL abilities.ConclusionsThe salivary HHV-6 DNA levels may be added as a new biomarker for caregiver exhaustion. We concluded that fatigue assessments should be performed by not only a questionnaire, such as the CFS, but also by a biomarker search, such as HHV-6, when estimating the caregiver burden for family caregivers of people with dementia.     

Informal costs of dementia care: estimates from the National Longitudinal Caregiver Study.

OBJECTIVES: The purpose of the study was to examine on a national level the informal costs of caring for elderly community-dwelling male veterans with dementia by female caregivers and the relationships between informal costs and disease severity, and between informal costs and dementia problem behaviors. METHODS: Female primary caregivers were drawn from the first wave (N = 2043) of the National Longitudinal Caregiver Study, a survey of informal caregivers of elderly male veterans diagnosed with probable Alzheimer's disease or vascular dementia. Cost measures include the following four items: value of caregiving time, caregiver's lost income, out-of-pocket expenditures for formal caregiving services, and caregiver's excess health costs. Disease severity was indexed by the number of impairments in activities of daily living. Patient's problem behaviors were measured using the Behavior Rating Scale-Dementia. RESULTS: The annual cost of providing informal care to elderly community-dwelling veterans with dementia was estimated to be $18,385 per patient in 1998. The larger components of this cost are caregiving time ($6,295) and caregiver's lost earnings ($10,709). All aspects of costs increase with disease severity and problem behavior. Most of this cost increase derives from the increased caregiving time required for the provision of physical care. DISCUSSION: This study provides a comprehensive estimate of the excess costs that result from providing informal dementia care in the community. Unlike previous studies, our estimates excluded costs that caregivers would have incurred if they had not been caregivers. Therefore, results reported here reflect only costs due to informal dementia care.     

Emotional and physical health of informal caregivers of residents at the end of life: the role of social support

OBJECTIVES: The objectives of this study were to examine the relationship between selected decedent and caregiver characteristics, facility-related perceptions, and emotional and physical health of 434 informal caregivers (94% family) of recently deceased residents of residential care/assisted living facilities and nursing homes. We also examined potential mediating effects of social support (informal, staff, and spiritual). METHODS: We analyzed data using linear mixed models. RESULTS: Among caregivers, younger age, female gender, more education, financial burden, other dependents, poorer perceptions of care, and more care involvement were associated with more emotional strain. More staff support also was associated with more emotional strain and partially mediated the relationship between having a trusted staff member and emotional strain. Characteristics associated with poorer physical health included unemployment, financial burden, poorer physician communication, and trusted staff member. Informal social support was directly related to better physical health and mediated the relationships between physical health and both physician communication and financial burden. DISCUSSION: Many characteristics related to end-of-life caregiving outcomes in long-term care are consistent with community-based studies, suggesting that end-of-life caregiving outcomes in long-term care are not markedly different than in other settings. However, the role of staff support may either facilitate or complicate emotional strain and merits additional study.     

Impact of two psychosocial interventions on white and African American family caregivers of individuals with dementia

PURPOSE: We developed manual-guided, replicable interventions based on common needs and cultural preferences of White and African American family caregivers (CGs) of individuals with dementia, and we evaluated these interventions after a 6-month follow-up. DESIGN AND METHODS: We randomly assigned White (n = 70) and African American (n = 48) CGs of individuals with dementia to either a skills training condition or a minimal support control condition. RESULTS: The degree of treatment implementation was methodically assessed, and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs. CGs in both groups reported decreasing levels of problem behaviors and appraisals of behavioral bother, and increased satisfaction with leisure activities over time. On a measure of appraisal of distress related to behavior problems, White CGs showed more improvement in the minimal support control condition, and African American CGs showed the greatest improvements in the skills training condition. Spouse and nonspouse CGs also showed differential responses to intervention. IMPLICATIONS: Brief manual-guided interventions can be effective with White and African American CGs, and greater attention should be paid to possible differential responses to interventions by race and relationship to care recipient.     

Effects of a home visiting program for older people with poor health status: a randomized, clinical trial in The Netherlands

OBJECTIVES: To evaluate the effectiveness of a home visiting program on health-related measures in a population of older people with poor health status.
DESIGN: Randomized, clinical trial.
SETTING: Community-dwelling citizens in the Netherlands.
PARTICIPANTS: Three hundred thirty people aged 70 to 84 randomly assigned to an intervention group (n=160) or a control group (n=170).
INTERVENTION: Eight home visits, lasting 1 hour or more, with telephone follow-up, over an 18-month period, conducted by experienced home nurses under supervision of a public health nurse; key elements of the (systematic) visits were assessment of health problems and risks, advice, and referral to professional and community services.
MEASUREMENTS: Self-rated health, functional status, quality of life, and changes in self-reported problems.
RESULTS: No differences were found between the intervention and control group in these and other outcome measures at the end of the intervention period (18 months).
CONCLUSION: The home visiting program did not appear to have any effect on the health status of older people with poor health and are probably not beneficial for such persons.     

Caregiver burden and depression among informal caregivers of HIV-infected individuals

BACKGROUND: Few studies have examined the factors associated with depression in informal caregivers of HIV-infected persons. OBJECTIVE: To investigate the relationship between depression and caregiver burden among informal caregivers of HIV-infected individuals. DESIGN: Cross-sectional study using baseline data from an ongoing randomized trial of a supportive telephone intervention. PARTICIPANTS: One hundred seventy-six dyads of HIV patients and their informal caregiver. MEASUREMENTS: Depression was defined as a Beck Depression Inventory >10. A Caregiver Strain Index >6 identified informal caregivers with a high caregiver burden. We used logistic regression to identify characteristics that were associated with depression in the informal caregiver. RESULTS: Informal caregivers were 42 years old (SD, 13), 53% female, 59% nonwhite, and 30% had education beyond high school. Forty-seven percent of informal caregivers were the patient's partner, 18% a friend, and 35% a family member. Twenty-seven percent of informal caregivers had a high caregiver burden, and 50% were depressed. We found significantly greater odds of informal caregiver depression with high caregiver burden (OR, 6.08; 95% CI, 2.40 to 15.4), informal caregiver medical comorbidity besides HIV (OR, 2.32; 95% CI, 1.09 to 4.92), spending all day together (OR, 3.92; 95% CI, 1.59 to 9.69), having to help others besides the HIV patient (OR, 2.55; 95% CI, 1.14 to 5.74), and duration of the HIV patient's diagnosis (OR, 1.01 per month; 95% CI, 1.00 to 1.01). CONCLUSIONS: High caregiver burden was strongly associated with depression among HIV-infected individuals' informal caregivers, who themselves had difficult life circumstances. Informal caregivers of HIV patients may be in need of both mental health services and assistance in caregiving.     

Caregiving and institutionalization of cognitively impaired older people: utilizing dynamic predictors of change

PURPOSE: The purpose of this study was to identify reliable predictors of nursing home entry over a 3-year period in a sample of 3,944 persons with dementia who resided in a home setting at baseline. Strengths of the analysis include a multiregional recruitment strategy, incorporation of salient caregiver characteristics, and a 3-year prospective design that allows for the modeling of change in important variables (e.g., care recipient functional status or caregiving indicators) when time to institutionalization is predicted. DESIGN AND METHODS: Data were derived from the control sample of the Medicare Alzheimer's Disease Demonstration Evaluation (MADDE). A Cox proportional hazards model was used to predict time to institutionalization among individuals with dementia (baseline was enrollment into MADDE). Predictors included care recipient demographics, caregiver demographics, and time-varying measurements of care recipient functional status, caregiving indicators, and service utilization. Indicators of change were also incorporated to capitalize on the prospective data available. RESULTS: Although several results were consistent with prior findings, caregiving indicators (i.e., burden and self-rated health) and community-based service use were significant predictors of earlier placement. Change in caregiver instrumental activities of daily living and care recipient activities of daily living were also related to expedited institutionalization. IMPLICATIONS: The findings emphasize the importance of incorporating both care recipient and caregiver function and service use patterns when targeting programs designed to prevent or delay institutionalization for people with dementia.     

The Role of Self-Efficacy in the Alzheimer's Family Caregiver Stress Process: A Partial Mediator between Physical Health and Depressive Symptoms

Physical health has been commonly regarded as an outcome in caregiving research; however, it may act as a predictor of depressive symptoms of caregivers. This current study investigated the relationship between physical health and depression in family caregivers of persons with Alzheimer's disease. Also, it examined caregiving self-efficacy as a possible mediator of the relationship. One hundred thirty-four family caregivers were interviewed. The caregivers self-reported their current physical health status, depressive symptoms, and perceived self-efficacy. Using a self-efficacy measure consisting of three subscales, path analyses were conducted to specifically assess these domains of caregiving self-efficacy. The results showed that poorer perceived physical health was directly and indirectly associated with increased depressive symptoms. The indirect path was mediated by the specific domain of caregivers' self-efficacy. These findings suggest that caregiving self-efficacy may function as a mechanism through which perceived physical health influences depressive symptoms, and this mechanism can be domain-specific.     

Caregiving intensity and caregiver burden among caregivers of people with dementia: The moderating roles of social support

Using the Pearlin stress process model, the present study aimed to test if there was an association between caregiving intensity and caregiver burden, to analyze what type of association existed, and to test if different indicators of social support moderated such association among caregivers of people with dementia. Data from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health (REACH II) (N = 637) were used. Caregiver burden (12-item Zarit caregiver burden scale), caregiving intensity (caregiving hours), and social support (Lubben social network, received support, satisfaction with support, and negative interactions) were the main measurements. Separate multivariate regression models were conducted with Stata 16. The results showed that the relationship between caregiving hours and caregiver burden was a nonlinear inversed U shape after controlling all of the socio-demographic variables. Further analyses showed that when caregiving hours reached 14 hours per day, the levels of burden were the highest. In addition, received support, satisfaction with support, and social network significantly buffered the relationship between caregiving hours and caregiver burden when they were examined separately. However, only social network played a significant buffering role when examining the four social support indicators simultaneously. These findings suggest the need for programs and practices that emphasize the importance of identifying, gaining, and strengthening positive aspect of social support, especially in how to broaden a caregiver's social network while caring for a family member with dementia.     

Distrust of the health care system and self-reported health in the United States

CONTEXT: Despite theoretical concerns that health care related distrust may lead to poor health outcomes by interfering with effective health care, little is currently known about the prevalence or outcomes of distrust of the health care system in the United States.
OBJECTIVE: To investigate the association between distrust of the health care system and self-reported health status among the general population in the United States.
DESIGN: Random-digit-dialing telephone survey.
PARTICIPANTS: Nine hundred and sixty-one adult residents of the continental U.S.
PRIMARY MEASURES: Distrust of the health care system and self-reported health status.
RESULTS: Distrust of the health care system is relatively high in the United States, with between 20% and 80% of respondents reporting distrust for each item on the Health Care System Distrust scale and a median scale score of 31 (potential range from 10 to 50). Distrust of the health care system is strongly associated with self-reported fair/poor health (odds ratio [OR] 1.40%, 95% confidence interval [CI] 1.12 to 1.75 for each standard deviation increase in distrust), even after adjusting for sociodemographic characteristics, access to health care and trust in primary physicians. In contrast, low trust in one's primary physician is much lower (only 10% to 20% of respondents reported distrust for each item) and is not associated with health status.
CONCLUSIONS: Distrust of the health care system is relatively high in the general population in the United States and is strongly associated with worse self-reported health. Further studies are needed to assess the direction of this association and the mechanisms involved.