Initial examination of the psychometric properties of the short Hebrew version of the Zarit Burden Interview

Objectives: Given the sharp increase in individuals with cognitive and physical impairments, the evaluation of burden has become common in both caregiving research and clinical practice. The Zarit Burden Interview (ZBI) is the first and one of the most commonly used measures of caregiver burden. This study examines the psychometric properties and factor structure of a Hebrew version of Bédard et al.'s [Bédard, M., Molloy, D.W., Squire, L., Dubois, S., Lever, J.A., & O’Donnell, M. (2001). The Zarit Burden Interview: A new short version and screening version. The Gerontologist, 41, 652–657] short ZBI scale (ZBI-HS).

Methods: A total of 148 primary caregivers of individuals with cognitive and/or physical impairments completed the ZBI-HS. The factor structure of the ZBI-HS was assessed using exploratory factor analysis (EFA) and concurrent validity was examined.

Results: The EFA supported the two-factor structure as reported by Bédard et al. (2001 Bédard, M, Molloy, DW, Squire, L, Dubois, S, Lever, JA and O’Donnell, M. 2001. The Zarit Burden Interview: A new short version and screening version. The Gerontologist, 41: 652–657. [Crossref], [PubMed], [Web of Science ®] [Google Scholar]). Concurrent validity was supported by the ZBI-HS negative association with caregivers’ well-being and positive association with caregivers’ distress over behavioral problems of care-recipients.

Conclusion: These findings suggest that the short version of the ZBI-HS can be used as an effective tool for measuring caregiving burden.     

Zarit Caregiver Burden Interview: Development,reliability and validity of the Chinese version

Aims: To develop a specific scale used in measuring caregiver burden in China, and to evaluate its reliability and validity. Methods: Participants from the First and Second Affiliated Hospital of China Medical University and the Hospital of Tiefa Coal Industry Group completed the Chinese version of the Zarit Caregiver Burden Interview. Results: A total of 523 caregivers were included. The internal consistency of the Zarit Caregiver Burden Interview was high (Cronbach's α 0.875). The item–total correlations were all statistically significant (P < 0.01). Confirmatory factor analysis confirmed the five factors of the Zarit Caregiver Burden Interview in this study, and the goodness‐of‐fit indices reported for this 5‐factor model all fell within the acceptable range. Conclusions: The Chinese version of the Zarit Caregiver Burden Interview is reliable and valid for use. This study has important implications for burden measurement in Chinese caregivers.     

Validation of 'personal strain' and 'role strain': subscales of the short version of the Japanese version of the Zarit Burden Interview (J-ZBI_8)

The eight-item short version of the Japanese version of the Zarit Burden Interview (J-ZBI_8) has been confirmed for reliability and validity, and its two subscales (personal strain and role strain) are based on the factor structure of the ZBI. It has been demonstrated that these subscales have good reliability. The aim of the present study was to confirm their construct validity. A total of 51 impaired elderly who had been receiving regular nurses' visits in Kyoto Prefecture, Japan and their family primary caregivers, participated in the present study. Each caregiver was asked to complete a questionnaire which included the J-ZBI_8, the hours spent in caregiving, and the physical and cognitive disability of the impaired elderly. A principal component analysis identified the following two principal components of these variables: 'Activities of Daily Living deficits' and 'behavioral disturbances'. Consequently, Barthel Index (BI) and Troublesome Behavior Scale (TBS) were selected as the representative variable, respectively, for each component. We subsequently calculated the Spearman's rank correlations among the subscales of J-ZBI_8, BI and TBS. Personal strain was found to be correlated with TBS (rho = 0.48, P < 0.01), while role strain was correlated with the BI (rho = -0.29, P = 0.04). The correlation between personal strain and BI was not significant, nor was the correlation between role strain and TBS. These findings indicate that the personal strain and role strain measured by J-ZBI_8 correspond to the personal strain and role strain of the ZBI originally described by Whitlatch et al. Therefore, the construct validity of the J-ZBI_8 subscales is confirmed.     

The optimal short version of the Zarit Burden Interview for dementia caregivers: diagnostic utility and externally validated cutoffs

Objectives: Using a sample of dementia caregivers, we compared the diagnostic utility of the various short versions of the Zarit Burden Interview (ZBI) with the original scale to identify the most optimal one. Next, we established externally validated cutoffs for the various ZBI versions using probable depression cases as a reference standard.

Methods: Caregivers (N = 394; 236 males; Age_mean = 56 years) were administered the ZBI and a self-report depression measure. Participants who exceeded the cutoff for the latter were identified as probable depression cases. For each of the ZBI versions, a receiver operating characteristic (ROC) curve was plotted against probable depression cases. The area under these ROC curves between the short versions and the original were then compared using a non-parametric approach.

Results: Compared to the original ZBI, the AUROC were similar for the 6-item, 7-item, and two 12-item versions, but significantly worse for the other short variants. The sensitivity and specificity of the cutoffs for all ZBI versions ranged from 77.3% to 85.2% and 60.1% to 79.8%, respectively.

Conclusions: The original ZBI had good utility in identifying probable depression in caregivers, while the 6-item variant can be a useful alternative when short versions are preferred.     

Beyond the global score of the Zarit Burden Interview: useful dimensions for clinicians

OBJECTIVES: The purpose of this study was to explore the structure of the Zarit Burden Interview (ZBI) for informal caregivers of patients suffering from AD or related disorders, and to examine the relations of the dimensions found with functional disabilities and other patient health indicators. DESIGN: 152 dyads of community-dwelling older adults with dementia and their primary caregivers were analysed. METHODS: Caregiver burden was measured by the 22-item ZBI. Caregivers' and care recipients' characteristics were collected with the MDS (Minimum Data Set) of the RAI (Resident Assessment Instrument) Home Care instrument. Data on dementia (diagnosis, severity, MMSE) were also obtained. Burden data were analysed by principal component analysis (PCA) with varimax rotation. Relationships between scores on PCA factors and care recipients' health indicators were studied with inferential statistical tests. RESULTS: Three dimensions of burden were found: effect on the social and personal life of caregivers, psychological burden and feelings of guilt. Some health variables were linked to these dimensions. Spouses and children perceived burden differently. Spouse caregivers emphasized the deterioration of their personal and social life. Children, less involved in daily care, were more prone to feel guilt that they were not doing enough for their parent.     

Reliability and validity of the Japanese version of the Zarit Caregiver Burden Interview

Abstract  Despite a rapid increase in disabled elderly in Japan, the burden of the caregiver has not been properly assessed due to a lack of objective measurements. Our study was aimed at adapting and validating the Zarit Caregiver Burden Interview (ZBI) in Japan, which is one of the most widely used measurements for caregivers' burden in the United States. Sixty-six caregivers answered the self-administered questionnaire, involving the Japanese version of the ZBI and questions regarding their caregiving situation. Our study demonstrated that the Japanese version of the ZBI had equally as high reliability and validity as the original version. The Japanese ZBI had a high test—retest reliability (r = 0.76) and internal consistency (Cronbach's alpha = 0.93). The total score of the ZBI was highly correlated with the caregivers' score of the Center for Epidemiologic Studies Depression Scale (CES-D) score (r = 0.50), as well as a single global rating of burden (r = 0.71). It was also shown that demographic distribution of the score of the Japanese version had a similar trend to that of the original version. Caregivers who looked after patients with behavioral disturbances were found to have a significantly higher ZBI score than those who looked alter patients without behavioral disturbances, which is consistent with previous findings. It is concluded that the Japanese version of the ZBI can be used to measure feelings of burden of caregivers in the Japanese population and can be used for cross-cultural comparison.     

Validating a Cantonese short version of the Zarit Burden Interview (CZBI-Short) for dementia caregivers

Objectives: The present study aimed to develop and validate a Cantonese short version of the Zarit Burden Interview (CZBI-Short) for Hong Kong Chinese dementia caregivers.

Methods: The 12-item Zarit Burden Interview (ZBI) was translated into spoken Cantonese and back-translated by two bilingual research assistants and face validated by a panel of experts. Five hundred Chinese dementia caregivers showing signs of stress reported their burden using the translated ZBI and rated their depressive symptoms, overall health, and care recipients' physical functioning and behavioral problems. The factor structure of the translated scale was identified using principal component analysis and confirmatory factor analysis; internal consistency and item-total correlations were assessed; and concurrent validity was tested by correlating the ZBI with depressive symptoms, self-rated health, and care recipients' physical functioning and behavioral problems.

Results: The principal component analysis resulted in 11 items loading on a three-factor model comprised role strain, self-criticism, and negative emotion, which accounted for 59% of the variance. The confirmatory factor analysis supported the three-factor model (CZBI-Short) that explained 61% of the total variance. Cronbach's alpha (0.84) and item-total correlations (rho = 0.39–0.71) indicated CZBI-Short had good reliability. CZBI-Short showed correlations with depressive symptoms (r = 0.50), self-rated health (r = ?0.26) and care recipients' physical functioning (r = 0.18–0.26) and disruptive behaviors (r = 0.36).

Conclusions: The 12-item CZBI-Short is a concise, reliable, and valid instrument to assess burden in Chinese dementia caregivers in clinical and social care settings.     

EDUCA study: Psychometric properties of the Spanish version of the Zarit Caregiver Burden Scale

Objectives: The Zarit Caregiver Burden Scale, translated and validated into Spanish, is sensitive to the application of a Psychoeducational Intervention Program (PIP) for the prevention and reduction of burden in caregivers of Alzheimer's disease (AD) patients (EDUCA study). The data obtained in EDUCA was used to reanalyse its psychometric properties and the cut-off points of the Zarit scale.

Methods: The scale was administered to 115 caregivers of patients with AD who were randomised to receive a PIP or standard care for four months. Internal reliability and a factorial analysis of principal components were assessed, and the impact of PIP on each of the subscales was evaluated. A cut-off point was defined for the Zarit scale to identify the caregivers most sensitive to receiving a PIP.

Results: A good internal reliability (Cronbach alpha coefficient of 0.92) was obtained, with three principal components (burden, competency and dependence) explaining 54.75% of the variance. The application of PIP showed statistically significant differences versus standard care for the dependence subscale (p = 0.0082) (p = 0.062 for the burden scale). The Zarit scale cut-off points which combine better sensitivity and specificity were 56/57 and 59/60, for the 5/6 and 6/7 cut-off points of the General Health Questionnaire (GHQ-28) scale, respectively.

Conclusions: This study confirms the good psychometric properties of the Zarit scale found in previous studies. The dependence component appeared to be most influenced by the application of a PIP in the clinical trial. Caregivers with a Zarit scale score of 60 or more benefit most from the PIP.     

Dementia caregiving in spousal relationships: A dyadic perspective

Objectives: The number of couples facing a dementia diagnosis for one partner of the spousal dyad increases. Spousal caregiving can be a highly stressful experience associated with negative caregiver outcomes such as depression and poorer immune function. However, surprisingly little is known about how the illness and the required care effects patient's well-being and relational changes experienced by afflicted couples. The aim of this study was to provide a literature review on how the dyadic perspective is taken into account and on how dementia effects both parts of the dyad.

Methods: In order to outline findings about individual and dyadic well-being of affected couples, we conducted a literature search to review the three types of studies. First, studies focusing on one partner's perspective, usually the perspective of the caregiver; second, studies including the caregiver's and partially the care receiver's view; third, studies directly referring to both partners’ perspectives.

Results: The majority of studies neglect the individual with dementia by exclusively assessing caregiver variables or only indirectly including patients’ characteristics. Very few studies embrace dyadic and relational variables to execute how both partners experience the illness, spousal caregiving, and changes in the relationship. Despite the arguable validity of self reports of individuals with dementia, some studies demonstrated the usefulness of including both partners’ perspectives.

Discussion: Results indicate the urgent need of integrating the perspective of the individual with dementia to improve the understanding of the effects of dementia caregiving. Directly assessing the dyadic perspective of affected couples provides essential information for interventions.     

The subjective burden of informal caregivers of persons with dementia: extended validation of the German language version of the Burden Scale for Family Caregivers (BSFC)

Objective: In research as well as in the practice of caregiver counselling, the subjective burden of family caregivers is considered an important characteristic of home care. The objective of the present study was to provide an extended validation of the German language version of the Burden Scale for Family Caregivers (BSFC) published in 2001.

Methods: Extended validation was performed using medical, interview, and health insurance data of 351 informal caregivers and their relatives who had dementia. Cronbach's alpha was calculated to assess the internal consistency of the items, and an exploratory factor analysis was conducted to determine the structure of the BSFC. The discriminatory power and item difficulties of the 28 BSFC items were examined. Five research questions addressed construct validity. Question six addressed the BSFC score as a potential predictor of institutionalization at a follow-up time of 2.5 years (predictive validity).

Results: Exploratory factor analysis indicated that the BSFC had a single-factor structure. Cronbach's alpha for the total scale was 0.93. A significant increase in the BSFC score was observed when the severity of cognitive impairment increased, persons with dementia showed disturbing behaviour, caregivers were diagnosed with depression, care requirements increased, or the family caregiver and the person with dementia lived together. Caregiver burden emerged as a significant predictor of institutionalization. The validity of the BSFC was confirmed by the results.

Conclusion: The BSFC score allows for a valid assessment of the total caregiver burden in both research and practice. The BSFC is available for free in 20 languages (http://www.caregiver-burden.eu).     

Association between cultural factors and the caregiving burden for Chinese spousal caregivers of frail elderly in Hong Kong

Objectives: The aim of this study was to explore the relationship between cultural factors and the caregiving burden of Chinese spousal caregivers who provided care to their frail partners.

Method: A sample consisting of 102 Chinese caregivers for frail elderly spouses was recruited from home care services across various districts in Hong Kong. Structured interviews were conducted with the participants in their homes, measuring demographics, the functional status of the spouse, the degree of assistance required in daily care, perceived health, the caregiver's orientation to traditional Chinese family values, social support, coping, and caregiver burden.

Results: Findings of regression analysis indicated that gender, activities of daily living (ADL) status, orientation to traditional Chinese family values, passive coping, and marital satisfaction associated with caregiver burden. Being female, having lower functioning in ADL or a strong orientation toward traditional Chinese family values, employing the strategies of passive coping more frequent, or experiencing a low degree of marital satisfaction were associated with high levels of caregiver burden.

Conclusion: These findings provided a basis for developing appropriate interventions to minimize the caregiver burden of spousal family caregivers.     

Dimensional analysis of burden in family caregivers of patients with obsessive-compulsive disorder

Aims: Obsessive-compulsive disorder (OCD) also generates emotional burden in the patient's family members, but no study has evaluated the specific dimensions of burden. The objectives were to evaluate the dimensions of the Zarit Burden Interview (ZBI) and possible correlates. Methods: This was a cross-sectional study involving 47 patients and 47 caregivers, using a sociodemographic questionnaire; the ZBI; the Self Reporting Questionnaire; the Family Accommodation Scale; and the Yale-Brown Obsessive-Compulsive Scale. The ZBI factor analysis was conducted using Varimax Rotation. Results: Six factors were identified, explaining 74.2% of the total variance: factor 1, interference in the caregiver's personal life (36.6% of the variance); factor 2, perception of patient's dependence (10.8%); factor 3, feelings of irritation or intolerance (9.2%); factor 4, guilt (7.2%); factor 5, insecurity (5.6%); and factor 6, embarrassment (4.8%). The six ZBI factors were associated with greater OCD severity and with greater accommodation to the patient's symptoms, and factors 1, 2, 5 and 6 with caregiver's psychological morbidity. Caregiver's sex (female) was associated with factors 5 and 6, relationship with the patient (being a parent or son/daughter) with factor 5, higher educational level with factor 6, living with the patient with factor 3, worse self-evaluation of health with factors 1, 5 and 6, and occupational status (not working) with factors 1, 2, 5 and 6. Conclusion: The dimensions of burden identified indicate the most affected aspects of a caregiver's life and could guide the planning of more specific interventions. Thus, the caregiver could participate more effectively in the OCD patient's treatment, with a lower impact on his/her life.     

Dynamic process of family burden in dementia caregiving: a new field for psychotherapeutic interventions

Families caring for a patient with dementia are prone to significant physical, psychological and social stress. It is now well established that the caregiver burden does not only negatively affect the caregiver's physical and mental health, but is also associated with an increase in behavioural and psychiatric symptoms of dementia. Burden determinants include the quality of the relationship between the patient and caregiver; patient variables, such as the need to manage the behavioural and psychological symptoms of dementia; and also caregiver variables, such as the satisfaction of caring, demographic characteristics and societal roles. The standardised assessment of interventions for caregivers in dementia care remains a difficult task. In recent years, family interventions that focus on the process of burden itself in relation to the caregiver's subjective experience of personal growth and enrichment have been proposed. This new approach is based on the identification of tasks and challenges faced by family members throughout the different stages of the disease. In this context, brief crisis interventions transform periods of disorganisation experienced by the family into opportunities for change, whereas rehabilitation interventions developed by professional caring networks offer a continuous assessment and advice to the family. This article provides a critical review of the consequences and determinants of caregiver burden in dementia care with special reference to the emerging notion of the caregiver's subjective experience in the context of family processes.     

The indirect effect of positive aspects of caregiving on the relationship between cognitive decline and dementia caregiver burden

Background

Research has linked increased cognitive decline in a dementia care recipient to worsening caregiver burden, but the presence of positive aspects of caregiving is associated with better outcomes. As cognitive decline worsens, a lack of positive caregiving experiences could lead to burden for the caregiver. This study investigated relationships among dementia caregiver burden, cognitive decline, and positive aspects of caregiving in dementia, predicting an indirect effect of positive aspects of caregiving.

Methods

Data from 724 patients of an outpatient memory clinic in Ohio were examined and dyads included based on clinically supported patient diagnoses on the dementia spectrum. Caregivers completed the Zarit Burden Interview (ZBI) and Positive Aspects of Caregiving (PAC) measures. The Montreal Cognitive Assessment and Mini-Mental State Examination were used to estimate cognitive decline, standardized to create a single variable. Multiple potential covariates were considered for inclusion in the model. A cross-sectional mediation analysis using the Hayes PROCESS macro explored the presence of an indirect effect of PAC on the relationship between cognitive decline and ZBI using 5000 bootstrap samples.

Results

Only the potential covariate caregiver age was correlated with any of the primary variables; this variable was controlled in analyses. Significant relationships emerged between cognitive decline and ZBI (r = −0.12, P < 0.001), between PAC and ZBI (r = −0.23, P < 0.001), and between cognitive decline and PAC (r = −0.07, P < 0.05). An indirect effect of positive aspects of caregiving on the relationship between cognitive decline and ZBI was statistically significant (B = 0.0092, 95% bias-corrected confidence interval: 0.0008, 0.0185), accounting for 14.4% of the variance in the model.

Conclusions

A lack of positive aspects of caregiving could be partially responsible for development of dementia caregiver burden as cognitive decline worsens. Longitudinal examination of these relationships is needed to understand causality fully. Findings may help healthcare providers tailor treatment to alleviate caregiver burden.     

Caregiving burden and psychological distress in Chinese spousal caregivers: gender difference in the moderating role of positive aspects of caregiving

Objectives: This study endeavors to advance the current literature by examining the gender differences in the caregiving experiences and the stress-buffering role of positive aspects of caregiving (PAC) among Chinese spousal caregivers of frail elders in Hong Kong.

Method: Forty-nine husband caregivers and 121 wife caregivers of frail elders in Hong Kong (N = 170) responded to the Positive Aspects of Caregiving (PAC) scale, the Zarit Burden Interview (ZBI), the 21-item Depression, Anxiety, and Stress Scales (DASS-21), and demographic questions. These spousal caregivers were diverse in age, and their care receivers were diverse in terms of age and health condition.

Results: As predicted, there were significant gender differences in the moderating effects of PAC on the relationships of caregiving burden to depression, anxiety, and overall psychological distress. While PAC significantly buffered the effects of caregiving burden on depression, anxiety, and overall psychological distress for wife caregivers, the moderating effects of PAC were not significant for husband caregivers. Unexpectedly, wife caregivers reported lower PAC, higher caregiving burden, and higher psychological distress.

Conclusion: As these findings suggest that PAC is lower but more beneficial for Chinese wife caregivers than Chinese husband caregivers, helping professionals are recommended to use strengths-based interventions that target PAC when working with Chinese wife caregivers.     

Comparison of caregiver responses to English and Hebrew language versions of an abridged Zarit Burden Interview

The provision of informal care to infirm family members is of central importance to social gerontology; concomitantly, caregiver burden is a topic of considerable research interest. To this end, psychometrically sound instruments are required to advance cross-national research. The current study builds upon previous research examining the reliability and validity of responses to a brief Hebrew language version of the Zarit Burden Interview. For this study, factorial validity of responses to this instrument is examined relative to a representative English Canadian sample of caregivers. Invariance analyses comparing English and Hebrew responses support a 2-factor model of burden (role strain, personal strain); furthermore, invariance analyses comparing responses indicate that caregivers interpret and respond to the majority of items in a consistent manner. This finding suggests reliable translation of items from English to Hebrew. Caregiver burden is discussed in the context of changing demographics and the growing prevalence of disorders affecting older adults.     

Brief Chinese version of the Family Experience Interview Schedule to assess caregiver burden of family members of individuals with mental disorders

Background

Caregiver burden is an important issue that needs to be addressed when developing management programs for persons with chronic mental illnesses, but there is, as yet, no reliable way for assessing this in China.

Aim

Assess the validity and reliability of a brief adapted Chinese version of the Family Experience Interview Schedule (FEIS) among caregivers of inpatients with mental disorders in China.

Methods

We first translated and back-translated the original 114-item FEIS and administered it to 606 primary caregivers of psychiatric inpatients. After excluding 9 items about sociodemographic variables and 9 items that over 15% of respondents were unable to answer, we conducted an exploratory factor analysis using a random half of the sample on the remaining 96 items and, based on the results of the factor analysis, selected the items to be included in the final shortened scale. Correlation analysis, confirmatory factor analysis, and internal consistency measures were used to assess the reliability and validity of the final scale using data from the second half of the sample.

Results

The final scale included 28 items that loaded on five dimensions: (a) patients’ violent behavior; (b) patients’ suicidal tendency; (c) caregivers’ depression and anxiety; (d) disruption of caregivers’ daily routines; and (e) caregivers’ satisfaction with health services. These five dimensions explained 50.5% of the total variance. Confirmatory factor analysis found reasonable fit of this 5-factor model (χ² /df=2.94, p<0.001, goodness-of-fit index [GFI]=0.85, comparative fit index [CFI]=0.85, root-mean-square error of approximation [RMSEA]=0.08). The correlation coefficients between each item and the corresponding factor were all above 0.5. The Cronbach α coefficient of the entire scale was 0.76 and that for the five dimensions varied between 0.71 and 0.84.

Conclusion

The five dimensions of family burden assessed by the 28-item brief Chinese version of FEIS have good internal consistency and, thus, appear to assess valid dimensions of family burden in Chinese caregivers of persons with serious mental illnesses. Further work is needed to assess the test-retest reliability of this scale and its sensitivity to change over time.     

Reducing the burden of caring for Alzheimer's disease through the amelioration of "delusions of theft" by drug therapy

BACKGROUND: Delusions of theft (delusions involving the theft of possessions) are one of the most frequent neuropsychiatric manifestations of Alzheimer's disease (AD). OBJECTIVE: The current study investigated the presence and extent of such delusions before and after drug treatment in a group of AD patients, and the consequent effects on the burden of care on caregivers. METHOD: The study was an open-label cohort design. The delusions studied consisted only of those involving theft of possessions. Sixteen AD patients served as subjects in order to assess the efficacy of Risperidone administration, in the reduction or elimination of these delusions. The caregiver burden was evaluated using the Zarit Caregiver Burden Interview (ZBI) before the administration of Risperidone and 12 weeks after administration, for cases where delusions of theft were eliminated or reduced. RESULTS: The burden of care on caregivers was significantly reduced (p < 0.001) through the elimination or reduction of delusions of theft. CONCLUSION: Delusions of theft are considered to be a major factor in increasing the burden of care, and the treatment of these, through appropriate drug therapy, is therefore of great importance in the continuation of satisfactory care in the home.