Analysis of the moderating effect of self-efficacy domains in different points of the dementia caregiving process

Introduction: Studies analyzing the moderator role of self-efficacy have centered their attention on the relationship between stressors and distress. However, drawing upon the stress and coping model, the moderator effects of self-efficacy may appear in the relationship between other key elements of the stress process.

Objectives and method: The purpose of this study was to analyze, in a sample of 167 dementia family caregivers, (1) the moderating effect of self-efficacy for managing behavioral problems on the relationship between frequency of behavioral problems and burden; and (2) the moderating effect of self-efficacy for controlling upsetting thoughts on the relationship between burden and caregivers’ distress (depression and anxiety).

Results: While no support has been found for the hypothesis that self-efficacy for managing behavioral problems moderates the relationship between frequency of behavioral problems and burden, our findings support the moderator role of self-efficacy for controlling upsetting thoughts in the relationship between burden and distress. No differences in distress measures are found between caregivers with high and low scores on self-efficacy for controlling upsetting thoughts when they report low levels of burden. However, when the levels of burden are high, caregivers with high self-efficacy for controlling upsetting thoughts report significantly lower levels of distress than caregivers with low self-efficacy for controlling upsetting thoughts.

Conclusion: Self-efficacy for controlling upsetting thoughts may be particularly effective for caregivers who report high burden scores, attenuating the impact of burden on caregivers’ distress (depression and anxiety).     

Social support and well-being in dementia family caregivers: The mediating role of self-efficacy

Objectives: The study investigated self-efficacy as a possible mediator of the relationship between the social support and depressive symptoms of primarily informal caregivers, mainly family members, of patients with dementia in Hong Kong.

Method: One hundred and thirty-four caregivers were interviewed. Path analyses were conducted using a self-efficacy scale that consists of three subscales assessing three domains of caregiving self-efficacy. Self-efficacy for obtaining respite, responding to disruptive patient behaviours, and controlling upsetting thoughts about caregiving were measured.

Results: Results showed that self-efficacy acted as a partial mediator between social support and depressive symptoms of these caregivers.

Conclusion: Findings suggest that self-efficacy may function as a mechanism through which social support influences depressive symptoms, and the importance of this self-efficacy mechanism can be domain-specific.     

The relationship between family functioning and caregiving appraisal of dementia family caregivers: caregiving self-efficacy as a mediator

Objectives: The aim of this study was to explore caregiving self-efficacy as a mediator for the association between family functioning and caregiving appraisal of dementia family caregivers in Taiwan.

Method: This study adopted a cross-sectional correlational design. Purposive sampling was used to recruit 115 dyads of dementia patients and family caregivers from the outpatient neurological clinics of two hospitals in northern Taiwan. Data were gathered through interviews with a structured questionnaire, which included demographic characteristics for caregivers and patients, family functioning, caregiving self-efficacy, as well as positive and negative aspects of caregiving appraisal.

Results: Family functioning, patients' activities of daily living score, Neuropsychiatric Inventory caregiver distress, and three domains of self-efficacy were significantly associated with caregiver burden. Hierarchical multiple regression analyses indicated that self-efficacy for obtaining respite (SE-OR) significantly explained 20.5% of the variance in caregiver esteem. Caregiver perceived worsened health status, family functioning, and SE-OR significantly explained 59% of the variance in caregiver burden. The mediation test only supported the partially mediating role of SE-OR on the relationship between family functioning and caregiver burden, while the mediating effect of self-efficacy for responding to disruptive behaviours and controlling upsetting thoughts were insignificant.

Conclusion: Our findings provided preliminary evidence for health professionals recommending that future studies should assess the family dynamic and health problems of caregivers, and develop appropriate family-centred interventions that focus on strengthening interfamily support and respite services to alleviate caregiver burden.     

An RCT to evaluate the utility of a clinical protocol for staff in the management of behavioral and psychological symptoms of dementia in residential aged-care settings

Objectives: Behavioral and psychological symptoms of dementia (BPSD) cause significant stress and distress to both aged-care residents and staff. This study evaluated a training program to assist staff to manage BPSD in residential care.

Method: A randomised controlled trial (RCT) was employed. The study was included in the Australian and New Zealand Clinical Trial Register residential care facilities. Staff (n = 204) and residents (n = 187) were from 16 residential care facilities. Facilities were recruited and randomly assigned to four staff training conditions: (1) training in the use of a BPSD-structured clinical protocol, plus external clinical support, (2) a workshop on BPSD, plus external clinical support, (3) training in the use of the structured clinical protocol alone, and (4) care as usual. Staff and resident outcome measures were obtained pre-intervention, three months and six months post-intervention. The primary outcome was changes in BPSD, measured using the Cohen-Mansfield Agitation Inventory (CMAI) as well as frequency and duration of challenging behaviors. Secondary outcomes were changes in staff adjustment.

Results: There were improvements in challenging behaviors for both intervention conditions that included training in the BPSD instrument, but these were not maintained in the condition without clinical support. The training/support condition resulted in sustained improvements in both staff and resident variables, whereas the other conditions only led to improvement in some of the measured variables.

Conclusion: These results demonstrate the effectiveness of the BPSD protocol in reducing BPSD and improving staff self-efficacy and stress.     

Impact of dementia on caring for patients' diabetes

Objective: To explore caregivers’ challenges and quality-of-life issues managing diabetes in patients with dementia.

Method: We conducted six focus groups with 21 caregivers of patients with dementia and type 2 diabetes. Focus groups were digitally recorded, transcribed, and translated using a software coding system. Emergent themes were identified and confirmed.

Results: Three themes emerged. (1) Memory loss was the first identified cause of self-care neglect leading to caregiver intervention. (2) Behavioral and psychological symptoms of dementia (BPSD) disrupted the daily diabetes care routine, with ‘denial’ of having diabetes or memory loss (anosognosia) being the most disruptive. (3) Caregivers reported that caring for both diabetes and dementia was highly burdensome, felt overwhelmed with BPSD, and wanted more support from family and patients’ healthcare providers.

Conclusion: Caregivers of patients with dementia and diabetes face extraordinary challenges managing both conditions and the accompanying BPSD. Their identified need for a greater response from the healthcare system should be tested in quality improvement programs for this overlooked yet rapidly growing population.     

Spouse caregivers and behavioral and psychological symptoms of dementia

Background: Only a few studies have specifically considered the role of caregiver characteristics in the presence of behavioral and psychological symptoms of dementia (BPSD). The aim of this study was to determine whether there were differences in the presence of individual BPSD between community-dwelling dementia care recipients with spouse caregivers and those with non-spouse caregivers.

Methods: Care recipients (n = 109) and their primary caregivers were recruited from memory clinic outpatients at the public psychiatric hospital in Sapporo City, Japan. Data were collected by questionnaire. Relationship with the care recipient was categorized as either ‘spouse’ or ‘non-spouse.’ The frequency of BPSD occurrence observed by the caregiver was assessed using the Troublesome Behavior Scale (TBS). Logistic regression analyses were performed to examine whether there were differences with regard to each of the 14 TBS items between spouse and non-spouse caregivers.

Results: The number of spouse caregivers was 47 (43.1%). TBS items presented by >50% care recipients were ‘repetition and/or clinging’ and ‘ill-natured denial and/or distortion.’ After adjustment for the characteristics of caregivers and care recipients, non-spouse caregivers were found to be significantly associated with the presence of ‘hiding and/or losing things,’ ‘rummaging,’ ‘crying and/or screaming,’ and ‘interfering with a happy home circle,’ compared with spouse caregivers.

Conclusions: Our results suggest that non-spouse caregivers need more support with regard to certain symptoms of individual BPSD compared with spouse caregivers. Identifying caregiver characteristics that are independently associated with each individual BPSD may help customize interventions for caregivers with specific characteristics.     

Self-efficacy for managing dementia may protect against burden and depression in Alzheimer's caregivers

Background: Self-efficacy is the belief that one can perform a specific task or behaviour and is a modifiable attribute which has been shown to influence health behaviours. Few studies have examined the relationship between self-efficacy for dementia-related tasks and symptoms of burden and depression in caregivers.

Methods: Eighty four patient/caregiver dyads with Alzheimer's disease were recruited through a memory clinic. Patient function, cognition and neuropsychiatric symptoms were assessed together with caregiver burden, personality, depressive symptoms, coping strategies and self-efficacy for completing tasks related to dementia care.

Results: 33% (28) of caregivers reported significant depressive symptoms (CES-D?≥?10). In multivariate analyses, caregiver burden was predicted by self-efficacy for symptom management, neuroticism, patient function and neuropsychiatric symptoms while caregiver depression was predicted by self-efficacy for symptom management, caregiver educational level, neuroticism, emotion-focused coping, dysfunctional coping and patient function. In patients with moderate to severe impairment (MMSE?≤?20), self-efficacy for symptom management behaved as a mediator between patient neuropsychiatric symptoms and symptoms of burden and depression in caregivers.

Conclusions: Further longitudinal investigation is warranted to determine if self-efficacy might be usefully considered a target in future interventional studies to alleviate symptoms of burden and depression in Alzheimer's caregivers.     

The moderating effect of religiosity on caregiving burden and depressive symptoms in caregivers of patients with dementia

Objectives: This study explored whether religiosity/spirituality has a protective role against negative caregiving outcomes, in a large multicenter nationwide sample of caregivers of patients with dementia in South Korea. Additionally, this study was the first to examine whether religiosity/spirituality could affect caregiving outcomes according to the various religious affiliations of caregivers.

Methods: The study was conducted on a sample of 476 caregivers of patients with dementia participated in the Clinical Research Center for Dementia of South Korea (CREDOS). We examined the moderating effect of each of the three dimensions of religiosity/spirituality (organizational religious activity, ORA; non-organizational religious activity, NORA; intrinsic religiosity, IR) on the relationship between activities of daily living (ADL) of patients with dementia and caregiving burden and depressive symptoms of caregivers, using a series of hierarchical regression analyses. In addition, these analyses were conducted according to the religious affiliations of the caregivers.

Results: ORA, NORA, and IR of religiosity/spirituality alleviated the effect of ADL of patients on caregiving burden. ORA and IR moderated the relationship between ADL of patients and depressive symptoms of caregivers. These moderating effects of religiosity on caregiving outcomes were different according to various religious groups.

Conclusion: We have identified religiosity/spirituality as a protective factor for caregivers of patients with dementia. The sub-dimensions of religiosity as moderators were different by religious affiliations of caregivers. Further studies are needed to investigate the specific religiosity-related factors which could positively impact the mental health of the caregivers of patients with dementia by religions.     

Can domestic helpers moderate distress of offspring caregivers of cognitively impaired older adults?

Objective: This study examined the moderating effect of domestic helpers on distress of offspring caring for parents with cognitive impairments and with or without behavioural problems.

Method: This secondary analysis of data involved 5086 Hong Kong Chinese adults aged 60 or older applying for public long-term care services from 2010 to 2012. All variables were measured using the mandatory Hong Kong version of the Minimum Data Set-Home Care 2.0.

Results: Regarding taking care of parents with cognitive impairments, 10.7% of offspring primary caregivers were aided by domestic helpers, 55.54% reported distress, and 75.70% lived with their parents. Assistance from domestic helpers reduced offspring caregiver distress if the offspring provided psychological support to parents (ratio of OR = 0.655, p < .05) and were not living with parents (ratio of OR = 1.183, p < .01).

Conclusion: These findings might suggest: a) the positive effects of audience on psychological responses to stress; b) caregiving is usually less stressful for informal caregivers not residing with care recipients. Conversely, having a domestic helper could add to caregiving distress if offspring caregivers live with their parents, most likely because offspring may witness difficulties that domestic helpers face in providing dementia care.     

Factors associated with anger and anger expression in caregivers of elderly relatives

Objectives: Anger is a common feeling among family caregivers of elderly dependents. However, this feeling has received less attention than other emotional effects of caring. This study measures anger in caregivers and analyzes its predictors.

Method: Trait anger and anger expression (expression-in, expression-out and expression index), caregiver and care recipient features, stressors (e.g. care demands and support), appraisal (e.g. burden) and resources (e.g. coping, self-efficacy) were assessed in 111 caregivers of elderly dependent relatives. Staged stepwise multiple linear regression analyses were carried out for each of the four anger scores.

Results: Caregivers presented mild anger levels and showed expression-in rather than expression-out of anger. Stepwise multiple linear regression analyses showed that a bad relationship between caregiver and care recipient, the presence of disruptive behaviors and caregivers’ low efficacy to handle them, and mostly the use of emotion-focused coping were the significant predictors of trait anger, anger expression index and anger expression-out. Explained variance for each of these regression models was 38%, 33% and 27%, respectively. Burden was the only significant predictor for internal anger expression (8% explained variance).

Conclusion: Results highlight that interventions aimed to improve caregivers’ strategies to address memory and behavior problems and to promote the use of effective coping strategies could be helpful to prevent anger and expression-out of anger. Reducing burden in caregivers might result in reductions of anger expression-in. Data underscore the need to consider anger feeling and both in-expression and out-expression of anger separately in order to understand anger experience in caregivers.     

Caregiver depression is associated with a low sense of coherence and health-related quality of life

Objectives: The main objective is to examine the sense of coherence (SOC) of spouse caregivers. The aim was further investigate the association of SOC, health-related quality of life (HRQoL), depressive symptoms, distress and how severity of Alzheimer's disease (AD) affects SOC.

Method: 17O patient–spouse caregiver dyads in which the patient has recently diagnosed mild AD. Caregivers completed SOC scale (SOC-29), HRQoL (15D), Beck depression and general health questionnaire scale. The assessment of AD-related symptoms was made using mini mental state examination, clinical dementia rating, neuropsychiatric inventory and functional performance using activities of daily living (ADCS-ADL) scale.

Results: Male caregivers’ SOC was significantly higher than female caregivers. The main predictor for low SOC was depression, with 37% of spousal caregivers reporting depressive symptoms. Women reported more depressive symptoms and distress. Caregivers’ HRQoL was as high as 0.8714, and a significant correlation was found between SOC and depression, r = ?0.632 and distress r = ?0.579. Furthermore, significant correlations were found between HRQoL and depression (r = ?0.572) and distress (r = ?0.568). The main predictors for high HRQoL were female gender and low distress.

Conclusion: Spouse caregivers with low SOC seem to be a vulnerable group of caregivers. The many negative effects of perceived health accumulate in these caregivers during the very early phases of the caregiving process. Vulnerable caregivers need to be recognized at the time of AD diagnosis so that they can receive psychological support and counselling in addition to prevent morbidity in these caregivers.     

Behavioral and psychological symptoms of dementia in older residents in long-term care facilities in Japan: a cross-sectional study

Objective: To investigate the prevalence of the behavioral and psychological symptoms of dementia (BPSD) and associated factors in residents in long-term care (LTC) facilities.

Method: We conducted a cross-sectional survey of older residents with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected LTC facilities in Hokkaido, Japan. The questionnaire included sociodemographic characteristics, health conditions, living environments, and a brief questionnaire form of the Neuropsychiatric Inventory for assessing BPSD.

Results: We revealed that the prevalence of BPSD in LTC facilities (percentage of people exhibiting at least one BPSD) in residents with dementia or similar symptoms was 64%. Having Alzheimer's disease, an imbalance between activities of daily living and cognitive function, poor relationships with other residents, and persistent requests in daily life were significantly associated with having BPSD.

Conclusion: The prevalence of BPSD in LTC facilities was relatively low compared with other countries. The factors found to relate to BPSD may provide useful information for developing care methods to address BPSD in LTC residents.     

Multiple mediators of the relations between caregiving stress and depressive symptoms

Objective: This study tested a model for explaining how stress is associated with depressive symptoms in a sample of spouse caregivers of patients with Alzheimer's disease. It was hypothesized that more depressive symptoms would be significantly correlated with both ‘primary’ caregiver stressors (i.e., care recipient problem behaviors) and ‘secondary’ stress (i.e., role overload), but that this relationship would be significantly mediated by four variables: (1) personal mastery, (2) coping self-efficacy, (3) activity restriction, and (4) avoidance coping.

Method: We used an asymptotic and resampling strategy for simultaneously testing multiple mediators of the stress-to-depressive symptoms pathway.

Results: Greater stress was significantly related to more depressive symptoms. Increased stress was also associated with reduced personal mastery and self-efficacy, as well as increased activity restriction and avoidance coping. Finally, these four mediators accounted for a significant amount of the relationship between stress and depressive symptoms.

Discussion: These results suggest multiple pathways by which both primary and secondary caregiver stresses may be associated with increased depressive symptoms, and may argue for multiple treatment targets for caregiver interventions.     

Psychosis associated behavioral and psychological signs and symptoms in mild cognitive impairment and Alzheimer's dementia

Objectives: The aim of this study is to determine the prevalence of psychosis in mild cognitive impairment (MCI, Petersen's criteria) and patients with Alzheimer's dementia, and to characterize the associated behavioral and psychological signs and symptoms of dementia (BPSD).

Method: A cross-sectional analysis of baseline data from an ongoing, prospective, longitudinal study on BPSD was performed, including 270 MCI and 402 AD patients. BPSD assessment was performed through Middelheim Frontality Score (MFS), Behave-AD, Cohen-Mansfield Agitation Inventory (CMAI) and Cornell Scale for Depression in Dementia (CSDD). Psychosis was considered to be clinically relevant when delusions and/or hallucinations occurred at least once in the last two weeks prior to the BPSD assessment.

Results: The prevalence of psychosis in AD (40%) was higher than in MCI (14%; p < 0.001). AD patients with psychosis showed more severe frontal lobe, BPSD, agitation and depressive symptoms (MFS, Behave-AD, CMAI and CSDD total scores), whereas MCI patients with psychosis only showed more severe frontal lobe and physically non-aggressive agitated behavior. In addition, only in psychotic AD patients, all BPSD and types of agitation were more severe compared to non-psychotic AD patients. Comparing MCI and AD patients, MCI patients with psychosis did not show more severe frontal lobe, behavioral and psychological (Behave-AD), depressive symptoms or agitation than AD patients without psychosis.

Conclusion: AD patients clearly display psychosis associated BPSD, whereas MCI patients only display more severe frontal lobe symptoms and physically non-aggressive agitated behavior, but also less pronounced than in AD.     

Psychometric properties of the Valued Living Questionnaire Adapted to Dementia Caregiving

Objectives: Caring for a relative with dementia is associated with physical and emotional health problems in caregivers. There are no studies analysing the role of personal values in the caregiver stress process.

This study aims to analyse the psychometric properties of the Valued Living Questionnaire Adapted to Caregiving (VLQAC), and to explore the relationship between personal values and stressors, coping strategies and caregiver distress.

Method: A total of 253 individual interviews with caregivers of relatives with dementia were conducted, and the following variables were assessed: personal values, stressors, cognitive fusion, emotional acceptance, depression, anxiety, and satisfaction with life. An exploratory factor analysis and hierarchical regression analyses were carried out.

Results: Two factors were obtained, Commitment to Own Values and Commitment to Family Values which explain 43.42% of variance, with reliability coefficients (Cronbach's alpha) of .76 and .61, respectively. Personal values had a significant effect on emotional distress (depression and anxiety) and satisfaction with life, even when controlling for socio-demographic variables, stressors and coping strategies.

Conclusion: Results suggest that the personal values construct of dementia caregivers is two-dimensional. The personal values of the caregivers play an important role in accounting for distress and satisfaction with life in this population.     

Gratitude and coping among familial caregivers of persons with dementia

Objectives: Gratitude is widely perceived as a key factor to psychological well-being by different cultures and religions. The relationship between gratitude and coping in the context of familial dementia caregiving has yet to be investigated.

Design: This study is the first to examine the associations among gratitude, coping strategies, psychological resources and psychological distress using a structural equation modelling approach.

Results: Findings with 101 Chinese familial caregivers of persons with dementia (mean age = 57.6, range = 40–76; 82% women) showed that gratitude was related to the greater use of emotion-focused coping (positive reframing, acceptance, humour, emotional social support seeking, religious coping) and psychological resources (caregiving competence and social support). Psychological resources and emotion-focused coping in turn explained the association between gratitude and lower levels of psychological distress (caregiving burden and depressive symptoms).

Conclusion: The present results indicate the beneficial role of gratitude on coping with caregiving distress and provide empirical foundation for incorporating gratitude in future psychological interventions for caregivers.     

Self-efficacy for controlling upsetting thoughts and emotional eating in family caregivers

Objectives: Self-efficacy for controlling upsetting thoughts was examined as a predictor of emotional eating by family caregivers of physically and cognitively impaired older adults.

Methods: Adult women (N = 158) providing healthcare assistance for an older family member completed an online survey about caregiving stressors, depressive symptoms, self-efficacy, and emotional eating. A stress process framework was used as a conceptual model to guide selection of variables predicting emotional eating scores.

Results: A hierarchical multiple regression was conducted and the overall model was significant (R² = .21, F(4,153) = 10.02, p < .01); self-efficacy for controlling upsetting thoughts was a significant predictor of caregivers’ emotional eating scores after accounting for IADL, role overload, and depression scores.

Conclusion: These findings replicate previous research demonstrating the relationship between managing cognitions about caregiving and behavioral responses to stressors, and point to the importance of addressing cognitive processes in efforts to improve caregiver health behaviors.     

Meditation-based interventions for family caregivers of people with dementia: a review of the empirical literature

Objectives: Providing care for a family member with dementia is associated with increased risk of adverse mental health sequelae. Recently, interventions utilising meditation-based techniques have been developed with the aim of reducing psychological distress among dementia caregivers. The present review aimed to critically evaluate the extant empirical literature in order to determine: (1) whether meditation-based interventions can reduce depression among dementia caregivers and (2) whether meditation-based interventions can reduce subjective burden among dementia caregivers.

Method: After adhering to inclusion and exclusion criteria, a total of eight studies were included in the present review. Methodological quality was assessed using one of two scales dependent on study design.

Results: The results provide tentative evidence that meditation-based interventions do indeed improve levels of depression and burden in family dementia caregivers.

Conclusions: The review highlighted the strengths and weakness of the studies’ methodological designs. Whilst this novel review offers evidence in support of meditation-based interventions to improve the psychological distress of family dementia caregivers, future research should direct efforts to conduct larger scale, more rigorous studies. Clinical implications of the findings are also discussed.     

Emotional suppression,caregiving burden,mastery, coping strategies and mental health in spousal caregivers

Objectives: The main aim was to explore the multiple mediation effects of personal resources (mastery, engagement and disengagement coping strategies) between caregiving burden and depression in spousal caregivers, based on integrated stress process models. A further aim was to examine whether emotional suppression moderates the relationship between perceived burden and depression.

Method: Cross-sectional data were collected in 2010–2011 by structured interviews from a sample of 110 spousal caregivers. Coefficients strategy with bootstrapping tested the strength and significance of the conditional indirect effects of simultaneous multiple mediators; and the conditional effect of burden on depression at different emotional suppression values.

Results: Caregiving burden was indirectly associated with depression, through mastery and disengagement coping, but not through engagement coping. Mastery was negatively associated with depression, while disengagement coping was positively associated with depression. Emotional suppression and functional disability were positively associated with depressive symptoms. A significant burden-by-emotional suppression interaction was found for predicting depressive symptoms.

Conclusion: The study supports the conditional indirect effect in which burden can affect depression by reducing the mastery and increasing the disengagement coping simultaneously. The study provides also initial support for the moderating effect of emotional suppression, which can increase the deleterious effects of burden on depression. Researchers and practitioners should be aware of these issues of family care in spousal caregivers.     

The use of psychotropic drugs for behavioral and psychological symptoms of dementia among residents in long-term care facilities in Japan

Objective: To examine whether the use of psychotropic drugs (PDs) was related to behavioral and psychological symptoms of dementia (BPSD) focusing on the prevalence, numbers of symptoms, severity, and care burden among the elderly with BPSD living in long-term care facilities in Japan.

Method: We conducted a cross-sectional survey among older people with dementia or similar symptoms (n = 312) using a questionnaire for care staff in 10 selected long-term care facilities. A brief questionnaire form of the Neuropsychiatric Inventory was used to assess BPSD.

Results: PDs were used in 45% among all participants and 47.5% among those exhibiting at least one BPSD. We found that use of PDs was associated with greater numbers, severity, and care burden of BPSD. Also, there was significantly more use of PDs among people who had specific BPSD symptoms, such as delusions, anxiety, and disinhibition, compared with those who did not.

Conclusion: The use of PDs among residents in long-term care facilities with dementia or similar symptoms was relatively low compared with previous reports from other countries. Nonetheless, the greater numbers, severity, and care burden of BPSD were associated with the use of PDs.