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DIFFERENCES IN THE LEVEL OF DEPRESSION
BETWEEN SPOUSE AND DAUGHTER CAREGIVERS
OF ELDERLY DEMENTIA PATIENTS

presented by

Juliet Alfonso-Santos

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DIFFERENCES IN THE LEVEL OF DEPRESSION BETWEEN
SPOUSE AND DAUGHTER CAREGIVERS OF ELDERLY
DEMENTIA PATIENTS
By

Juliet Alfonso-Santos

A THESIS

Submitted to
Michigan State University
in partial fulfilment of the requirements
for the degree of

MASTER OF SCIENCE
College of Nursing

1998

ABSTRACT
DIFFERENCES IN THE LEVEL OF DEPRESSION BETWEEN
SPOUSE AND DAUGHTER CAREGIVERS OF ELDERLY
DEMENTIA PATIENTS
By

Juliet Alfonso-Santos

This study examines the level of depression experienced by wife, husband and
daughter caregivers of elderly dementia patients. Its main focus is to identify which group
is most at risk for developing depressive symptomatology (measured in terms of the 15
question, gender bias free CBS-D Scale). Results revealed that there were no substantial
differences in the mean levels of depression among the three caregiver groups. However,
there were two significant findings: 1) the average depression scores among all caregiver
groups are high and points to clinical depression risk, and 2) high care demands explain part
of the reason for increased depressive symptomatology. Caregiver age, relationship to

patient and duration of care appeared to have little impact on depression.

Copyright by
JULIET ALF ONSO-SANT OS
1998

DEDICATION

To my husband, Melvin,
whose genuine concern for my success
supported my endeavor by taking on my
role for a time with a positive
attitude.

To my 8 years old, Elizabeth,
whose piano music and singing relaxed
and rejuvenated me...

To my 5 years old, Lauren,
whose contagious laughter,
charisma and sense of humor kept a smile
on my face...

To my 3 1/2 years old, Michael,
our "Angel Boy", whose hugs and kisses
constantly kept my priorities in
perspective...

To my mother, Juana Alfonso,
whose goal oriented, persevering genes
pervade my being and whose prayers gave

me courage to achieve and succeed...

....you are all heaven sent.

iv

ACKNOWLEDGMENT

To Dr. Manfred Stommel .....
my professor, thesis chairman,
mentor and friend...
whose expert guidance, dedication to
excellence and love for teaching
patiently assisted me in completing this
thesis in a timely manner...
...and whose encouragement made the

process almost bearable...

To Dr. Georgia Padonu & Dr. Celia Wills...
my thesis committee members...
whose insightful suggestions and kind
words made this challenging process a

little less stressfirl...

Thank you does not seem to suffice...

TABLE OF CONTENTS

LIST OF TABLES ...................................................................................................... vii
LIST OF FIGURES ................................................................................................... viii
INTRODUCTION ........................................................................................................ 1
Purpose of the Study ......................................................................................... 4
Key Concepts .................................................................................................... 4
LITERATURE REVIEW ............................................................................................. 5
Influencing Factors on Depression ................................................................... 9
Hypothesis .................................................................................................... ll
THEORETICAL FRAMEWORK ............................................................................ 12
Study Model .................................................................................................. l4
NEED FOR STUDY ................................................................................................ 17
METHODOLOGY ................................................................................................... 17
Original Studies ............................................................................................ 17
Sample for Current Analysis ........................................................................ 18
Operational Definitions & Instrumentation .................................................. 19
ANALYSIS ............................................................................................................... 21
RESULTS ................................................................................................................. 23
Socio-Demographic Characteristics of Caregivers ....................................... 23
Socio-Demographic Characteristics of Care Recipients .............................. 25
CES_D Scale Scores .................................................................................... 26
Caregiver Health .......................................................................................... 26
Care Demands .............................................................................................. 26
Caregiver Relation to Patient ........................................................................ 29
DISCUSSION ........................................................................................................... 30
Implications for Advanced Nursing Practice & Primary Care ..................... 33
Limitations of Research ................................................................................ 35
Future Studies ............................................................................................... 37
LIST OF APPENDICES
A - Items from the Center for Epidemiologic
Studies Depresson Scale (CBS-D) ................................................... 38
B - Revised 15 Items CES-D Scale .............................................................. 40
C - Cognitive Deficit Scale .......................................................................... 42
REFERENCES ........................................................................................................ 44

vi

II.

III.

IV.

VI.

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

LIST OF TABLES

Socio-Demographic Characteristics of Caregivers .............. 24
Socio-Demographic Characteristics of

Caregivers Recipients .............................................. 25
CBS-D Scale Caregiver Depression Scores ........................ 26

Weekly Involvement In Tangible Care Tasks
by Caregiver ............................................................ 28

Depression Scores Regressed on 7 Covariates
Representing 6 Issues .............................................. 29

Caregiver Unadjusted and Adjusted Mean
Depression Scores .................................................... 3O

vii

LIST OF FIGURES

I. Figure l Lazarus & Folkman's Model of Stress Adaptation .............. 13

11. Figure 2 Dementia Caregiver's Model of Stress Adaptation ............. 15

viii

INTRODUCTION

Dementia is a major source of morbidity in the elderly in the United States.
Between 6 and 7 percent of persons 65 years or older suffer from moderate to severe
dementia and, among those 85 years or older, the prevalence is at least 20 percent
(Baumgarten, Hanley, Infante-Rivard, Battista, Becker & Gauthier, 1994). It is estimated
that over 50% of all nursing home patients suffer fi'om dementia (F uj imoto &
Shimomura, 1996) and unfortunately, no specific treatement or cure exists for most
progressive dementias (Boss,l994). Therapy is primarily focused on maintaining and
maximizing the remaining physical and mental capacities, restoring functions if possible,
and adjusting to lost abilities.

The dementia syndrome may be caused by over 60 different disorders, most are
due to Alzheimer's disease, followed by multi-infarct dementia or a combination of the
two (F ujimoto & Shimomura, 1996). It is a commonly occurring neurologic disorder
with unknown etiology, however, several possible theories of disease etiology are
currently under investigation. A key theory is that a loss of central nervous system
stimulation by acetylcholine is responsible. This neurotransmitter is needed for recent
memory at the biochemical level (Boss, 1994). As the level of acetylcholine is reduced,
the individual is less and less able to store information until all recent memory is lost.
Other possible causes of dementia include infections, other neurodegenerative disorders,

toxins and metabolic disorders (F ujimoto & Shimomura, 1996).

The initial clinical manifestations of dementia are insidious, developing over
months or years, and often attributed to ”normal" forgetfulness, emotional instability, or
some illness. As the disorder advances, there are progressive memory loss, emotional
lability, disorientation, confusion and inability to concentrate. Abstraction, problem
solving and judgment gradually deteriorate while failures in arithmetic calculation ability,
language and visuospatial orientation occur (Boss, 1994). Motor changes may occur if
posterior frontal lobes of the brain are involved causing rigidity, flexion posturing,
propulsion and retropulsion. There may be a loss of executive cerebral functions with
declining intellectual ability. As a result, the affected person regresses mentally,
physically and emotionally to a debilitated, dependent state thereby requiring increasing
assistance with basic needs until death ensues from complications of immobility in the
terminal stage (Aneshensel, Pearlin & Schuler, 1993).

It is well documented that caring for an elderly relative with dementia results in
considerable stress (Haley & Pardo, 1987; Shields, 1992; Robinson, 1989; Collins,
Stommel, Wang & Given, 1994b; Baumgarten, Hanley, Infante-Rivard, Battista, Becker,
& Gauthier, 1994). In particular, empirical evidence strongly support clinical
observations that primary caregivers experience substantial negative social, psychological
and health effects related to the caregiving role. Providing care and support to a
dementia, patient has been likened to exposure to multiple and severe long term stressors.
Thus, it would seem reasonable to expect that caregivers' physical and psychological
stamina are depleted over time compromising their own health (Schultz & Williamson,
1991; Baumgarten, et al., 1994). Common responses to the stress of dementia care

include anger, depression, guilt, worry and marital stress (Anthony-Bergstone, Zarit &

Gatz, 1988). It has been documented that 50 percent of all caregivers experience
emotional and physical stress at a level that meet the criteria for a diagnosis of depression
(Shields, 1992).

The 1982 National Long Term Care Survey and Informal Caregivers Survey
provided descriptive information regarding family caregivers (Gallagher, Rose, Rivera,
Lovett & Thompson, 1989). In this sample, the majority (72%) were women, with adult
daughters comprising 29% of all caregivers and wives constituting another 23%.
Husbands accounted only for 13% of the sample. During the time the patient first begins
to deteriorate, one member of the family, usually a spouse or a daughter (Shields, 1992),
assumes the primary responsibility for the elderly dependent relative. The burden of care
quickly rests upon this individual with other family members most often helping only on
occasion. The 1997 American Psychiatric Association Practice Guideline for the
Treatment of Patients with Alzheimer's Disease and other Dementias of Late Life
suggests that health care providers must be vigilant in detecting negative experiences in
caregivers which increase the risk for substandard care, neglect, or abuse of patients
which are indicative that caregivers themselves are in need of care (1997).

From a clinical point of view, however, there is a need to know whether different
caregivers, such as wife, husband, or daughter, experience significantly different levels of
depression. This would allow targeting of high risk populations for depression in order to

provide support early on to prevent adverse health effects in caregivers.

Purpose of the Study

Thus, the purpose of this study is to identify those caregiver groups that may be at
highest risk for depressive symptomatology. In particular, this study will examine which
among the following groups- wives, husbands, or daughters- are at highest risk to suffer
from depressive symptomatology. For the purpose of this paper, sons will not be
included in the study because very few son caregivers were included in the original study

due to the degree of difficulty in finding son caregivers in the community.

Key Concepts

This research focuses on the following key concepts: dementia, depression,
primary caregiver, family relationship, and gender differences.

1) Dementia is referred to as an insidious cognitive impairment which results in
labile emotions, hostility, mood swings, confusion, loss of judgment and
executive functions thereby rendering an individual physically and emotionally
dependent.

2) Major depression is defined as a mental disorder marked by altered mood, loss
of interest in all usually pleasurable outlets such as food, sex, work, friends,
hobbies or entertainment. Diagnostic criteria include the presence of altered
moods nearly every day, significantly diminished interest or pleasure in most or

all activities, and three or more of the following: (DSM-IV, 1994)

g)

h)

Poor appetite significant weight loss, or increased weight gain
Insomnia or hypersomnia

Psychomotor agitation or retardation

Feelings of hopelessness

Loss of energy or fatigue

Feelings of worthlessness, self reproach or excessive inappropriate guilt
Complaints or evidence of a diminished ability to think or concentrate
Recurrent thoughts of death, suicidal ideation, a wish to be dead, or

attempted suicide

3) Primary caregiver refers to the individual providing the majority of the care to

the elderly dependent individual.

4) Family relationship refers to the family member category of the patient's

caregiver, either the husband, wife, or daughter.

5) Gender difference refers to the differential response to caregiving and difference

in the level of depression between male and female caregivers.

LITERATURE REVIEW

It is well documented in the literature that wives make up 2/3 of the spouse

caregivers and, among child caregivers, it is mostly daughters, as well as daughters-in-

law, who care for elderly dependent parents (Barnes, Given & Given, 1992). There is

also substantial evidence that different types of family caregivers, such as wives,

husbands, and daughters differ in their susceptibility to depression. For instance, Schultz

and Williamson (1991) found wives are especially vulnerable to the stress of caregiving
and tend to be in the higher risk group for depression when compared to daughters
(Robinson, 1989; Hooker, et al., 1992; Gallagher, et al., 1989). In part, this appears to be
due to the fact that wife caregivers are older, more infirm, have more chronic conditions
(Baumgarten, et al., 1992), often live without a child at home, and must assist the
dementia spouse alone (Robinson, 1989). Thus, wives are more likely to be cut off from
people with whom they formerly associated or interacted. In addition, there often is a
great difference in the meaning of an illness in one's husband or in one's father. Adult
children as well as other relatives often go through a decision process of whether or not to
take on the caregiving role, whereas wives do not have this prerogative. They are more
burdened with day to day care and have taken on the role due to an overwhelming sense
of duty (Horowitz & Shindelman, 1983; Robinson, 1989). This is consistent with the
study by Haley and Pardo (1989) which claimed that with the progression of dementia,
behavioral problems and caregiving stressors develop in a mounting fashion. It is
assumed that caregiving stressors increase steadily over time as the patient deteriorates.
The best predictors of depression among wife caregivers were found to be:
1) caregiver health, and 2) attitude (Robinson, 1989). It seems that wife caregivers have a
negative attitude toward seeking outside assistance due to their view that caregiving is
part of their marital responsibility. This belief seems to give rise to feelings of failure and
dependency when they have to ask for help. When wives do seek assistance and the
desire for support is unmet, greater stress is experienced and depression is more likely to
occur (Robinson, 1989). George and Gwyther (1986) further supported this finding upon

discovery that wife and husband caregivers report significantly more physician visits and

poorer health than adult children caregivers.

Many wife caregivers refuse the idea of vacationing away from their dependent
spouse. It seems that the more mentally or physically disabled the dependent is, the less
likely it is that the carer goes on vacation-«a fine example of the "inverse care law"
(Jones & Peters, 1992). This implies that those most needing a holiday are the ones least
likely to receive it, claiming that there is no one else who can care for the elderly, not
even available respite care. Among those having the option of respite care, 17% of wife
caregivers simply reported that they did not want to have a vacation away from their
loved one. Instead, they would like their dependent spouse to go with them.

A study by Cohen, et al. (1990) explains the reactions of 516 primary caregivers
of patients with Alzheimer disease or related dementia, registered at University Medical
Center hospital in Wisconsin, Florida and Illinois. The caregiver groups were as follows:
38.2% spouses, 45.3% adult children, 16% below age 45, 35% ages 45-59, 28% were 60-
74, 21% were over 75; and 73.3% of caregiver were female. Consistent with other
literature, the authors discovered that wife caregivers had the highest rates of depressive
symptomatology. Often the wife caregivers perceived little or no help even if there were
more people in the same household, and frequently this meant more work and
responsibility (Bourgeois, Beach, Schultz & Burgio, 1996). Residing with the patient
was not associated with increased depression or symptomatology.

In contrast, there is also research which claims that daughters are the most likely
to report deleterious effects on their lives as a result of caregiving (Jones & Peters, 1992).
These authors assert that lack of privacy and personal freedom greatly affects family life

negatively. The Equal Opportunity Commission supported the finding that for non-

spouse carers, caring for elderly dependents, while trying to meet the needs of the
immediate family, is a major problem (Jones & Peters, 1992). According to the authors
of the study, one fourth of the daughter caregivers had not had a vacation in 5 years. A
tenth of the sample, mostly daughters, also reported giving up employment to become a
caregiver for the dependent parent. One fifth of the sample reported unbearable amounts
of stress as a consequence to their role.

There are few documented instances of middle aged daughter caregivers who were
frequently characterized as caught between the competing demands of parents, spouse,
children, home and career (Bergstone, et al., 1988) and have been referred to as "women
in the middle" (Brody, 1990). This is in conflict with the expectation of many daughters
in their middle years that their caring responsibilities and ties to the home will be
reduced, not increased. The unforeseen requirement to provide care brings with it major
alterations in lifestyle and future plans regarding occupational and leisure activities which
had to be sacrificed temporarily. This is consistent with other findings (Franks &
Stephens, 1996) that adult-daughter caregivers are extremely overwhelmed and taxed by
their caregiving responsibilities due to interference with other social roles.

Although the majority of caregivers are women, several studies have noted a
substantial number of husbands who are primary caregivers for their wives (F uller-Jonap
& Haley, 1995). According to the 1982 Long-Term Care Survey, 28% of caregivers are
men, most of whom are husbands (Stone, Cafferata & Sange, 1987). Male spousal
caregivers of dementia patients are of particular interest since gerontologists have
forecasted an increase in the actual percentage of men serving as caregivers (Stone, et al.,

1987). In addition, husband caregivers could be a group particularly vulnerable to stress

given that older men have shorter life expectancies and greater health difficulties than
women. This finding is consistent with George and Gwyther (1986) who report that
spousal caregivers have greater numbers of disability days and increased physician visits
for respiratory infections.

Schultz and Williamson (1991) have found that male spousal caregivers of
dementia patients were the only group within a longitudinal sample to show increased
depression over time. This is consistent with the study by Collins, Stommel, Wang and
Given (1994b) whose findings revealed that female bereaved caregivers experienced a
pattern of decreasing depression following their dependent's death, while male caregivers
experienced a rise in the level of depression. This may be due in part to having chosen to
be the caregiver for someone with whom they have had a very positive, loving
relationship. If true, these men experience the loss much harder. However, the
depression level during caregiving may be related to difficulty in adapting to the

mounting demands of the patient as the disease progresses.

Influencing Factors On Depression

There are various other factors known to influence depression among caregivers
of the dementia patient. However, for the purpose of this paper only four have been
chosen for discussion: 1) age, 2) health, 3) caregiving demands, and 4) duration of care.

Anthony-Bergstone, Zarit & Gatz (1988), in studying the symptoms of
psychological distress among caregivers of dementia patients, found that, in any

caregiving sample, age is confounded with the relationship of the caregiver to the

dementia patient. Older caregivers tend to be spouses and younger caregivers tend to be
sons or daughters, however, child caregivers can sometimes be quite old. Obviously,
younger caregivers would tend to be stronger, more agile than older spouse caregivers
often suffering from numerous chronic conditions such as osteoporosis, arthritis, and
other painful, physically limiting diseases. These confounding variables along with age
and its cohort effects may contribute to depressive symptomatology.

Robinson (1989) asserted that caregiver health was the best predictor of
depression. Health has been consistently identified in the literature as an important
variable of concern for caregiving wives. In this study, only 30% of wife caregivers
reported their health as excellent, the majority rated their health as good to fair. Overall,
most literature asserted that good health has a positive impact on the duration of care
(Robinson, 1986).

Another contributing factor associated with depression is the duration of
caregiving role. A study found this marker to be associated with chronicity of stressors
experienced by the caregiver (Pearlin, Mullah, Semple & Skaff, 1990). In general,
husband and wife caregivers were older and had been caregivers longer than daughters,
therefore, may be more prone to depression. This finding, however, is not consistent
across studies. The duration of care was found in one study to be related to depression
(Baumgarten et al., 1994) but unrelated to depression in two others (Draper etal., 1992;
Kielcolt-Glaser et al., 1991).

Caregiving demands is another factor influencing depression levels in dementia
caregivers. It is important to control for this variable since different caregiver groups take

care of patients requiring varying amounts of care. Jones and Peters (1992) reported

10

higher rates of stress for carers of older dependents (particularly 85 years and over), carers
of more dependent and more disabled elderly persons; carers of close relatives (spouses
but especially children) and, independently of relationship, female carers. These factors
were found to have deleterious effects on the social and family life of the caregivers and
are associated with great amounts of stress as reported by the carers. Those caregivers
caring for the very fi'ail dependent are most likely to be daughters, since they almost
always take on the role afier their parent's death or when the parent is no longer able to

function in the caregiver role.

Hypothesis

The primary focus of this study is to identify the difference in mean levels of
depression among husband, wife and daughter caregivers. Based on the literature review,
it is hypothesized that: wives will be at highest risk for depression, followed second by
daughters and finally husbands having the least risk. This hypothesis will be tested in a
two-step process: first, the degree of depression will be tested using the revised CES-D
scale and followed by regression analysis of the independent variables (age, health,
duration of care, care demands and caregiver relation to patient). The mean CES-D

scores of wife, husband and daughter caregivers will be compared using Chi-square.

11

THEORETICAL FRAMEWORK

Lazarus and Folkman (1984) conceptualized adaptation to stress as an interaction
of personal and environmental factorsuthe nature of the stressor, the individual's
interpretation of the stressor, personal resources, and coping efforts (Figure 1). This
theory suggests that adaptation efforts are process-oriented with the expectation that there
will be change in the ways of coping as stressful situations unfold (Pruchno & Resch,
1989). Lazarus and Folkman (1984) define coping as all efforts to manage a stressful
situation. According to this definition, methods of coping may be more or less effective
in alleviating stress, thus reducing depression risk. However, even those behaviors which
do not directly reduce stress are considered coping efforts to help minimize depressive
episodes. The definition avoids equating coping, or adaptation, with mastery but does
seem to encompass efforts to minimize, avoid, tolerate, accept and overcome the situation

as part of the process (Lazarus & Folkman, 1984).

12

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In an attempt to manage depressive symptomatology in caregivers, two coping
efforts are identified: 1) problem focused, and 2) emotion focused (F olkman & Lazarus,
1980). Problem-focused efforts to adapt refer to methods aimed at managing or altering
the problem causing the stress. Emotion-focused efforts are aimed toward regulating the
individual's emotional response to the problem when an appraisal reveals that nothing can
be done to modify harmful, threatening or challenging conditions (F olkman & Lazarus,
1980). This suggests that the stresses common in dementia which are not controllable by
the caregiver, will be most successfully dealt with by combining both strategies (Figure 2)
which focus on organizing an effective support and service network ("problem focused")

and on managing the emotional stress aroused by the illness ("emotion focused").

Study Model

In this study, the factors contributing to caregiver depression are assumed to be
first and foremost the caregiver's relationship to the care recipient as well as increased
care demands, poor health, increased duration of care and age of the caregiver. These
factors particularly focus attention on the chronic, long term nature of dementia with
progressive patient deterioration, lack of support and available resources. While some
caregivers manage well, others experience a host of simultaneous stressors which add to
the heavy weight of caregiving. Among these are personal crisis (newly diagnosed
illness, lack of insurance, finances, marriage problems, job insecurity, etc.),
environmental stressors (housing difficulty, lack of transportation, etc.) and

developmental stressors (Medicaid/Medicare limitations, retirement, decreased social

14

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15

security benefits, menopause, etc.). The accumulation of these stressors without adequate
adaptation mechanisms have been known to contribute to a multitude of mental health
symptoms such as depression, nervousness, anxiety, sleeplessness, frustration and
lowered morale (Brody, 1990).

Two important factors are vital in the caregiver process of adaptation:

1) perception of the situation (severity of the problem), and 2) personal coping
mechanisms (attitude, outlook, source of spiritual strength, etc.). These factors provide
the base for the ongoing process of adaptation to the arduous demands of caregiving.
Two adaptation pathways may be implemented together or one at a time to balance the
"teeter-totter" effect of providing care (Figure 2): 1) problem focused, and 2) emotion
focused.

The problem focused pathway seeks the support of family, friends and significant
others in an effort to adapt to caregiving tasks and responsibilities. For example, respite
care, agency service and health care provider support are activated to address the physical
and medical needs of the patient, thereby, helping to reduce the strain on the primary
caregiver. The second pathway, emotion focused adaptation, seeks to adapt via the
emotional assistance of counselors, network of fi'iends, and support groups. In the
language of adaptation, men can be expected to use more problem-focused efforts and
women more emotion-focused efforts (F olkrnan & Lazarus, 1980). However, both
genders may benefit by implementing both approaches to adaptation. In addition, stress
management and relaxation techniques may also be utilized to help the caregiver adapt to
the stress of round-the-clock surveillance required due to disruptive, even dangerous,

behaviors such as wandering, night time wakefulness, turning on the stove or water faucet

16

and leaving them unattended (Brody, 1990).

NEED FOR STUDY

The results of previous research imply the need for reducing the impact of
caregiver burden and the prevention and treatment of depression among the high risk
caregiver population. (Pruchno & Resch, 1989).

It is crucial to identify those caregiver groups that are at high risk for depression in
order to provide adequate support and community services (Collins, King, Given &
Given, 1994a). Without such support, caregivers frequently become frustrated and
overwhelmed thus leading to heightened risk of substandard care and earlier admission to

a long term care facility.

METHODOLOGY

Original Studies: Two studies were used as the basis for this secondary analysis:
1) Family Homecare - A Commmrity Based Model (Barbara A. Given, Principal
Investigator, 1987-1991). National Center for Nursing Research, Grant#1 R01
NR01915-01 (N=307).
2) Impact of Alzheimer's Disease on Family Caregivers (Clare E. Collins, Principal
Investigator - 1989-1991). National Institute of Mental Health, Grant #2 R01

MH41766-03 (N=226).

17

Both longitudinal panel studies (repeated interview process involving the same
subjects spaced several months apart consisted of convenience samples of self selected
caregiver-patient dyads. The samples were located with the assistance of 145 community
agencies including local chapters of the Alzheimer's Association, the Michigan
Association of Adult Day Care Centers and various health agencies in southwest
Michigan. These groups were instrumental in contacting possible subjects via mailings
and were efficient in identifying the caregivers of dependent elderly relatives being cared
for at home (Collins, Stommel, Wang & Given, 1994b). Eligibility criteria for inclusion
in both studies were: a) patients had to be at least 64 years of age; b) dependent in at least
two activities of daily living or instrumental activities of daily living, and c) had to have a
primary caregiver. Caregivers were considered eligible to participate in the study if they
were: a) family members, b) considered to be the primary caregivers, and c) the
dependent relative was residing in the home at the time of entry into the study. For the
dementia study, the additional eligibility criterion required that the patient had diagnosis
of Alzheimer's disease or other progressive dementia. All data collection were conducted
in their own home to assure that the caregiver was the exclusive source for all
information.

Sample for Current Analysis:

A few caregivers who were neither spouse or daughter of the care- recipient were
excluded. Thus, a total of 246 caregiver-dementia patient dyads were included in the
current analysis, of which 36 are from the Family Home Care Study and 210 fi'om the
Alzheimer's Disease Study. Since this is a secondary analysis, the procedure for the

protection of human subject was submitted by the original researchers and was approved.

18

A second request for permission to perform secondary analysis and guarantee the
anonymity of the subjects was submitted to and approved by the University Committee on

Research Involving Human Subjects (UCRIHS).

Operational Definitions and Instrumentation

Depression. To measure depressive symptomatology, the current analysis
employs a shortened version of the Center for Epidemiologic Studies Depression Scale
(CES-D). The revised 15 Question CES-D Scale has been shown to produce bias-free
responses with respect to gender, thus, proving to be an equally good measure of
depressive symptomatology among men and women. The revision was the result of
discussions in the literature regarding the original CES-D Scale (Radloff, 1977) which
focused on possible age bias. The process resulted in identification of two CES-D items
which showed "gender specific" response patterns ("talked less than usual", and "had
crying spells") among men and women (Stommel, et al., 1990).

In addition, three other CES-D items were excluded due to their poor
psychometric qualities ("thought life a failure", "people were unfriendly", and "people
dislike me"). Four of the 15 remaining items were reverse coded since these were worded
positively in the questionnaire: 1) just as good as others, 2) hopefirl about future, 3)
happy, and 4) enjoyed life. The revised 15 item scale correlated very highly with the
original 20 item scale (0.98). The shortened version barely affected its overall reliability
as evidenced by Chronbach's alpha of 0.89 for the 20 item scale versus 0.88 for the 15

item scale (Stommel, et al., 1993).

19

In the CBS-D instrument, subjects are asked to respond to the items detailing
depressive symptoms by indicating how often they experienced these symptoms during
the past month: "rarely or none of the time" (=0), "some or a little of the time" (=1),
"occasionally or a moderate amount of time" (=2), "most or all of the time" (=3). For the
original 20 -item scale, summated scale scores can range from 0 to 60. To preserve the
same range, the mean score for the 15 item version is multiplied by 20.

Caregiver health was measured in two ways: 1) by having the caregiver rate his
or her own health on a scale ranging from excellent health (=1), to poor health (=4); and
2) by a count of 14 commonly occurring morbidities such as arthritis, glaucoma, high
blood pressure, emphysema, heart trouble, effects of stroke, diabetes, kidney/urinary tract
disease, cancer/leukemia, nervous disorders, stomach/intestinal problems, prostate
problems, and broken hip.

Care demands. The first measure of care demands include caregiver
involvement in tangible (objective) care task based on the concept of fi'equency of
assistance (Stommel, et. al., 1995). The caregivers were asked to indicate how often the
patient required assistance for any activity with confirmed dependency. The caregivers
were also asked to report the frequency of assistance for the same activity rendered by
informal and formal care providers in a typical week. Answers ranged from no
involvement (0), once a week (1), several (two to six) times a week (3.5), once a day (7),
and several times a day (14). This coding scheme provides an approximate interval level
of measurement of the weekly frequency of care rendered by the caregivers. The
frequency of assistance scores for individual activities were then summated (the IADLs

and ADLs combined) reflecting all instances of assistance that patients received in a 7

20

day period (Stommel, et. al, 1995).

The second measure of care demands utilized the cognitive deficit questionnaire
(intangible or subjective measure) comprised of 6 questions reflecting the caregiver's
perception of the patient's cognitive deficit (Appendix C). Subjects were asked how
frequently their relative displayed the following behaviors: seem confused, forgets what
day it is, gets the present mixed up with the past, forgets where he/she is, forgets
important or recent events and repeats self or asks the same question over and over. A
Likert-type scale was used to identify answer categories: "not at all" (=0), "sometimes"
(=1), "most of the time" (=2), "always" (=3). The scale's internal consistency was found
to be Cronbach's alpha = .77 (Stommel et al., 1990).

Duration of care was measured by asking the caregiver to estimate how long they
have been providing assistance in terms of years and months. For the current analysis, the
duration of care measure was rounded off to the nearest year.

Caregiver age was measured by asking the caregiver to indicate their exact
birthdate. Age in years was obtained by subtracting the birthdate from the interview date.

Gender was measured by having the caregiver indicate sex: female (=0), and
male (=1). Family relationship was measured by indicating whether the caregiver was a

wife (=1), husband (=2), or daughter (=3).

ANALYSIS

The data for this analysis come from longitudinal, non-experimental panel

studies. Thus, even with the use of multivariate statistical analysis models, the influence

21

22

of unmeasured extraneous variables cannot be ruled out.

The main research questions/hypotheses focused on a comparison of depression
levels among 3 groups of caregivers: wives, husbands, and daughters. Depression was
measured on a continuous, standardized scale (the CES-D) with a potential range from 0-
60 ( higher scores reflect greater depressive symptomatology). Thus, analysis of variance
(AN OVA) which is used to test for differences in mean scores across comparison groups,
is an appropriate statistical procedure. Further complications arise from the need to take
into account the effects of other variables on depression, such as care demands, duration
of care, age, and health of the caregiver. Using an analysis of covariance (ANCOVA)
approach, it is possible to account for the simultaneous effects of these other variables
and to adjust the mean differences among the four groups of interest accounting for these
variables. The F -test is used to determine if the independent variables (both the
relationship factor and the covariables) explain systematic variations. A statistically
significant F value results in rejection of the Null Hypothesis (the independent variables
have no effect on depression). To test for pairwise differences among the three pairs of
caregivers (wife-husband, wife-daughter, husband-daughter), Tukey's post hoc

comparison test was used to control for Type I error.

22

RESULTS

Table 1 and 2 shows the socio-demographic characteristics of the sample
respondents. Among the 246 dementia caregivers, 48% were wives, 25% were husbands,
and 27% were daughters (Table l). 73% were spouse caregivers compared to only 27%
of daughter caregivers. The patient profile comprised a fairly equal distribution of males

(51%) and females (49%). Only 5% of the caregivers lived apart from their relative
while the other 95% lived together with the patient. As expected, the majority of
caregivers (75%) were female and 25% were male. 98% (N=241) of the caregivers were
Caucasian and 2%(N =5) were African-Americans. The mean caregiver age was 63 years
while the patient's mean age was almost 73 years. The average duration of care was

almost 4 1/2 years.

23

TABLE 1
Socio- Demographic Characteristics

 

 

 

 

of Caregivers
(N=246)
Mean SD Range

Caregiver age 62.6 yrs. 10.99 27-86 yrs.
Years of caregiving 4.4 yrs. 3.13 _<_ 1 yr 222yrs.

N Percentage
Living arrangement
Caregiver & patient 235 95.5
Caregiver & patient in
different household 1 1 4.5
Gender
Female 185 75.2
Male 61 24.8
Relation to patient
Wife 1 19 48.4
Husband 61 24.8
Daughter 66 26.8
Marital status
Single 1 l 4.5
Married 222 90.2
Widowed 8 3.3
Divorced/separated 5 2.0
Employment status
F ull-time 49 19.9
Part-time 25 10.2
Not employed 172 69.9
M
Some high school or less 40 16.2
High School graduate 59 24.0
Some college 93 37.8
College graduate/graduate degree 54 22.0
Race/Ethnicig
White/Caucasian 240 97.6
African-American 5 2.0
Other 1 .4

24

TABLE 2
Socio- Demographic Characteristics

 

 

 

 

of Care Recipients
Mean SD Range
Patient Age 72.5 yrs. 8.48 54-99 yrs.
Household Income $21,500.00 $18,320.62 $1 ,000-$152,503
(median)
N Percentage
Gender sex
Female 121 49.2
Male 125 50.8
Patient ma_rital status
Married 186 76%
Widowed 60 24%

 

The actual minimum score on the 15 item CES-D Scale was zero (least depressed)

and the observed maximum score was 49 (most depressed). Using accepted cut-offs

(Weissman, 1987) 26% were not likely to be clinically depressed (CES-D =<16) while

60% scored 2 16 and can be considered at high risk for depression (Table 3). Having

60% of these caregivers in this danger zone is quite impressive since the non-caregiver

general population scores have been found to be in the lower ranges and mean scale

scores not exceeding 10 on the 20 item CBS-D Scale (Stommel, et a1. 1993). This finding

is consistent with Shields’ study (1992) in which 50% of all caregivers experienced

depression. It is important to emphasize that the CES-D Scale has been found to have an

80% accuracy rate in screening for clinical depression (Weissman, 1987).

25

TABLE 3
CES-D Scale Caregiver Depression Scores

 

 

N Percentages
<16” 98 39.8
_>_16c 148 60.2

 

Mean=18.96, median= 19.0, SD= 9.69, minirnum= O, maximum= 49.
Less likelihood of clinical depression.
c. 80% likelihood of clinical depression.

9‘!”

Table 3 shows that approximately one-third of all caregivers reported
experiencing mild levels of emotional distress. However, there are proportionately more
caregivers who have CBS-D scores of 16 or higher (60%) compared to the number of
caregivers who have scores of less than 16. This finding implies that there is significant
clinical depression among the caregivers. This is consistent with the findings of
Anthony-Bergstone, et al. (1988), in which common responses to the stress of dementia
included depression.

Caregiver health. 25% of the caregivers reported having excellent health while
56% reported good health (Table 5). Only 2% claimed they currently experience poor
health. Several caregivers (N=73) reported being in perfect health as reflected by zero
illness count. However, the average illness count reported was 1.5 across the caregiver
groups.

The first measure of care demands is based on tangible or objective care tasks
performed by the caregiver per week (Table 4). The mean involvement per week is 30.5

(SD=15.3). The scores ranged from one (minimal care demand) to sixty-seven

26

(extremely heavy care demand). The high caregiving demand score have been found to
be directly correlated to the level of depression experienced by 60% of the caregivers.
The caregivers with the highest score can be anticipated to be at most risk for depression.
The second measure of care demands employed here is the patient's cognitive
disability score (intangible or subjective care demand) (Table 5). The sample mean score
for this scale was 1.7 (SD=.72). The scores ranged from zero (no deficit) to 3 (total
deficits) on the cognitive disability scale. As expected, older patients showed more
cognitive deficits (r=.184). The implications of the cognitive deficit care demands are
uncertain. Since the cognitive deficit scale is constructed by the rater (caregiver self-
report), it is naturally assumed that some responses haVe been colored by the rater's
"mood". It is difficult to ascertain if the responses reported are due to the stress of care

demands or merely the negative outlook of the caregiver towards life in general.

27

TABLE 4
Weekly Involvement In Tangible Care Tasks by Caregiver
(Care Demands)(N=246)

 

 

N %
Frequency of involvement "b
1-12 28 I I .2
13-24 69 27.8
25-36 59 23 .8
37-48 54 21.8
49-60 33 12.4
61-67 3 1 .2

 

a. Frequency of involvement includes ADLS such as: bathing, dressing, grooming,
toileting, eating, stool & urine incontinence, etc.; and IADLs such as: shopping,
cooking, laundry, housework, managing money, transportation, etc.

b. Mean = 30.54, median = 30.0, SD = 15.33, minimum = 1.00, maximum = 67.0

A key issue to address is the difference in the level of depression between spouse
and daughter caregivers of the elderly dementia patient. Tables 5 and 6 Show the main
results from the AN COVA which addresses the research hypotheses. The model
contained 7 covariates (Table 5) and 1 relationship factor ( Table 6). The model as a
whole accounted for 21.4% of the variation in caregiver depression scores (overall
F =7.79, p<.001). However, among the covariates, only two were statistically significant:
self-rated health (p<.0001) and frequency of care involvement (p<.007). Caregiver self
rated health may be significant secondary to an already depressed caregiver reporting
personal well being through "negative lenses", thus rating themselves as more ill than
others.

Caregiver relation to patient was not found to be statistically significant (F=l .22,

p= .297). This may be due to dementia's overwhelming intensity as the condition

28

worsens, thus overshadowing this variable. As the disease progresses, caregiver relation

(wife, husband, or daughter) to the patient does not seem to matter since the dementia

care demand is so great and frequently results in difficult role adaptation.

TABLE 5

Depression Scores Regressed on 7 Covariates
Representing 6 issues

 

 

 

Mean Square F Sig.

l. Caregiver Age (in yrs) 170.2 2.21 .138
2. Duration of Care (in yrs) 50.72 .659 .418
3a. Caregiver Self rated Health 2,141.52 27.81 .000

(subjective)
3b. Count of Caregiver Illness 70.94 .921 .338

far less likely that this

objective measure is affected

by depression (objective)
4a. Frequency of caregiver

Involvement per week

(care demand) 562.08 7.30 .007
4b. Patient Cognitive Deficit Score 254.08 3.30 .071
5. Caregiver Relation to Patient 93.86 1.22 .297
a. Model Goodness of Fit: R = .462, R2 = .214

A key issue to address is the difference in the level of depression between spouse

and daughter caregivers of the elderly dementia patient. Table 6 shows the remaining

results of the AN COVA focusing on the main question of interest: are there differences in

mean depression scores of wife, husband, and daughter caregivers? While the unadjusted

depression means in the sample were found to be highest among wives (19.61), husbands

(18.87), and daughters (17.89), none of the observed mean difference among the 3 groups

were statistically significant (F-tesF.664; p=.516). After adjusting the observed means

29

for the influence of all the covariates, group differences became even smaller: 19.6

(wives), 18.9 (husbands), and 18.9 (daughters). These findings remained insignificant

 

 

 

(p=.297).
TABLE 6
Caregiver Unadjusted and Adjusted Mean Depression Scores
Unadjusted Adjusted
N Group Mean' SD Group Mean”
Wives 1 19 19.61 9.42 19.40
Husbands 61 18.87 9.54 18.86
Daughters 66 17.89 10.35 18.91
a. Group mean before covariates (age, health, duration of care and care demands)
are accounted for using AN OVA.
b. Group mean after covariates are accounted for using AN COVA.

c. F= .664, p=.516(oneway), F=1.219, p=.297(mu1tivariate)

In addition, post hoc, pairwise comparisons between wife, husband and daughter

groups were conducted using Tukey's difference test (T ukey HSD). The results revealed

that no pairwise comparison is statistically significant (with all Cls containing the value

of 0). Thus, the main hypothesis was not supported; there was no statistically significant

difference in the mean depression scores of the three caregiver groups.

DISCUSSION

This paper reports an examination of data for three caregiver groups (husbands,

wives, or daughters) at risk for depression. It was hypothesized that wives were at

highest risk followed by husbands and daughters. The results of analyses performed to

30

test this hypothesis did not support differences in mean levels of depression among the
groups.

A review of the literature revealed that four variables were frequently associated
with depression: caregiver age, health, duration of care and care demands. It was found
that only two of these variables had significant effects on the level of depression:
caregiver health and care demands. The main finding, however, is that, in the care of the
dementia patient, caregiver relationship to patient does not seem to be an important
factor. This finding came as a surprise, because previous studies involving mostly non-
dementia patients had shown differences in depression by caregiver relation. A possible
explanation is that dementia is so overwhelming that perhaps other variables become less
important in their impact on depression with the exception of care demands and caregiver
health. Such findings strongly suggest that perhaps caregiver depression levels may be
decreased if respite care or other community resources are utilized to assist the primary
caregiver with delivery of care thus minimizing care demands.

No significant relationship was found between duration of care and depression
scores despite its central place in the theoretical model of caregiver adaptation. This
finding is consistent with the studies of Draper, et al. (1992) and Kielcolt-Glaser, et al.
(1991). This may be attributed partly to measurement error which is affected by the
vague onset of dementia symptomatology and the subjective, self reported length of care
in years. Since dementia is an insidious, progressive illness, one may have difficulty
identifying the start of caregiving due to the ambiguity of the disease onset. Another
contributing factor is the mis-specification of the relationship between duration of care

and depression. Although the statistical model assumed a linear relationship, it is likely

31

that any relationship between duration of care and depression (if it exists) is non-linear.
Depression does not necessarily worsen as duration of care increases. It may, in fact, be
that depression level is highest at the initial caregiving period, in the middle, or at the end
when the patient is in the terminal phase of the illness and the caregiver has exhausted all
resources as well as physical and emotional strength.

The DSM-IV criteria for depression have been listed in this study. However, in
comparing the DSM-IV, a diagnostic tool, with the revised 15 item CES-D Scale, a
screening tool, it is particularly interesting to note that all items in the DSM-IV have been
addressed by the 15 item CES-D except for "suicidal" intent. This may have purposely
been omitted by the original author of the CES-D Scale due to the ethical and legal
implications to the health care professional. The CES-D Scale was developed to focus on
the assessment of depressive "mood". However, individuals with high CBS-D scores may
not always be suicidal. Higher CES-D scores may correlate with higher depression risk
but it is not an accurate indicator for the severity index of depression.

A key concept which may explain the null finding in levels of depressive
symptomatology among wife, husband and daughter caregivers is the fact that husbands
have more external support when in a caregiving situation. Society does not generally
view men as care takers, thus when they do take on the role, more sympathy from
relatives and other support systems result in greater assistance. Without this increased
support in comparison to wife and daughter caregivers, it is conceivable that husbands
may actually experience even higher depression levels. In contrast, the female caregiver
may not be viewed as needing assistance since the role "comes naturally" to them and

society expects the wife to care for her husband. If the wife is unable to assume this

32

"duty", the daughter is usually the next expected caregiver. In this study, the majority of
female caregivers are at high risk for depressive symptomatology.

In conclusion, while there were no statistically significant differences in the levels
of depression among wife, husband, or daughter caregivers, two significant findings
remain:

1) the average depression scores among all of these dementia caregivers is

high compared to the general population and points to clinical
depression (CES-D=18 in daughters, 19 in spouses)

2) high care demands explain part of the reason for increased depressive

symptomatology

Implications for Advanced Nursing Practice & Primary Care

Caregiving for the dementia patient is not something most people typically are
socialized to desire or seek. However, confronted with the need for care, family members
most often rise to the occasion due to various reasons. Some become caregivers by
default: they are female or unemployed outside the home (Aneshensel, et al., 1993).
Some are initially reluctant or resentful but later become dedicated to the role. However,
there are those who are committed initially, but wanes eventually, due to tremendous
stress. Regardless of how caregivers are channeled into the role, the data in this study
suggest that more than half succmnb to depression.

In any population in which CBS-D scores are at 60% greater than or equal to 16,

the recognized cut off point for clinical depression risk, APNS in primary care must be

33

vigilant in identifying caregivers at risk. As an assessor, the APN should utilize the 15
item CES-D Scale in screening for depression risk, evaluate the family's perception of the
situation, coping mechanisms and care demands, as well as identify which types of
supportive care must be implemented to assist the caregiver. It is important for the APN
to provide ongoing, supportive treatment for both patient and caregiver with regular
monitoring and periodic reassessment of the caregiving situation (Barnes, et al., 1992).

As the coordinator of care, the APN must respond promptly to all caregivers
presenting with specific or nonspecific somatic complaints through medical intervention,
psychotherapy and referral to support groups. Another option is to encourage the
caregiver to utilize respite care, a short term, intermittent care to provide rest from the
burden of sustained caregiving. Regular and planned rest should be provided in order to
maintain a fulfilling social and family life thus helping maintain their own identity.
Expedient intervention for these individuals is of utmost importance in order to preserve
emotional equilibrium within the home, therefore, enhancing caregiver adaptation and
quality of care provision for the elderly dementia patient.

It may also be beneficial to begin the intervention process using the emotion
focused approach first (stress management, relaxation techniques professional counseling,
support from family and friends). The data in this study suggests that although care
demands in the dementia case contained hands on tasks, the cognifitive deficit portion is
subjective and is not amenable to problem focused approach. The dual nature of this
variable cannot be properly addressed without utilizing the emotion focused approach.

In general, most caregivers may benefit from stress management, relaxation technique,

referral to support groups, professional counseling and a supportive network of friends

34

and relatives which is the goal of the emotion focused approach. Using both approaches
in concert may prove to be effective in the APN management of the depressed caregiver.
The ultimate goal for the caregiver is to maintain emotional wellness, therefore,

decreasing the rate of early extended care facility placement of the elderly.

Limitations of Research

There are several limitations to the current study that should be noted. First, the
samples were part of a convenient sampling process from support group agencies. These
individuals were seeking external assistance and have already acknowledged a degree of
psychological distress with their mere presence in the support group. The sample does
not include isolated caregivers (those not seeking outside support), who for the most part,
may need help the most or may have a much lower true prevalence of depression.

A second limitation of this study is its ethnically homogeneous, small sample.
Results may be quite different if the sample included better representation from other
ethnic groups such as Asians, Hispanics and African-Americans whose response to
stressful situations varies markedly.

Thirdly, it can not be known with certainty the degree to which the sample
respondents experienced depression prior to the caregiving role. It is very likely that rates
reported are inflated by their “distress factor”. This distress factor pushes people to seek
help and makes it more likely that the phenomena of interest (depression) will be present

in a detectable way (Gallagher, etal., 1989).

35

Future Studies

Future studies should focus on which resources are most beneficial to caregivers
and the effective implementation of such programs while involving representation from
the general population. Studies of APN interventions leading to successful care provision
in the home without nursing home placement would be of interest.

Care demands also deserve a deeper exploration. A search involving caregivers
with regular respite care and other agency or family support while measuring depression
may be of value. Future researchers should fru'ther investigate the total CES-D Scale
score while looking at "mood" and the somatic subscale to determine what percentage of
CES-D scores is correlated with the somatic complaints while comparing caregiver and
non-caregiver groups. Considerable research is needed on the factors that may predispose

family caregivers in the development of depression.

36

APPENDIX A

37

10.

ll.

12.

l3.

14.

15.

l6.

l7.

l8.

19.

20.

APPENDIX A

Items from the Center for Epidemiologic Studies Depression Scale (CES-D)

I was bothered by things that usually don't bother me.
I did not feel like eating; my appetite was poor.

I felt that I could not shake off the blues even with help from my family or friends.
I felt that I was just as good as other people.

I had trouble keeping my mind on what I was doing.
I felt depressed.

I felt that everything 1 did was an effort.

I felt hopeful about the future.

I thought my life had been a failure.

I felt fearful.

My sleep was restless.

I was happy.

I talked less than usual.

I felt lonely.

People were unfriendly.

I enjoyed life.

I had crying spells.

I felt sad.

I felt that people dislike me.

1 could not get "going."

Radloff, LS, (1977)

38

APPENDIX B

39

10.

11.

12.

13.

14.

15.

APPENDIX B

Revised 15 Items CES-D Scale

I was bothered by things that usually don't bother me.
I did not feel like eating; my appetite was poor.

I felt that I could not shake off the blues even with help from my family or friends.
I felt that I was just as good as other people.

I had trouble keeping my mind on what I was doing.
I felt depressed.

I felt that everything I did was an effort.

I felt hopeful about the future.

I felt fearful.

My sleep was restless.

I was happy.

I felt lonely.

I enjoyed life.

I felt sad.

I could not get "going."

Radloff, LS. (1977)
Revised by Stommel, Given, C., Given 8.,

Schultz, & McCorkle (1993)

40

APPENDIX C

41

APPENDIX C

Cognitive Deficit Scale

List of items that constitute the patient's cognitive deficit scale. The subjects were asked:
"How frequently has your relative displayed the following behaviors?" Answer categories
included "not at all" (=0), "sometimes" (=1), "most of the time" (=2), "always " (=3). The

scale includes the following 6 items: (Stommel, et a1, 1990)

 

 

Does your relative seem confused?

Does your relative forget what day it is?

Does your relative get the present mixed up with the past?
Does your relative ever forget where he/she is?

Does your relative ever forget important or recent events?

Does your relative repeat himself/herself or ask the same question over and over again?

 

Chronbach's Alpha: 0.77 (present sample of N=246)

42

 

flfl§Sflll
FAX Silky-1171

neuummfiuuhwmy
nuennuoiaumq
Quinn-am-

ASUeaaMmmeuua
alenmnvnnlu

 

MICHIGAN STATE

UNIVERSITY
April in. 1998

1'0: Manfred Starr-eel
A-230 Life Sciences Building

RE: IRES: 98-188
TITLE: DIFFERENCES IN THE LEVEL OF DEPRESSION BETWEEN
SPOUSE AND DAUGHTER CAREGIVERS OP ELDERLY
DEMENTIA PATIENTS
REVISION REQUESTED: N/A
CATEGORY: l-E
APPROVAL DATE: 04/07/98

The university Committee on Research Involving Human Subjects'iUCRIHSl
review of this preject is complete. I am pleased to advise that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this prOject and any reVisions listed
above.

RIIIIRL: UCRIKS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project be and one year must use the green renewal
form (enclosed with t e original agproval letter or when aL
preject is renewed) to seek u te certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishin to continue a project beyond the time need to submit it
again or complete reView.

RIVIsloNB: UCRIHS must review any changes in rocedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
reVise an approved protocol at an other time during the year,
send your written request to the. CRIBS Chair, requesting reVised
approval and referenCin the preject's IRB I and title.L Include
Ln ur request a descr ption of the change and any reVised
ins ruments. consent forms or advertisements that are applicable.

saosnaus/

CIANGIB: Should either of the followin arise during the course of the

work, investigators must noti UCRIHS promptly: (l) roblems

(unexpected side effects, comp aints. e c.) involving uman

subjects or 12) changes in the research environment or new

information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help. lease do not hesitate to contact us
at (517)355-2180 or FAX (51714 2- 171.

Sincerely,

  
 
  
 

     
 
 

Ph.D.

 

vid 3. N
UCRIHS Cha

Efl:bcd

right.
ir

cc: liet Santos

463

REFERENCES

44

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