Amanda Leggett

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

OBJECTIVES This study examines the association of daily cortisol with depressive mood and anger. METHOD Depressive mood, anger and 2 markers of cortisol, area under the curve (AUC), and cortisol awakening response (CAR) were examined for caregivers (N = 164) of individuals with dementia (IWDs) across 8 days, some of which IWDs attended an adult day service (ADS) program. Caregivers were primarily female (86.7%) with a mean age of 61.99. First, multilevel models were run with CAR and AUC each as separate covariates of anger and depressive mood. A second set of models examined contextual factors of caregivers (i.e., care-related stressors and amount of ADS use) were added to the models for anger and depressive mood (Model 2). RESULTS On days where caregivers had AUCs below their average they expressed higher anger scores. However in Model 2, anger was associated with more care-related stressors, but not ADS use or daily cortisol. Caregivers who on average had smaller CARs were more likely to be depressed. In Model 2, depressed mood was associated with more care-related stressors and a low average CAR. DISCUSSION We found that hypocortisol patterns, reflective of chronic stress experienced by caregivers, are associated with negative mood.

The Impact of Sleep Disturbance on the Association Between Stressful Life Events and Depressive Symptoms

OBJECTIVES Sleep problems are common across the adult life span and may exacerbate depressive symptoms and the effect of common risk factors for depressive symptoms such as life stress. We examine sleep disturbance as a moderator of the association between stressful life events and depressive symptoms across five waves (25 years) of the nationally representative, longitudinal American Changing Lives Study. METHOD The sample includes 3,597 adults aged 25 years or older who were surveyed up to five times over 25 years. Multilevel models were run to examine between- and within-person variability in sleep disturbance and life event stress as predictors of depressive symptoms, and an interaction to test sleep disturbance as a moderator is included in a second step. RESULTS Life events and sleep disturbance were associated with elevated depressive symptoms at the between- and within-person levels. A significant sleep disturbance by interaction of life events was found, indicating that when individuals experienced an above average number of life events and slept more restlessly than usual, they had a higher risk for depressive symptoms than individuals who experienced above average stress but slept well. DISCUSSION Sleeping restfully may allow individuals the rejuvenation needed to manage stress adaptively and reduce depressive symptom burden.

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

OBJECTIVE Sleep complaints are common among caregivers and are associated with detriments in mental and physical health. Cortisol, a biomarker of the stress process, may link sleep with subsequent health changes in caregivers. The current study examines whether sleep duration is directly associated with the cortisol awakening response (CAR), or whether it is moderated by Adult Day Services (ADS) use, an intervention found previously to influence daily CAR by reducing stressor exposure. METHOD Associations were examined in caregivers (N = 158) of individuals with dementia (IWD) on days when IWDs attended ADS and days when IWDs did not attend ADS. Data were gathered over 8 consecutive days. Caregivers were primarily female (87.3%) with a mean age of 61.59. A multilevel growth curve model tested the association of an interaction of todays ADS use and last nights sleep duration with todays CAR as the outcome. RESULTS The interaction between ADS use and within-person sleep duration was significant such that when an individual sleeps longer than their average but does not use ADS, they have a smaller or blunted CAR. On the other hand when an individual sleeps longer than their average and uses ADS, they have a higher but nonsignificant CAR. Sleeping shorter than usual was associated with a dynamic rise regardless of ADS use. CONCLUSIONS Findings indicate that ADS use moderates the association between sleep duration and CAR such that longer than average sleep is associated with blunted, dysregulated cortisol patterns only on non-ADS days.

Predictors of New Onset Sleep Medication and Treatment Utilization Among Older Adults in the United States

BACKGROUND Sleep disturbances are common among older adults resulting in frequent sleep medication utilization, though these drugs are associated with a number of risks. We examine rates and predictors of new prescription sleep medications and sleep treatments, as well as sleep treatments without a doctors recommendation. METHODS Participants were 8,417 adults aged 50 and older from two waves of the nationally representative Health and Retirement Study (HRS) who were not using a sleep medication or treatment at baseline (2006). Logistic regression analyses are run with sociodemographic, health, and mental health factors as predictors of three outcomes: new prescription medication use, sleep treatment use, and sleep treatment out of a doctors recommendation in 2010. RESULTS New sleep medication prescriptions were started by 7.68%, 12.62% started using a new sleep treatment, and 31.93% were using the treatment outside of their doctors recommendation. Common predictors included greater severity of insomnia, worsening insomnia, older age, and use of psychiatric medications. New prescription medication use was also associated with poorer mental and physical health, whereas new sleep treatment was associated with being White, higher educated, and drinking less alcohol. CONCLUSIONS Starting a new prescription sleep medication may reflect poorer health and higher health care utilization, whereas beginning a sleep treatment may reflect an individuals awareness of treatments and determination to treat their problem. Clinicians should be aware of predictors of new sleep medication and treatment users and discuss various forms of treatment or behavioral changes to help patients best manage sleep disturbance.

Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs

OBJECTIVES Explore the relationship between behavioral and psychological symptoms of dementia (BPSD; specifically, delusions, hallucinations, and agitation/aggression) and associated caregiver distress with emergency department (ED) utilization, inpatient hospitalization, and expenditures for direct medical care. DESIGN/SETTING/PARTICIPANTS Retrospective cross-sectional cohort of participants with dementia (N = 332) and informants from the Aging, Demographics, and Memory Study, a nationally representative survey of U.S. adults >70 years old. MEASUREMENTS BPSD of interest and associated informant distress (trichotomized as none/low/high) were assessed using the Neuropsychiatric Inventory (NPI). Outcomes were determined from one year of Medicare claims and examined according to presence of BPSD and associated informant distress, adjusting for participant demographics, dementia severity, and comorbidity. RESULTS Fifty-eight (15%) participants with dementia had clinically significant delusions, hallucinations, or agitation/aggression. ED visits, inpatient admissions, and costs were not significantly higher among the group with significant BPSD. In fully adjusted models, a high level of informant distress was associated with all outcomes: ED visit incident rate ratio (IRR) 3.03 (95% CI: 1.98-4.63; p < 0.001), hospitalization IRR 2.78 (95% CI: 1.73-4.46; p < 0.001), and relative cost ratio 2.00 (95% CI: 1.12-3.59; p = 0.02). CONCLUSIONS A high level of informant distress related to participant BPSD, rather than the symptoms themselves, was associated with increased healthcare utilization and costs. Effectively identifying, educating, and supporting distressed caregivers may help reduce excess healthcare utilization for the growing number of older adults with dementia.

The Association Between Benzodiazepine Use and Depression Outcomes in Older Veterans.

Benzodiazepines (BZDs) are commonly prescribed to older adults with depression, but it is unknown whether they improve antidepressant (AD) adherence or depressive symptoms. We followed 297 older veterans diagnosed with depression and provided a new AD medication prospectively for 4 months. Data include validated self-report measures and VA pharmacy records. At initial assessment, 20.5% of participants were prescribed a BZD. Those with a BZD prescription at baseline were significantly more likely than those without to have a personality disorder, schizophrenia spectrum disorder, or other anxiety disorder, and higher depressive symptom and anxiety symptom scale scores on average. In adjusted regressions, BZD use was not significantly associated with AD adherence, any improvement in depressive symptoms, or a 50% reduction in depressive symptoms. Our results suggest BZD use concurrent with AD treatment does not significantly improve depressive outcomes in older veterans.

“What Hath Night to Do with Sleep?”: The Caregiving Context and Dementia Caregivers’ Nighttime Awakenings

ABSTRACT Objectives: Care provision for persons with dementia can be rewarding yet may disrupt caregiver’s sleep health. Using the National Health & Aging Trends Study and the National Study of Caregiving, we examine care receiver and caregiver contextual factors, caregiver health and psychological wellbeing as predictors of caregivers’ nighttime awakenings. Methods: The sample for this cross-sectional study included 451 caregivers for individuals with dementia surveyed by telephone. Results: Nighttime awakenings (1 item measure of waking and not being able to return to sleep) almost every night were reported by 16% of caregivers and 10% reported that helping the care receiver caused their sleep to be interrupted most nights. In a multinomial logistic regression, caregivers’ greater nighttime awakenings were associated with caring for care recipients with higher fall risk, as well as caregiver characteristics of more chronic medical conditions and emotional difficulty of the care role. Conclusions: Emotional caregiving difficulties were associated with nighttime awakenings even accounting for caregivers’ health and care receivers’ disability. Thus, interventions improving caregiver distress may improve sleep health. Clinical implications: Clinicians should screen caregivers for nighttime awakenings so that evidence-based interventions and treatments can be implemented to prevent persistent sleep disturbances.

The effect of sleep disturbance on the association between chronic medical conditions and depressive symptoms over time

Chronic medical conditions (CMC) and sleep disturbances are common among adults and associated with depression. We tested sleep disturbance as a moderator of the effect of CMC on depressive symptoms. The sample includes 3597 adults surveyed up to five times over 25 years (1986-2012) from the nationally representative Americans Changing Lives Study (ACL). A multi-level model was estimated to examine sleep disturbance as a moderator of the CMC and depressive symptom association, with a second interaction tested for age as a moderator of the within-person level variability in CMC and depressive symptom association. Sleep disturbance and CMC were associated with depressive symptoms at the between-person level, while only sleep disturbance was associated with depressive symptoms at the within-person level. Sleep disturbance significantly interacted with CMC such that more CMCs were associated with more depressive symptoms among individuals sleeping well, but poor sleep was associated with worse depression regardless of CMC. A second interaction between age and within-person variability in CMC was found significant, suggesting that younger adults had higher symptoms of depression at times of below average CMC relative to older adults. The effect of CMC on depressive symptoms may depend on sleep as well as age. Sleeping restfully may allow individuals with CMC the rejuvenation needed to cope with illness adaptively.

Caregiving Stress and Its Toll on Health From a Psychoneuroimmunological Perspective

Purpose of ReviewThe purpose of this review was to discuss the psychological and physiological effects of caregiving stress in the general population as well as among cancer caregivers.Recent FindingsAlthough caregiving for a loved one with cancer may be shorter in duration (i.e., number of months), it is often more intense (i.e., number hours per day) than caring for individuals with other chronic illnesses because cancer treatment has shifted toward outpatient therapy and placed a significant burden of informal caregiving on families, especially spouses/partners.SummaryInformal caregiving psychologically and physiologically taxes the caregiver and may negatively influence the caregiver’s health and well-being, regardless of chronic disease population. Unique to breast cancer and other female cancer populations, males often find themselves in the caregiving role. In addition, a paucity of research examining the role of caregiving among the cancer survivorship population exists, despite it being a very real possibility that survivors may find themselves in this position, given advancements in cancer treatment.

Depressive Symptoms in Recipients of Home- and Community-Based Services in the United States: Are Older Adults Receiving the Care They Need?

OBJECTIVE To understand unmet depression needs of older adults, the current study investigates depressive symptoms, psychiatric treatment, and home- and community-based service (HCBS) use in a nationally representative sample of older adults in the United States. METHODS Participants included 5,582 adults aged 60 and over from the 2010-2012 waves of the nationally representative Health and Retirement Study. Weighted bivariate analyses were used to examine the frequency of depressive symptoms (Center for Epidemiologic Studies Depression Scale) and psychiatric treatment among HCBS recipients compared with non-HCBS recipients. Weighted logistic regression models were used to evaluate the effect of depressive symptoms on HCBS use. RESULTS HCBS recipients had a higher frequency of depressive symptoms compared with nonrecipients (27.5% versus 10.4%, respectively). In particular, transportation service recipients had the highest frequency of depressive symptoms (37.5%). HCBS recipients with depressive symptoms were no more likely than nonrecipients to receive psychiatric services. Depressive symptoms were associated with HCBS use, above and beyond sociodemographic and health risk factors. CONCLUSION Depressive symptoms are more frequent among HCBS recipients compared with nonrecipients; however, depressed HCBS recipients are no more likely to receive psychiatric services, suggesting unmet depression needs. HCBS may be a key setting for depression detection and delivery of mental health interventions.