Raeanne C. Moore

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 Alzheimers 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.

Activity Restriction and Depression in Medical Patients and their Caregivers: A Meta Analysis

Depression commonly occurs in conjunction with a variety of medical conditions. In addition, family members who care for patients with medical diagnoses often suffer from depression. Therefore, in addition to treating illnesses, physicians and other healthcare professionals are often faced with managing secondary mental health consequences. We conducted a systematic review and meta-analysis of the association between activity restriction and depression in medical patients and their caregivers. A total of 34 studies (N = 8053) documenting the relationship between activity restriction and depression were identified for the period between January 1980 and June 2010. Effect sizes were calculated as Pearson r correlations using random-effects models. The correlation between activity restriction and depression was positive and of large magnitude (r = 0.39; 95% CI, .34-0.44). Activity restriction was most strongly correlated with depression in medical patients (r = 0.45; 95% CI, 0.42-0.48), followed by caregivers (r = 0.34; 95% CI, 0.28-0.41) and community-dwelling adults (r = 0.28; 95% CI, 0.25-0.31). Activity restriction associated with medical conditions is a significant threat to well-being and quality of life, as well as to the lives of their caregivers. Assessment and treatment of activity restriction may be particularly helpful in preventing depression.

Ecological momentary assessment versus standard assessment instruments for measuring mindfulness, depressed mood, and anxiety among older adults

As mobile data capture tools for patient-reported outcomes proliferate in clinical research, a key dimension of measure performance is sensitivity to change. This study compared performance of patient-reported measures of mindfulness, depression, and anxiety symptoms using traditional paper-and-pencil forms versus real-time, ambulatory measurement of symptoms via ecological momentary assessment (EMA). Sixty-seven emotionally distressed older adults completed paper-and-pencil measures of mindfulness, depression, and anxiety along with two weeks of identical items reported during ambulatory monitoring via EMA before and after participation in a randomized trial of Mindfulness-Based Stress Reduction (MBSR) or a health education intervention. We calculated effect sizes for these measures across both measurement approaches and estimated the Number-Needed-to-Treat (NNT) in both measurement conditions. Study outcomes greatly differed depending on which measurement method was used. When EMA was used to measure clinical symptoms, older adults who participated in the MBSR intervention had significantly higher mindfulness and significantly lower depression and anxiety than participants in the health education intervention at post-treatment. However, these significant changes in symptoms were not found when outcomes were measured with paper-and-pencil measures. The NNT for mindfulness and depression measures administered through EMA were approximately 25-50% lower than NNTs derived from paper-and-pencil administration. Sensitivity to change in anxiety was similar across administration modes. In conclusion, EMA measures of depression and mindfulness substantially outperformed paper-and-pencil measures with the same items. The additional resources associated with EMA in clinical trials would seem to be offset by its greater sensitivity to detect change in key outcome variables.

A case-controlled study of successful aging in older HIV-infected adults.

OBJECTIVE There is a growing public health interest in the aging human immunodeficiency virus (HIV)-infected (HIV+) population, although there is a dearth of research on successful aging with HIV. This study aimed to understand the risk and protective factors associated with self-rated successful aging (SRSA) with HIV. DESIGN Cross-sectional, case-controlled. SETTING HIV Neurobehavioral Research Program and the Stein Institute for Research on Aging at University of California, San Diego. PARTICIPANTS Eighty-three community-dwelling HIV+ and 83 demographically matched HIV-uninfected (HIV-) individuals, enrolled between December 1, 2011, and May 10, 2012, mean age of 59 years, primarily white men, 69% with acquired immune deficiency syndrome (AIDS), who had been living with an HIV diagnosis for 16 years. Diagnostic criteria for HIV/AIDS were obtained through a blood analysis. MEASUREMENTS Participants provided ratings of SRSA, the primary outcome measure, as part of a comprehensive survey that included measures of physical and emotional functioning and positive psychological traits. Relationships between how the different variables related to SRSA were explored. RESULTS While SRSA was lower in the HIV+ individuals than their HIV- counterparts, 66% of adults with HIV reported scores of 5 or higher on a 10-point scale of SRSA. Despite worse physical and mental functioning and greater psychosocial stress among the HIV+ participants, the 2 groups had comparable levels of optimism, personal mastery, and social support. Higher SRSA in HIV+ individuals was associated with better physical and emotional functioning and positive psychological factors, but not HIV disease status or negative life events. CONCLUSIONS Successful psychosocial aging is possible in older HIV+ individuals. Positive psychological traits such as resilience, optimism, and sense of personal mastery have stronger relationship with SRSA than duration or severity of HIV disease. Research on interventions to enhance these positive traits in HIV+ adults is warranted.

Cognitive Complaints Correlate With Depression Rather Than Concurrent Objective Cognitive Impairment in the Successful Aging Evaluation Baseline Sample

Objective: Whether subjective cognitive complaints are suggestive of depression or concurrent cognitive impairment in older adults without dementia remains unclear. The current study examined this question in a large (N = 1000), randomly selected, community-based sample of adults aged 51 to 99 years without a formal diagnosis of dementia (Successful AGing Evaluation [SAGE] study). Methods: The modified Telephone Interview for Cognitive Status (TICS-m) measured objective cognitive function, the Cognitive Failures Questionnaire (CFQ) measured subjective cognitive complaints, and the 9-item Patient Health Questionnaire (PHQ-9) measured depression. Spearman ρ correlations and linear regression models were conducted to examine the relationship among variables in the baseline SAGE sample. Results: There was a weak association between TICS-m and CFQ scores (ρ = −.12); however, a moderate to large association was observed for CFQ and PHQ-9 (ρ = .44). Scores on the CFQ were not associated with TICS-m scores (β = −.03, P = .42) after controlling for PHQ-9 and variables of interest, such as age, gender, ethnicity, and physical functioning, while PHQ-9 was significantly associated with CFQ scores (β = .46, P < .001) after controlling for variables of interest. Conclusions: Subjective cognitive complaints are more likely related to symptoms of depression rather than concurrent cognitive impairment in a large cross-section of community-dwelling adults without a formal diagnosis of dementia.

A randomized clinical trial of Behavioral Activation (BA) therapy for improving psychological and physical health in dementia caregivers: results of the Pleasant Events Program (PEP).

Dementia caregiving is associated with elevations in depressive symptoms and increased risk for cardiovascular diseases (CVD). This study evaluated the efficacy of the Pleasant Events Program (PEP), a 6-week Behavioral Activation intervention designed to reduce CVD risk and depressive symptoms in caregivers. One hundred dementia family caregivers were randomized to either the 6-week PEP intervention (N = 49) or a time-equivalent Information-Support (IS) control condition (N = 51). Assessments were completed pre- and post-intervention and at 1-year follow-up. Biological assessments included CVD risk markers Interleukin-6 (IL-6) and D-dimer. Psychosocial outcomes included depressive symptoms, positive affect, and negative affect. Participants receiving the PEP intervention had significantly greater reductions in IL-6 (p = .040), depressive symptoms (p = .039), and negative affect (p = .021) from pre- to post-treatment. For IL-6, clinically significant improvement was observed in 20.0% of PEP participants and 6.5% of IS participants. For depressive symptoms, clinically significant improvement was found for 32.7% of PEP vs 11.8% of IS participants. Group differences in change from baseline to 1-year follow-up were non-significant for all outcomes. The PEP program decreased depression and improved a measure of physiological health in older dementia caregivers. Future research should examine the efficacy of PEP for improving other CVD biomarkers and seek to sustain the interventions effects.

Self-Efficacy Buffers the Relationship Between Dementia Caregiving Stress and Circulating Concentrations of the Proinflammatory Cytokine Interleukin-6

OBJECTIVE the proinflammatory cytokine interleukin (IL)-6 has been linked with health morbidity, particularly risk for cardiovascular disease (CVD). The purpose of this study was to investigate the potential protective role of coping self-efficacy on the relationship between caregiving stress and circulating concentrations of IL-6. METHODS a total of 62 elderly caregivers of patients with Alzheimers disease (mean age: 74 years) were assessed for plasma concentrations of IL-6, caregiving-related overload, and coping self-efficacy. Multiple regression was used to examine the main effects of stress and self-efficacy, as well as the interaction between stress and self-efficacy, in predicting plasma IL-6 after controlling for age, gender, resting blood pressure, and obesity. RESULTS there was a significant interaction between stress and self-efficacy in predicting IL-6. Post-hoc examination indicated that when self-efficacy was low, stress was significantly related to IL-6 (β = 0.43). However, when self-efficacy was high, stress was not significantly related to IL-6 (β = -0.10). CONCLUSION caregiving stress in combination with low coping self-efficacy is significantly related to IL-6, a known risk marker for health morbidity, particularly CVD. However, stress was not associated with IL-6 with high self-efficacy. Although limited and preliminary, these results point to a potential protective effect of self-efficacy on caregiver health that can be tested in longitudinal studies.

Complex interplay between health and successful aging: role of perceived stress, resilience, and social support.

Psychological and psychosocial resources, including resilience and social support, have traditionally been studied in the context of the stress paradigm and, more recently, in the context of successful aging. This study used moderated mediation analyses to examine the role of perceived stress in the relationships between physical and mental health functioning and self-rated successful aging (SRSA) and whether differences between people in level of resilience and social support changes the role of perceived stress in these relationships. A cross-sectional study of 1,006 older adults (mean age: 77 years) completed scales addressing SRSA, physical and mental health functioning, perceived stress, resilience, and social support. Results indicated that the strength of relationships between both physical and mental health functioning and SRSA were reduced after accounting for variation in level of perceived stress. The role of perceived stress in the association between mental health functioning and SRSA was found to be stronger among participants with the highest levels of resilience, and the influence of perceived stress on the degree of relationship between physical health functioning and SRSA was stronger among those with greatest social support. These findings suggest that interventions to reduce perceived stress may help break the link between disability and poor well-being in older adults. The findings further suggest that the impact of such interventions might differ depending on psychological resources (i.e., resilience) for mental health disabilities and external resources (i.e., social support) for those with physical health problems. The complex interplay of these factors should be taken into account in clinical settings.

Influence of Caregiver Burden on the Association Between Daily Fluctuations in Pleasant Activities and Mood: A Daily Diary Analysis

Much research has focused on behavioral activation and its effect on depression, but less is known about the effects of leisure activities on the two distinct affective domains of depression: positive affect (PA) and negative affect (NA). Furthermore, individual factors (i.e., stress level) may moderate the impact of behavioral activation on affect. The present study utilized a daily diary approach to examine the moderating effect of stress on the relationship between leisure satisfaction and both PA and NA. Twenty-five dementia caregivers completed activity and affect measures four times daily for 14 days. Results were analyzed using multilevel modeling, an approach that considers intra-individual differences in activity and affect over time. Results supported the hypothesis that caregivers with higher burden display a stronger association between leisure satisfaction and affect than caregivers with lower burden. Specifically, caregivers with higher burden had a stronger positive relationship between leisure satisfaction and PA and a stronger negative relationship between leisure satisfaction and NA. These findings suggest that screening caregivers for level of burden may help identify those most likely to benefit from behavioral interventions.

The relationship between self-efficacy and resting blood pressure in spousal Alzheimer's caregivers.

OBJECTIVE To examine whether high levels of self-efficacy for problem-focused coping were significantly related to several resting BP measures in spousal Alzheimers disease caregivers. DESIGN Cross-sectional. METHODS Participants included 100 older caregivers (mean age = 73.8 ± 8.14 years) providing in home care for a spouse with Alzheimers disease. All participants completed a 13-item short form of the Coping Self-Efficacy Scale and underwent an in-home assessment where a visiting nurse took the average of three serial BP readings. Multiple regression was used to examine the relationship between self-efficacy and mean arterial pressure (MAP), systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) after controlling for age, gender, smoking history, body mass index, the care recipients clinical dementia rating, diabetes, alcohol use, and the use of antihypertensive medications. RESULTS Overall, high levels of self-efficacy for problem-focused coping were associated with lower MAP, SBP, and PP. Self-efficacy for problem-focused coping was marginally associated with resting DBP, but not significant. In addition, we conducted secondary analyses of the other two self-efficacy scales to explore the relationship between each dimension and MAP. We found that there were no significant relationships found between MAP and self-efficacy for stopping unpleasant thoughts/emotions or self-efficacy for getting social support. CONCLUSIONS The present study adds to the current body of literature by illustrating the possibility that higher self-efficacy can have physiological advantages, perhaps by buffering chronic stresss impact on resting BP. Another contribution of the current study is its attempt to understand the role of each individual component of self-efficacy. These findings invite future research to investigate whether caregivers might experience cardiovascular benefits from interventions aimed at enhancing self-efficacy.