Rosalie A. Kane

The longitudinal effects of early behavior problems in the dementia caregiving career

Using multiregional, 3-year data from early career dementia caregivers, this study determines how behavior problems that occur early in the caregiving career influence time to nursing home placement and change in burden and depression over time. A Cox proportional hazards model indicated that caregivers who managed frequent behavior problems earlier are more likely to institutionalize. After controlling for important time-varying covariates in a series of growth-curve models, caregivers who were faced with severe, early behavior problems reported greater increases in burden and depression over the 3-year study period. The findings suggest the need to consider experiences early in the dementia caregiving career when accounting for key longitudinal outcomes and also emphasize the importance of attrition when attempting to model the health implications of informal long-term care over time.

Caregiver burden from a social exchange perspective: Caring for older people after hospital discharge

Using data from a sample of Medicare beneficiaries and their caregivers (n = 829 dyads), we examine caregiver burden through the lens of social exchange theory, conceptualizing burden as an evaluative component or outcome of the ongoing exchange relationship between the care receiver and the caregiver. We find burden is affected by the context in which the exchange occurs, which varies by the role relationship of dyad members (spouses, adult children, or extended family and nonfamily), as well as the level of need of the care receiver, the living arrangements, and the life course timing of care provision. Gerontological research has focused heavily on the demands of caring for elderly relatives, in particular the distress and burden that these demands place on their caregivers (Biegel & Blum, 1990; Dwyer & Coward, 1992; Young & Kahana, 1989). In much of this work, caregiver burden has been conceptualized first as a contemporaneous aspect of the caregiver-care-receiver dyad and second as a one-way process. Thus, in this literature, burden is the caregivers time-limited reaction to caring for another. Burden is viewed both as the direct consequence of providing assistance to an older relative (Montgomery, Gonyea, & Hooyman, 1985; Stull, Koloski, & Kercher, 1994) and as a direct cause of some care-receiver outcomes such as admission to a nursing home (Aneshensel, Pearlin, & Schuler, 1993; McFall & Miller, 1992; Zarit, Reever, & Bach-Peterson, 1980). We argue that caregiver burden be conceptualized as part of a reciprocal relationship that is not time limited. Looking at caregiver burden through the lens of social exchange theory, we view burden as an indicator of the ongoing exchange relationship in a caregiving dyad. The social exchange perspective provides an avenue for framing and applying a dynamic view of burden, and it responds to the challenge that gerontological research move toward theory-based explanations (Bengtson, Burgess, & Parrott, 1997; Dwyer & Coward, 1992; Kramer, 1997). We apply social exchange theory to an examination of the relative contributions of patient need, provision of informal care, receipt of formal care, perceptions of isolation, living arrangements, and life course timing to burden that are perceived by caregivers of older people who went home from the hospital and required help. The differential impact of these factors on burden will likely be tempered by ongoing relationships between members of the exchange dyad: that is, by whether the caregiver is a spouse, a child, a member of the extended family, or not a family member. SOCIAL EXCHANGE THEORY The four core assumptions of social exchange theory, described by Molm and Cook (1995), are as follows: People depend on one another for the things they value, people behave in ways that increase the outcomes they value and decrease outcomes they do not value, people engage in ongoing, mutually contingent exchanges with specific partners over time, and all outcomes obey a principle of satiation-that is, diminishing marginal utility or, conversely, increasing marginal costs. Once an outcome is achieved or acquired, its value and desirability decreases, especially at the upper thresholds. To illustrate, when only a small amount of care is required and this care does not interfere with other responsibilities and routines, small additions of time and tasks performed will be unlikely to have much of an impact on feelings of burden. However, if a great deal of care is needed that pushes the level of care the individual feels physically and emotionally capable of providing and if the demands of providing care spill over to other areas of the caregivers life, every additional need or request may be sorely felt and have a big impact on the caregivers perception of burden. The concepts of power and dependence are central to social exchange theory (Molm, 1991: Molm & Cook, 1995). …

Variation in State Spending for Long-Term Care: Factors Associated with More Balanced Systems

Pressures to turn over responsibility for long-term care to the states will exacerbate the already sizable difference in such efforts. This article describes the nature of the interstate variation in the types and amounts of long-term care provided under Medicaid. The average Medicaid long-term care expenditure on persons sixty-five years and older varies from

S/HMOs, the second generation: building on the experience of the first Social Health Maintenance Organization demonstrations.

2,720 in New York to

Family Care for Older Adults with Disabilities: Toward More Targeted and Interpretable Research.

380 in Arizona. Likewise, payments for home and community-based services (HCBS) vary from

Staff training and turnover in Alzheimer special care units: comparisons with non-special care units.

1,180 in New York to

Use of Mental Health Care by Community‐Dwelling Older Adults

29 in Mississippi. Only a modest portion (28 percent) of the variance in total long-term care expenditures appears to be related to differences in population characteristics, and even less (7 percent) appears to be related to differences in HCBS expenditures. When supply factors (e.g., nursing home beds) are added, the explained variance increases to 52 percent and 17 percent, respectively. Medicare replaces some--but not most--of the difference in Medicaid home and community-based services payments.

Adult foster care for the elderly in Oregon: a mainstream alternative to nursing homes?

ocial Health Maintenance Organizations (SMMOs) are S milestones in the quest for improved and better integrated systems of acute care and long-term care (LTC). As part of a long-lived demonstration program implemented at four sites in the mid 1980s, S/HMO leaders were involved heavily in fashioning technology for LTC in managed care. In 1991, while the evaluation of SMMOs was still in progress, Congress reaffirmed its enthusiasm to continue S/HMOs and stipulated that new S/HMOs be created. In January 1995, the Health Care Financing Administration (HCFA) awarded planning grants to six prospective second generation S/HMOS.~ These projects are now engaged in developing their plans, including their benefit structures and rates. Like their predecessors, the second generation S/HMOs are intended to demonstrate the integration of acute care and LTC within a capitated managed-care framework. The second generation differs from the first, however, in several key respects: ( 1 ) Rather than controlling for adverse selection by proportional enrollment at various impairment levels, they will establish reimbursement rates based on the individual members impairment and illness profile at time of enrollment and annually thereafter. An enrollees reimbursement rate will not change during each year if an enrollees status changes (as occurred with S/HMO I); rather, the rate will apply for the full enrollment year. (2 ) They have committed to clinical as well as financial integration. Building upon the experience of the first SMMOs, they are planning state-ofthe-art geriatric health care programs, which will apply, as appropriate, to all enrollees, not just those who use LTC. (3) The projects are committed to coordinating the acute care with a set of flexible, user-friendly, efficient LTC services. (4) Sites plan a special emphasis on serving underrepresented groups, including rural, Medicaid, and minority populations.

Perceived Need for Mental Health Care Among Community-Dwelling Older Adults

Family care of the elderly is key to the long-term care system, and its importance has led to an abundance of research over the past two decades. Several methodological and substantive issues, if addressed, could create even more targeted and interpretable research. The present review critically examines methodological topics (i.e., definitions of family caregiving, measurement of caregiving inputs) and conceptual issues (i.e., family involvement in long-term residential settings, and the care receivers perspective on care) that have received insufficient attention in the caregiving literature. Throughout this review recommendations are offered to improve these areas and advance the state of the art.

Beyond labels : nursing home care for Alzheimer's disease in and out of special care units

Nursing facility staff may not be properly trained to deal with behavioral symptoms of Alzheimers disease. We collected data about specialized dementia training and turnover among licensed nurses and nursing assistants in 400 nursing units in 124 Minnesota nursing facilities. Staff training may affect the retention of paraprofessional and professional nursing staff. A diversity of training methods, including workshops or seminars, films or videos, outside consultants, reading materials, training manuals, in-house experts, role playing techniques, or an orientation program for new staff, might be used to develop more effective training programs and reduce rates of nursing assistant turnover.