Steven H. Zarit

Assessment of behavioral problems in dementia: the revised memory and behavior problems checklist.

The Revised Memory and Behavior Problems Checklist (RMBPC), a 24-item, caregiver-report measure of observable behavioral problems in dementia patients, provides 1 total score and 3 subscale scores for patient problems (memory-related, depression, and disruptive behaviors) and parallel scores for caregiver reaction. Data were obtained from 201 geriatric patients and their caregivers. Factor analysis confirmed 3 first-order factors, consistent with subscales just named, and 1 general factor of behavioral disturbance. Overall scale reliability was good, with alphas of .84 for patient behavior and .90 for caregiver reaction. Subscale alphas ranged from .67 to .89. Validity was confirmed through comparison of RMBPC scores with well-established indexes of depression, cognitive impairment, and caregiver burden. The RMBPC is recommended as a reliable and valid tool for the clinical and empirical assessment of behavior problems in dementia patients.

Interventions with care givers of dementia patients: Comparison of two approaches.

We compared the effect of two approaches, family counseling and support groups, for relieving the stress and burden experienced by care givers of dementia patients. Both treatments are designed to implement features of a stress-management model that have been identified in prior research with this population: providing information about the patients disease and its effects on behavior, teaching behavioral problem solving for managing difficult behavior, and identifying potential support for care givers. Subjects were primary care givers of dementia patients living in the community; they included husbands, wives, daughters, and other relatives. Although subjects in the treatment groups made significant gains over time, they did not differ from wait-list subjects who showed similar improvements. One-year follow-up interviews indicated that gains made during the treatment period were maintained.

Useful services for families: research findings and directions

A major tenet of gerontological practice and policy has been that community‐based services relieve stress on family caregivers and delay or prevent institutionalization of frail elders. Evidence for benefits of community‐based services is examined from four perspectives: (1) relief for family caregivers; (2) benefits to older clients; (3) delay or prevention of institutionalization; and (4) cost‐effectiveness or cost‐benefits of a service. Studies are grouped according to the type of service (in‐home respite, adult day care, overnight respite, case management and multicomponent programs) and type of clients (dementia only or mixed). There are surprisingly few empirical studies overall and the reported benefits typically are modest. Methodological problems as well as providing relatively small amounts of service may have accounted for these findings. Studies in which clients and/or their families received adequate amounts of help showed more consistently positive outcomes. There is little evidence, however, to suggest that community services delay placement. More needs to be done to examine the benefits of innovative programs, and particularly to incorporate the dementia patients perspective into these evaluations. Copyright

Who Gets What and Why? Help Middle-Aged Adults Provide to Parents and Grown Children

OBJECTIVES Middle-aged adults engage in support exchanges with generations above and below. This study investigated (a) how support to one generation is associated with support to the other and (b) factors accounting for whether parents or offspring receive more support in a family. METHODS Middle-aged adults aged 40-60 years (N = 633) completed telephone interviews regarding their relationships and support exchanges with each grown child and living parent. RESULTS Multilevel models revealed that most participants provided more support to the average grown child than to the average parent. Yet, a proportion of the sample reversed this pattern, providing more support to parents. Mediation models revealed that middle-aged adults provided greater support to offspring because they viewed offspring as more important than parents and offspring had greater everyday needs (e.g., being a student, not married). Parental disability accounted for greater support to parents. DISCUSSION Discussion integrates solidarity theory, developmental stake, and contingency theory. Most middle-aged adults provide more to grown offspring than to parents, consistent with their greater stake in their progeny. Middle-aged adults also respond to crises (i.e., parental disability) and everyday needs (i.e., offspring student status) in providing intergenerational support, in accordance with contingency theory.

Incontinence Among Elderly Community-Dwelling Dementia Patients: Characteristics, Management, and Impact on Caregivers

Incontinence was identified by 36% of 184 caregivers as a problem in their care of older community‐dwelling patients with dementia. Incontinent dementia patients had greater impairment of cognitive function and more frequent behavioral problems than did patients without incontinence. Burden scores were higher among caregivers of incontinent patients, but multiple regression analyses indicated that factors other than incontinence contributed more to perceived burden. Follow‐up interviews revealed that incontinence had played an important role in most decisions to institutionalize among caregivers of patients who were placed in a nursing home between interviews; it rarely, however, was the primary reason. The majority of incontinent patients still residing in the community were being managed by nonspecific techniques such as diapers and toileting schedules. These data emphasize the need to educate community caregivers of dementia patients in the appropriate management of incontinence and the need for further research on methods of effectively targeting assessment and treatment strategies to this patient population.

Hospital-Diagnosed Dementia and Suicide: A Longitudinal Study Using Prospective, Nationwide Register Data

OBJECTIVE The current study aims to examine the risk of suicide in persons diagnosed with dementia during a hospitalization and its relationship to mood disorders. DESIGN Event-history analysis using time-varying covariates. SETTING Population-based record linkage. PARTICIPANTS All individuals aged 50+ living in Denmark (N=2,474,767) during January 1, 1990 through December 31, 2000. MEASUREMENTS Outcome of interest is suicide. Relative risks are calculated based on person-days spent in each stratum. RESULTS A total of 18,648,875 person-years were observed during the 11-year study period. During this period, 136 persons who previously had been diagnosed with dementia died by suicide. Men and women aged 50-69 years with hospital presentations of dementia have a relative suicide risk of 8.5 (95% confidence interval: 6.3-11.3) and 10.8 (95% confidence interval: 7.4-15.7), respectively. Those who are aged 70 or older with dementia have a threefold higher risk than persons with no dementia. The time shortly after diagnosis is associated with an elevated suicide risk. The risk among persons with dementia remains significant when controlling for mood disorders. As many as 26% of the men and 14% of the women who died by suicide died within the first 3 months after being diagnosed whereas 38% of the men and 41% of the women died more than 3 years after initial dementia diagnosis. CONCLUSIONS Dementia, determined during hospitalization, was associated with an elevated risk of suicide for older adults. Preventive measures should focus on suicidal ideation after initial diagnosis but also acknowledge that suicides can occur well after a dementia diagnosis has been established.

Current Research Issues in Caregiving to the Elderly

Caregivers for dependent elders have been the subject of numerous studies in recent years. This first wave of research demonstrates that caregiving is demanding and may be expensive to the caregiver socially, psychologically, physically, and financially. This article reviews the caregiving literature and focuses on current limitations and future directions for study in two areas: sampling and research design. Specifically suggested are ways to refine sampling procedures and to more carefully define what a caregiver is. In the design of caregiving studies, both group and individual differences offer insight into the impact of caregiving. In addition, dyadic measurement of the caregiver, the elder, and the family are suggested. Finally, in examining a progressive phenomenon such as Alzheimers disease or memory loss, longitudinal designs are necessary and timely.

Respite for Dementia Caregivers: The Effects of Adult Day Service Use on Caregiving Hours and Care Demands

The objective of this study was to determine whether adult day service use was related to decreases in primary caregiving hours (i.e., the time caregivers spent on activities of daily living/instrumental activities of daily living and behavior problems for care recipients) and care recipient function for these domains. Three-month longitudinal data from the Adult Day Care Collaborative Study (N = 400) were used. Adult day service users reported greater decreases in hours spent on behavior problems when compared to nonusers, even after controlling for baseline differences between the two groups. In addition, adult day service users reported decreased frequency of behavior problems in their relatives who attended adult day programs. The findings suggest that adult day services, if used over time, are effective in restructuring caregiving time and may offer potential benefits not only to family caregivers but to community-residing older adults who have dementia as well.

Formal and informal support: the great divide.

As we approach the next century, it is clear that neither formal services nor informal family caregivers can meet the needs of a growing population. It is therefore pertinent to reconceptualize the linkages between formal and informal care and move towards an integrative model. This paper explores several models of such an interface that exist in the literature and proposes that many of these overlap. Various predictors of formal service use are also explored, with an emphasis on the outcomes of both the informal caregiver and the care recipient. Implications for future research include further exploring and understanding the link between formal and informal support and the need to increase receipt of formal care among family caregivers. Copyright

EARLY COGNITIVE MARKERS OF THE INCIDENCE OF DEMENTIA AND MORTALITY: A LONGITUDINAL POPULATION-BASED STUDY OF THE OLDEST OLD

This study examines whether cognitive markers at prior examinations are indicative of subsequent dementia and mortality. The sample was composed of subjects aged 84–90 at baseline who were reexamined three times over a 6‐year period on a comprehensive biobehavioral battery. Dementia was evaluated at each examination using DSM–III‐R criteria. Results indicated that incident cases of dementia had lower cognitive scores both 2 and 4 years prior to diagnosis, compared to non‐demented survivors. Evidence for terminal decline was also found, as people who subsequently died also had lower cognitive performance at prior examinations, compared to non‐demented survivors. The findings suggest that mild cognitive dysfunction is an important clinical finding among the oldest old and may herald either the onset of dementia or mortality.