Susan K. Roepke

A Review of the Psychobiology of Dementia Caregiving: A Focus on Resilience Factors

The recent aging trend in the United States has resulted in exponential growth in the number of informal dementia caregivers. Caring for a family member with dementia has been associated with negative health outcomes that are likely related to physiologic changes resulting from stress. However, caregiving is not always associated with health morbidity. In this review, we highlight resilience factors that appear to have a beneficial relationship with health outcomes. Specifically, we highlight 11 studies that examined the relationship of one of three broad resilience domains (personal mastery, self-efficacy, and coping style) to caregiver health outcomes. Our main findings were that higher levels of personal mastery and self-efficacy, and increased use of positive coping strategies appear to have a protective effect on various health outcomes in dementia caregivers. Continued research is warranted to help guide prospective directions for caregiver interventions focusing on increasing caregiver resilience and the corresponding impact on caregiver health.

A comparison of psychosocial outcomes in elderly Alzheimer caregivers and noncaregivers.

OBJECTIVE To conduct an analysis of the stress, coping, and mood consequences of Alzheimer caregiving. DESIGN Cross-sectional. SETTING Community-based study. PARTICIPANTS Sample included 125 Alzheimer caregivers and 60 demographically similar older adults with nondemented spouses (i.e., noncaregivers). MEASUREMENTS We compared caregivers and noncaregivers on stress, coping, and mood outcomes. We also examined antidepressant use within the caregiver sample. An emphasis was placed upon effect size differences, including Cohens d as well as more clinically meaningful effect sizes. RESULTS Caregivers were significantly more likely to endorse depressive symptoms and to meet clinically significant cutoff for depression (40% for caregivers; 5% for noncaregivers). Approximately 25% of caregivers reported taking antidepressant medication, although 69% of these continued to experience significant symptoms of depression. Caregivers also utilized fewer positive coping and greater negative coping strategies than noncaregivers. CONCLUSION The number of caregivers will increase dramatically over the next two decades, and caregivers will likely seek care from primary care providers. We provide an overview of the psychological issues facing caregivers so that effective screening and treatment may be recommended.

Association Between Chronic Caregiving Stress and Impaired Endothelial Function in the Elderly

OBJECTIVES We examined the relationship between chronic caregiving stress and endothelial function. BACKGROUND Evidence suggests that caregiving stress is associated with pathophysiologic processes related to atherosclerosis. Endothelial dysfunction is a possible underlying mechanism explaining the relationship between caregiving stress and cardiovascular morbidity. We investigated the relationship between chronic caregiving stress and endothelial dysfunction assessed by reactive hyperemia-induced flow-mediated dilation (FMD). METHODS Seventy-eight elderly individuals participated in the study. Fifty-five were providing in-home care to a spouse with Alzheimers disease, and 23 were married and living with a healthy, nondemented spouse. Analysis of covariance was used to examine the relationships between advancing dementia severity (Clinical Dementia Rating scores) and FMD and nitroglycerin-induced vasodilation of the brachial artery. Multiple linear regression was used to examine the relationship between years of caregiving and FMD. RESULTS Clinical Dementia Rating scale scores were significantly related to FMD (p = 0.033), with participants caring for a spouse with moderate to severe dementia showing significantly worse FMD than those caring for a spouse with mild dementia (p = 0.028) and noncaregivers (p = 0.032). Within the caregiver sample, the number of years of caregiving was significantly related to FMD (r = -0.465, p < 0.001). CONCLUSIONS These results suggest that the chronic stress of caregiving is associated with impaired endothelial function, which may be a potential mechanistic link to the observed increased risk of cardiovascular disease in elderly caregivers.

Effects of Alzheimer caregiving on allostatic load.

This study aimed to determine if Alzheimer caregivers have increased allostatic load compared to non-caregivers. Potential psychological moderators (mastery, depression, and role overload) of the relationship between caregiving status and allostatic load were also explored. Eighty-seven caregivers and 43 non-caregivers underwent biological assessment of allostatic load and psychological assessments. Caregivers had significantly higher allostatic load compared to non-caregivers ( p < .05). Mastery, but not depression or overload, moderated the relationship between caregiving status and allostatic load. In conclusion, allostatic load may represent a link explaining how stress translates to downstream pathology, but more work is necessary to understand the role of psychological factors.

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.

Personal mastery is associated with reduced sympathetic arousal in stressed Alzheimer caregivers.

OBJECTIVES Spousal caregivers of Alzheimers disease patients are at increased risk for cardiovascular disease, possibly via sympathetic response to stressors and subsequent catecholamine surge. Personal mastery (i.e., belief that one can manage lifes obstacles) may decrease psychological and physiological response to stressors. This study examines the relationship between mastery and sympathetic arousal in elderly caregivers, as measured by norepinephrine (NE) reactivity to an acute psychological stressor. DESIGN Cross-sectional. SETTING Data were collected by a research nurse in each caregivers home. PARTICIPANTS Sixty-nine elderly spousal Alzheimer caregivers (mean age: 72.8 years) who were not taking beta-blocking medication. INTERVENTION After assessment for mastery and objective caregiving stressors, caregivers underwent an experimental speech task designed to induce sympathetic arousal. MEASUREMENTS Mastery was assessed using Pearlins Personal Mastery scale and Alzheimer patient functioning was assessed using the Clinical Dementia Rating Scale, Problem Behaviors Scale, and Activities of Daily Living Scale. Plasma NE assays were conducted using pre- and postspeech blood draws. RESULTS Multiple regression analyses revealed that mastery was significantly and negatively associated with NE reactivity (B = -9.86, t (61) = -2.03, p = 0.046) independent of factors theoretically and empirically linked to NE reactivity. CONCLUSIONS Caregivers with higher mastery had less NE reactivity to the stressor task. Mastery may exert a protective influence that mitigates the physiological effects of acute stress, and may be an important target for psychosocial interventions in order to reduce sympathetic arousal and cardiovascular stress among dementia caregivers.

A Longitudinal Analysis of the Relations Among Stress, Depressive Symptoms, Leisure Satisfaction, and Endothelial Function in Caregivers

OBJECTIVE Stress and depressive symptoms have been associated with impaired endothelial function as measured by brachial artery flow-mediated dilation (FMD), possibly through repeated and heightened activation of the sympathetic nervous system. Behavioral correlates of depression, such as satisfaction with leisure activities (i.e., leisure satisfaction), may also be associated with endothelial function via their association with depressive symptoms. This study examined the longitudinal associations between stress, depressive symptoms, leisure satisfaction, and endothelial function as measured by FMD. METHOD Participants were 116 older Alzheimers caregivers (M age = 74.3 ± 8.1; 68% women; 87% white) who underwent 3 yearly assessments of FMD, stress, depressive symptoms, and leisure satisfaction. Mixed-regression analyses were used to examine longitudinal relationships between constructs of interest. RESULTS A significant and positive association was found between leisure satisfaction and FMD (p = .050), whereas a negative relationship was found for stress (p = .017). Depressive symptoms were not associated with FMD (p = .432). Time (p < .001) and the number of years caregiving (p = .027) were also significant predictors of FMD, suggesting that FMD decreased over time and was worse the longer a participant had been a caregiver prior to study enrollment. CONCLUSIONS These results suggest that behavioral correlates of depression (i.e., engagement in pleasurable activities) may be related to endothelial function in caregivers, and behavioral treatments for depression may be particularly useful in improving cardiovascular outcomes in caregivers.

Toward a More Complete Understanding of the Effects of Personal Mastery on Cardiometabolic Health

OBJECTIVE A great deal of research has been devoted to identifying the psychological factors that might be associated with reduced risk for cardiovascular diseases. In particular, coping resources such as personal mastery might attenuate stress-related pathophysiology. The purpose of the present review was to examine the existing literature reporting associations between personal mastery and cardiometabolic health outcomes to determine which outcomes have been studied to date, investigate the extent of inconsistency in the literature, and propose new directions for research. DESIGN Systematic review of articles examining the associations between personal mastery and cardiometabolic health. MAIN OUTCOME MEASURES Studies were included if they examined objective measures of cardiometabolic function, cardiovascular events, and/or mortality. RESULTS Thirty-two studies were identified examining the effect of mastery on the following outcomes: mortality and/or cardiovascular events, psychoneuroendocrine stress systems, cardiovascular reactivity to acute stress, metabolic dysregulation, inflammation/coagulation, and evidence of large vessel disease from imaging methods. CONCLUSIONS Overall, mastery was associated with better cardiometabolic health and reduced risk for disease and/or death, typically with a small-medium effect size. A relatively small proportion of studies reported contradictory findings that higher mastery was associated with poorer cardiometabolic outcomes. The state of the current research suggests that future investigations should focus on 1) clarifying the mediators and moderators most relevant in the association between mastery and downstream disease, 2) testing the association between mastery and biological outcomes longitudinally, 3) examining the physiological impact of mastery-increasing interventions, and 4) studying the relationship between mastery and disease risk in diverse ethnic or sociocultural groups.

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.