ORIGINAL ARTICLE
Comprehensive analysis of patient and caregiver predictors for caregiver burden, anxiety and depression in Alzheimer’s disease Qing Lou, Shuling Liu, Ya Ruth Huo, Mengyuan Liu, Shuai Liu and Yong Ji
Aims and objectives. The primary aim of this study was to examine the correlations between patient and caregiver characteristics with caregiver burden, anxiety and depression in Alzheimer’s Disease. Secondary aim was to determine which behavioural and psychological symptoms had the greatest impact on caregiver burden, anxiety and depression in Alzheimer’s Disease. Background. Caregivers of individuals with Alzheimer’s Disease experience high levels of burden, both psychologically and physically. Previous studies have examined caregiver burden, anxiety and depression separately. However, no paper has examined these three psychological conditions simultaneously. Design. A cross-sectional design. Methods. A total of 310 patients with probable Alzheimer’s Disease and their primary caregivers were assessed. Cognitive impairment and neuropsychiatric symptoms were assessed with the Mini Mental State Examination, Montreal Cognitive Assessment, Clock Drawing Test and Neuropsychiatric Inventory, respectively. Caregiver burden, anxiety and depression were assessed with the ZBI, Generalised Anxiety Disorder Scale-7 and Patient Health Questionnaire-9, respectively. Results. All 12 neuropsychiatric symptoms in the Neuropsychiatric Inventory were significantly correlated with caregiver burden, anxiety and depression, with the top three neuropsychiatric predictors being depression, apathy and anxiety. Furthermore, higher levels of caregiver anxiety were associated with a longer duration of being a caregiver. Within caregivers, higher levels of depression were independently associated with higher numbers of additional caregivers, lower educational background and being the spouse of the patient. Higher levels of burden were associated with a longer duration of being a caregiver and being the spouse of the patient. Caregiver burden, anxiety or depression were not significantly correlated with hours/day of caring for the patient.
Authors: Qing Lou, BS, RN, Head Nurse, Department of Neurology, Tianjin Huanhu Hospital and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin; Shuling Liu, MSN, RN, Nurse, Department of Neurology, Tianjin Huanhu Hospital and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin, China; Ya Ruth Huo, MSN, Student, School of Medicine, University of New South Wales, Kensington, NSW, Australia; Mengyuan Liu, MSN, Researcher, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin; Shuai Liu, BS, RN, Nurse, Department of Neurology, Tianjin Huanhu Hospital, Tianjin; Yong
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What does this paper contribute to the wider global clinical community?
• Caregivers of individuals with
•
Alzheimer’s disease (AD) experience high levels of burden, both psychologically and physically. Our study can help practitioners be able to identify caregivers at risk for burden, anxiety and depression. Improving our understanding of caregiver stress in dementia will facilitate the future identification and management of these individuals.
Ji, PhD, MD, Director, Department of Neurology, Tianjin Huanhu Hospital, and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin, China Correspondence: Yong Ji, Director, Department of Neurology, and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Qixiangtai Road 122, Hexi District, Tianjin 300060, China. Telephone: +8613612048681. E-mail: [email protected] Shuling Liu and Qing Lou contributed equally to this work.
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2668–2678, doi: 10.1111/jocn.12870
Original article
Predictors of AD caregiver burden and emotion
Conclusions. Caregiver burden, anxiety and depression were significantly correlated with different neuropsychiatric symptoms in the Neuropsychiatric Inventory. Relevance to clinical practice. Practitioners are able to identify caregivers at risk for burden, anxiety and depression. Understanding which Neuropsychiatric Inventory symptom is more closely associated with distress in caregivers will help practitioners to be more specific and effective in detecting caregiver distress.
Key words: Alzheimer’s disease, caregiver burden, China, neuropsychiatric Accepted for publication: 1 March 2015
Introduction By 2030, exponential increases in dementia rates are predicted to lead to 66 million affected individuals worldwide and parallel increases in the number of carers and cost of care (Wortmann 2012). The gradual progressive impairment and behavioural symptoms that may emerge in the course of Alzheimer’s disease (AD) usually lead to relatives acting as informal caregivers. Caregiving not only causes higher levels of stress, depression and use of psychotropic drugs, it also has negative health consequences for both caregivers and patients (Clipp & George 1990, Irwin et al. 1997, Schulz & Beach 1999).Thus, it has become imperative to identify caregiver and patient predictors for caregiver burden, anxiety and depression. Identification and treatment of risk factors for caregiver stress will improve the quality of life for both patients and their caregivers, delay nursing home admission and reduce the significant social and economic cost of providing care to people with dementia (Schulz & Beach 1999, Suehs et al. 2014).
Background Among the many symptoms associated with dementia, the presence of neuropsychiatric symptoms such as disinhibition, hallucinations, depression and agitation is one of the most significant predictors of caregiver burden, anxiety and depression (Deimling & Bass 1986, Pruchno & Resch 1989, Zanetti et al. 1998, Rocca et al. 2010, Garcia-Alberca et al. 2013). These results have been confirmed in studies with caregivers from different cultural backgrounds (Pang et al. 2002). Although all of these studies have found an association between Neuropsychiatric Inventory (NPI) scores and caregiver burden, there are conflicting results regarding which of the 12 neuropsychiatric symptoms is most correlated with caregiver burden, anxiety and depression. In addition to patient factors, caregiver factors such as age, the number of years caring for the patient, educa-
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2668–2678
tion and relationship with the patient have also been found to be correlated with caregiver burden, anxiety and depression (Zanetti et al. 1998, Garre-Olmo et al. 2002, Rocca et al. 2010). Understanding the specific behavioural and psychological symptoms associated with greatest caregiver distress will assist health practitioners identify those caregivers at greatest risk. Previous studies have examined caregiver burden, anxiety and depression separately. To our knowledge, our paper is the first that will examine these three psychological conditions simultaneously. One could combine results from studies that assessed burden, anxiety and depression separately, but variance in patient characteristics across studies would reduce the validity of the combined data. Furthermore, it is not appropriate to assume that the same factor(s) cause the greatest caregiver burden, anxiety and depression. Determining which patient and caregiver factors affect caregiver burden, anxiety and depression is essential because treatment varies substantially; for example, between anxiety and depression. The main goal of this study is to improve our understanding of the patient-dependent causes of caregiver stress to facilitate the easier identification and management of these caregivers.
Method The primary aim of this study was to examine the correlations between patient and caregiver characteristics with caregiver burden, anxiety and depression in AD. The secondary aim of this study was to determine which behavioural and psychological symptoms had the greatest impact on caregiver burden, anxiety and depression in AD. From January 10, 2010 to June 1, 2014, 310 consecutive patients diagnosed with probable AD and their caregivers were selected from the Alzheimer’s Clinic of Tianjin Huanhu Neurological Hospital. This clinic is the only one available in central Tianjin, and as a result, is the largest and most specialised. A team of three AD specialist nurses and three registered neurologists assessed all patients and their
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Q Lou et al.
caregivers. Caregivers who were paid or who interacted with patients
Comprehensive analysis of patient and caregiver predictors for caregiver burden, anxiety and depression in Alzheimer’s disease Qing Lou, Shuling Liu, Ya Ruth Huo, Mengyuan Liu, Shuai Liu and Yong Ji
Aims and objectives. The primary aim of this study was to examine the correlations between patient and caregiver characteristics with caregiver burden, anxiety and depression in Alzheimer’s Disease. Secondary aim was to determine which behavioural and psychological symptoms had the greatest impact on caregiver burden, anxiety and depression in Alzheimer’s Disease. Background. Caregivers of individuals with Alzheimer’s Disease experience high levels of burden, both psychologically and physically. Previous studies have examined caregiver burden, anxiety and depression separately. However, no paper has examined these three psychological conditions simultaneously. Design. A cross-sectional design. Methods. A total of 310 patients with probable Alzheimer’s Disease and their primary caregivers were assessed. Cognitive impairment and neuropsychiatric symptoms were assessed with the Mini Mental State Examination, Montreal Cognitive Assessment, Clock Drawing Test and Neuropsychiatric Inventory, respectively. Caregiver burden, anxiety and depression were assessed with the ZBI, Generalised Anxiety Disorder Scale-7 and Patient Health Questionnaire-9, respectively. Results. All 12 neuropsychiatric symptoms in the Neuropsychiatric Inventory were significantly correlated with caregiver burden, anxiety and depression, with the top three neuropsychiatric predictors being depression, apathy and anxiety. Furthermore, higher levels of caregiver anxiety were associated with a longer duration of being a caregiver. Within caregivers, higher levels of depression were independently associated with higher numbers of additional caregivers, lower educational background and being the spouse of the patient. Higher levels of burden were associated with a longer duration of being a caregiver and being the spouse of the patient. Caregiver burden, anxiety or depression were not significantly correlated with hours/day of caring for the patient.
Authors: Qing Lou, BS, RN, Head Nurse, Department of Neurology, Tianjin Huanhu Hospital and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin; Shuling Liu, MSN, RN, Nurse, Department of Neurology, Tianjin Huanhu Hospital and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin, China; Ya Ruth Huo, MSN, Student, School of Medicine, University of New South Wales, Kensington, NSW, Australia; Mengyuan Liu, MSN, Researcher, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin; Shuai Liu, BS, RN, Nurse, Department of Neurology, Tianjin Huanhu Hospital, Tianjin; Yong
2668
What does this paper contribute to the wider global clinical community?
• Caregivers of individuals with
•
Alzheimer’s disease (AD) experience high levels of burden, both psychologically and physically. Our study can help practitioners be able to identify caregivers at risk for burden, anxiety and depression. Improving our understanding of caregiver stress in dementia will facilitate the future identification and management of these individuals.
Ji, PhD, MD, Director, Department of Neurology, Tianjin Huanhu Hospital, and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Tianjin, China Correspondence: Yong Ji, Director, Department of Neurology, and Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Huanhu Hospital, Qixiangtai Road 122, Hexi District, Tianjin 300060, China. Telephone: +8613612048681. E-mail: [email protected] Shuling Liu and Qing Lou contributed equally to this work.
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2668–2678, doi: 10.1111/jocn.12870
Original article
Predictors of AD caregiver burden and emotion
Conclusions. Caregiver burden, anxiety and depression were significantly correlated with different neuropsychiatric symptoms in the Neuropsychiatric Inventory. Relevance to clinical practice. Practitioners are able to identify caregivers at risk for burden, anxiety and depression. Understanding which Neuropsychiatric Inventory symptom is more closely associated with distress in caregivers will help practitioners to be more specific and effective in detecting caregiver distress.
Key words: Alzheimer’s disease, caregiver burden, China, neuropsychiatric Accepted for publication: 1 March 2015
Introduction By 2030, exponential increases in dementia rates are predicted to lead to 66 million affected individuals worldwide and parallel increases in the number of carers and cost of care (Wortmann 2012). The gradual progressive impairment and behavioural symptoms that may emerge in the course of Alzheimer’s disease (AD) usually lead to relatives acting as informal caregivers. Caregiving not only causes higher levels of stress, depression and use of psychotropic drugs, it also has negative health consequences for both caregivers and patients (Clipp & George 1990, Irwin et al. 1997, Schulz & Beach 1999).Thus, it has become imperative to identify caregiver and patient predictors for caregiver burden, anxiety and depression. Identification and treatment of risk factors for caregiver stress will improve the quality of life for both patients and their caregivers, delay nursing home admission and reduce the significant social and economic cost of providing care to people with dementia (Schulz & Beach 1999, Suehs et al. 2014).
Background Among the many symptoms associated with dementia, the presence of neuropsychiatric symptoms such as disinhibition, hallucinations, depression and agitation is one of the most significant predictors of caregiver burden, anxiety and depression (Deimling & Bass 1986, Pruchno & Resch 1989, Zanetti et al. 1998, Rocca et al. 2010, Garcia-Alberca et al. 2013). These results have been confirmed in studies with caregivers from different cultural backgrounds (Pang et al. 2002). Although all of these studies have found an association between Neuropsychiatric Inventory (NPI) scores and caregiver burden, there are conflicting results regarding which of the 12 neuropsychiatric symptoms is most correlated with caregiver burden, anxiety and depression. In addition to patient factors, caregiver factors such as age, the number of years caring for the patient, educa-
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 2668–2678
tion and relationship with the patient have also been found to be correlated with caregiver burden, anxiety and depression (Zanetti et al. 1998, Garre-Olmo et al. 2002, Rocca et al. 2010). Understanding the specific behavioural and psychological symptoms associated with greatest caregiver distress will assist health practitioners identify those caregivers at greatest risk. Previous studies have examined caregiver burden, anxiety and depression separately. To our knowledge, our paper is the first that will examine these three psychological conditions simultaneously. One could combine results from studies that assessed burden, anxiety and depression separately, but variance in patient characteristics across studies would reduce the validity of the combined data. Furthermore, it is not appropriate to assume that the same factor(s) cause the greatest caregiver burden, anxiety and depression. Determining which patient and caregiver factors affect caregiver burden, anxiety and depression is essential because treatment varies substantially; for example, between anxiety and depression. The main goal of this study is to improve our understanding of the patient-dependent causes of caregiver stress to facilitate the easier identification and management of these caregivers.
Method The primary aim of this study was to examine the correlations between patient and caregiver characteristics with caregiver burden, anxiety and depression in AD. The secondary aim of this study was to determine which behavioural and psychological symptoms had the greatest impact on caregiver burden, anxiety and depression in AD. From January 10, 2010 to June 1, 2014, 310 consecutive patients diagnosed with probable AD and their caregivers were selected from the Alzheimer’s Clinic of Tianjin Huanhu Neurological Hospital. This clinic is the only one available in central Tianjin, and as a result, is the largest and most specialised. A team of three AD specialist nurses and three registered neurologists assessed all patients and their
2669
Q Lou et al.
caregivers. Caregivers who were paid or who interacted with patients
