Anticipating an Easier Day: Effects of Adult Day Services on Daily Cortisol and Stress.

PURPOSE OF THE STUDY: Family caregivers experience high levels of stress that place them at risk for poor health outcomes. We explore whether an intervention which lowers caregivers' daily exposure to stressors, adult day services (ADS), leads to improved regulation of the stress hormone, cortisol, which has implications for health and well-being. DESIGN AND METHODS: Participants (N = 158) were family caregivers of individuals with dementia (IWD) who were using ADS. Eligibility included: the IWD had a dementia diagnosis, IWD used ADS at least twice a week, and IWD and caregiver lived in the same household. A within-subject treatment design was used to compare caregivers' diurnal cortisol responses on days they received the intervention (ADS use by the IWD) and days they did not. Participants completed daily interviews over eight consecutive days and provided five saliva samples on each of those days. Primary outcomes were salivary cortisol awakening response (CAR) and cortisol area under the curve with respect to ground (AUC-G). RESULTS: Caregivers with a "burned-out" or flattened CAR, and associated low AUC-G on non-ADS days displayed a more normative CAR and AUC-G response on ADS days. Restored cortisol regulation was also observed on ADS days among caregivers with the highest CAR and AUC-G levels on non-ADS days. IMPLICATIONS: Results indicate that ADS use improves caregivers' cortisol regulation, which could enhance long-term health outcomes. Effects may be due to caregivers' anticipation of an easier day when the IWD attends ADS.

Resistiveness to care during assistance with activities of daily living in non-institutionalized persons with dementia: associations with informal caregivers' stress and well-being.

OBJECTIVES: Resistiveness to care (RTC) refers to behavior problems that co-occur during assistance with activities of daily living (ADL). RTC are considered challenging, but are mostly studied in institutions with implications for patients and formal caregivers. RTC is associated with agitation, but agitation is considered a separate construct. Detection of RTC may be left out of common assessments of persons with dementia in studies of informal caregiving (e.g. global assessments of dementia behavioral symptoms, standard assessments of ADL function). This study examines how RTC (frequency and caregivers' stress appraisals of RTC) is related to caregivers' well-being. METHOD: 234 caregivers of people with dementia reported care receivers' ADL impairment (eating, bathing, dressing), RTC frequency (of eating, bathing dressing), and their stress appraisals of these behaviors (RTC appraisals). Caregivers also self-reported their role overload, role captivity, and depressive symptoms. Hierarchical linear regression models included independent variables (demographics, ADL impairment, RTC frequency, RTC appraisals) with three separate dependent variables (overload, captivity, depressive symptoms). RESULTS: Two-thirds of informal caregivers reported RTC. Care recipients' ADL impairment was associated with caregiver outcomes, but only before RTC was entered into the models. RTC frequency significantly predicted caregivers' overload, captivity, and depression. RTC appraisals predicted overload and captivity. CONCLUSION: RTC is common in persons with dementia residing at home, and RTC has more negative association with informal caregivers' well-being than assistance with ADL. Adding RTC frequency and appraisal items to standard ADL measures may better estimate caregivers' needs and risk, and identify modifiable environmental features by assessing behavioral symptoms in context.

Daily stressors and adult day service use by family caregivers: effects on depressive symptoms, positive mood, and dehydroepiandrosterone-sulfate.

OBJECTIVE: This study examines effects of daily use of adult day service (ADS) programs by caregivers of individuals with dementia (IWD) on a salivary biomarker of stress reactivity, dehydroepiandrosterone-sulfate (DHEA-S), and whether these effects on DHEA-S are associated with daily variability in positive mood and depressive symptoms. METHODS: We used a daily diary design of 8 consecutive days with alternation of intervention (ADS) and nonintervention days to evaluate within- and between-person effects of the intervention. Family caregivers (N = 151) of IWD who were using ADS were interviewed daily by telephone at home. Saliva samples were collected from caregivers five times a day for 8 consecutive days and were assayed for DHEA-S. Daily telephone interviews assessed daily stressors and mood. RESULTS: DHEA-S levels were significantly higher on days after ADS use. Daily DHEA-S levels covaried significantly with daily positive mood but not with depressive symptoms. CONCLUSION: These results demonstrate an association of ADS use by family caregivers and higher DHEA-S levels on the next day. Prior research has found that higher DHEA-S levels are protective against the physiologic damaging effects of stressor exposure and may reduce risks of illness. Regular use of ADS may help reduce depletion of DHEA-S and allow the body to mount a protective and restorative response to the physiologic demands of caregiving. To our knowledge, this is the first study to examine DHEA-S levels across the day in connection with an intervention that affected daily exposure to stressors.

The effects of adult day services on family caregivers' daily stress, affect, and health: outcomes from the Daily Stress and Health (DaSH) study.

PURPOSE: We examine the effects of use of adult day service (ADS) by caregivers of individuals with dementia (IWD) on daily stressors, affect, and health symptoms. Participants were interviewed for 8 consecutive days. On some days, the IWD attended an ADS program and on the other days caregivers provide most or all of the care at home. METHODS: Participants were 173 family caregivers of IWDs using an ADS program. Daily telephone interviews assessed care-related stressors, noncare stressors, positive events, affect, and health symptoms. Multilevel models with data nested within persons were used to examine effects of ADS use on daily stressor exposure, affect, and health symptoms. RESULTS: Caregivers had lower exposure to care-related stressors on ADS days, more positive experiences, and more noncare stressors. ADS use lowered anger and reduced the impact of noncare stressors on depressive symptoms. IMPLICATIONS: The findings demonstrate that stressors on caregivers are partly lowered, and affect is improved on ADS days, which may provide protection against the effects of chronic stress associated with caregiving.

Fidelity and acceptability of an adaptive intervention for caregivers: an exploratory study.

OBJECTIVE: There has been growing interest in providing tailored or adaptive interventions to family caregivers as a way of addressing their heterogeneity of risk factors and other needs. A particular challenge in an adaptive study is to implement the individualized intervention protocol as planned (program fidelity). This study explores the fidelity of implementation of an adaptive intervention for family caregivers of persons with dementia and its acceptability to caregivers. METHOD: Using a sample of 35 caregivers of person with dementia who participated in a program development study, we gathered information on acceptability and fidelity of the program from multiple sources, including caregiver and counselor reports and ratings of recordings of sessions. RESULTS: Findings show that caregivers have high levels of acceptance of the intervention plan and high ratings of satisfaction with the program. Ratings of satisfaction and counselor competence were not associated with the amount of treatment provided. Ratings by counselors and independent raters found good fidelity for two of the three program domains. DISCUSSION: The results demonstrate that trained counselors can follow a tailored intervention plan and that caregivers' experience of the program did not differ depending on how much intervention was provided. A next step is to determine how an adaptive protocol would affect caregiver outcomes.

Kin relationship of caregivers and people with dementia: stress and response to intervention.

OBJECTIVE: This study examined the effects of kin relationship on response to use of adult day services (ADS) on feelings of overload, depressive symptoms, and positive affect for family caregivers of people with dementia. METHODS: The sample consisted of 341 participants drawn from two studies of ADS. The studies used a quasi-experimental design, comparing family caregivers enrolling their care receiver with dementia in an ADS program to a control group not using ADS. Using multilevel model analysis, we examined the main and interaction effects of kin relationship (wife vs. daughters/daughters-in-law), intervention (ADS vs. non-ADS users), and time (baseline, 3 months, and 12 months) on overload, depressive symptoms, and positive affect. RESULTS: Kin relationship affected the response to intervention but in a somewhat different way for each outcome measure. For depressive symptoms, both wives and daughters using ADS had lower scores over time compared to controls. Both wives and daughters using ADS had lower feelings of overload over time, but daughters had a greater decline and wives' scores on this measure dropped only to the level found among controls. For positive affect, wives using ADS showed a considerable decline over time. CONCLUSIONS: These findings suggest that kin relationship is an important moderator of caregivers' response to intervention and warrant more attention both in the design and evaluation of interventions with family caregivers.

Effects of adult day care on daily stress of caregivers: a within-person approach.

UNLABELLED: OBJECTIVES. This article examined exposure to and appraisal of care-related stressors associated with use of adult day services (ADS) by family caregivers of individuals with dementia. METHODS: Using a within-person withdrawal design (A-B-A-B), we compared caregivers' exposure to and appraisal of behavior problems on days their relative attended and did not attend ADS. Participants were 121 family caregivers enrolling a relative with dementia in an ADS program. Daily assessments were obtained prior to the person's attending ADS for the first time and after 1 and 2 months of attendance on days the person attended and did not attend ADS. RESULTS: Total exposure to stressors and stress appraisals decreased significantly over time on ADS days compared with non-ADS days. Most of this difference was accounted by the time the person with dementia was away from the caregiver, but there were also significant reductions in behavioral problems during the evening and improved sleep immediately following ADS use. DISCUSSION. ADS use lowered caregivers' exposure to stressors and may improve behavior and sleep for people with dementia on days they have ADS. The study highlights how a within-person design can identify the effects of an intermittent intervention, such as ADS.

The structure of risk factors and outcomes for family caregivers: implications for assessment and treatment.

PURPOSE: We examined the associations among risk factors (e.g., behavioral problems, family conflict) and outcomes (e.g., overload, depression) commonly used in the research literature in order to inform the design of caregiver assessment and interventions. METHODS: A sample of 67 caregivers caring for a family member in the middle stages of dementia were assessed on 15 risk factors and six outcome measures. RESULTS: Risk factors were at best only moderately correlated with one another, suggesting their relative independence. Outcome measures showed somewhat higher correlations with one another, but participants varied in terms of the number and type of outcomes that were elevated. Multivariate results showed that risk factors differed in their contribution to models, predicting various outcomes. IMPLICATIONS: Caregivers possess unique combinations of risk factors and outcomes that suggest the need for individualized or tailored interventions. Designing an effective caregiver assessment and corresponding targeted intervention requires careful planning and selection of appropriate risk factors and outcomes.

The caregiver stress process and health outcomes.

OBJECTIVE: The authors examine the impact of two caregiving stressors, care receivers' behavior problems (an objective stressor) and caregivers' feelings of overload (a subjective stressor), on three dimensions of caregiver health. METHOD: The participants were 234 primary caregivers of elderly relatives with dementia living in the community who completed a comprehensive interview about their current care situation, including stressors and health. RESULTS: Higher levels of both objective and subjective stressors were associated with all three dimensions of caregiver health: poorer self-reported health, more negative health behaviors, and greater use of health care services. The association between objective stressors and health was mediated by caregivers' feelings of overload. CONCLUSIONS: These findings demonstrate caregivers' vulnerability to the effects of stressors across three dimensions of health and also underscore the importance of subjective appraisals of stress.

Impact of adult day services on behavioral and psychological symptoms of dementia.

PURPOSE: This study explored whether adult day service (ADS) use was associated with reductions in behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia. DESIGN AND METHODS: We used a quasi-experimental design to compare a group of 133 persons with dementia (PWDs) who initially enrolled in an ADS program to a control group not using these services (n = 68). Caregivers used a 24-hour log on multiple, consecutive days to report on five domains of BPSD. RESULTS: We used growth-mixture modeling techniques to model change in the BPSD domains over a 2-month period as well as to handle the preponderance of zeros that were inherent in the data. Results showed a relationship between ADS use and caregivers' report of fewer nighttime sleep-related problems for their PWDs. We found trends for other domains, specifically depressive symptoms and agitated behavior, but no significant group differences emerged for these and the other domains. IMPLICATIONS: The findings of ADS use on PWDs' duration of nighttime sleep problems provide some evidence of the benefits of ADS; the findings also support its utility as part of the continuum of care for PWDs and their caregivers. For other behavior domains, enhanced or more targeted behavioral strategies coupled with ADS might offer caregivers and their PWDs the best possible combination for ameliorating BPSD.

Life on the edge: patterns of formal and informal help to older adults in the United States and Sweden.

OBJECTIVE: Our objective in this study was to compare assistance received by individuals in the United States and Sweden with characteristics associated with low, moderate, or high 1-year placement risk in the United States. METHODS: We used longitudinal nationally representative data from 4,579 participants aged 75 years and older in the 1992 and 1993 waves of the Medicare Current Beneficiary Survey (MCBS) and cross-sectional data from 1,379 individuals aged 75 years and older in the Swedish Aging at Home (AH) national survey for comparative purposes. We developed a logistic regression equation using U.S. data to identify individuals with 3 levels (low, moderate, or high) of predicted 1-year institutional placement risk. Groups with the same characteristics were identified in the Swedish sample and compared on formal and informal assistance received. RESULTS: Formal service utilization was higher in Swedish sample, whereas informal service use is lower overall. Individuals with characteristics associated with high placement risk received more formal and less informal assistance in Sweden relative to the United States. DISCUSSION: Differences suggest formal services supplement informal support in the United States and that formal and informal services are complementary in Sweden.

Behavioral and psychological symptoms of dementia: the effects of physical activity at adult day service centers.

Adult day services (ADS) are an increasingly popular option for caregivers of people with dementia, but there is little research on the effects of activities on the behavior and mood of the client. This study examines participation by 94 individuals in different types of adult day-care activities and their association with changes in behavior and psychological symptoms of dementia (BPSD) for the client during a three-month span. Three domains of BPSD were examined: restless behaviors, mood behaviors, and positive behaviors. Using growth curve modeling, results show that the restless and mood behavior domains, on average, were stable over three months, whereas positive behaviors increased. For all three behavior domains there were individual differences in average level of BPSD. Average rate of change for individuals also varied from the mean for restless and mood behaviors. Physical activities, social activities, engaging activities, and watching and listening activities, along with a day-care dosage variable, were used as covariates to explain these individual differences in change. Engaging activities explained some of the individual variance for restless behaviors; as individuals increased one increment in engaging activities, they had fewer restless behavior problems over time. These results suggest that some features of programming may be related to improvements in restless behavior.

Memory Club: a group intervention for people with early-stage dementia and their care partners.

PURPOSE: Diagnosis of dementia in its early stages presents a window of opportunity for examining the immediate and long-term consequences of the illness at a point when the individual with memory loss can still participate in decision making. DESIGN AND METHODS: Memory Club is a 10-session group program designed to provide information about memory loss and resources for coping with it in an emotionally supportive atmosphere for people with dementia and their care partners. Memory Club sessions are structured so that dyads meet together, as well as separately with other care partners and people with dementia, respectively. This approach allows for time for the dyad to talk together about issues in a supportive setting, and for the people in the same role (person with dementia or the care partner) to share experiences with one another. RESULTS: A preliminary evaluation indicated that people with dementia and their care partners rated Memory Club very positively. IMPLICATIONS: Facing an inevitable decline, persons with early-stage dementia and their care partners found it helpful to talk with one another and with peers in the same circumstances about the disease and its effects.

Exploring assistance in Sweden and the United States.

PURPOSE: Few international comparisons of health services are performed using microlevel data. Using such data, this paper compares the need for and receipt of assistance with activities of daily living (ADLs) in comparable samples in the United States and Sweden, a country with a universal system of community-based services. DESIGN AND METHODS: Data from national surveys of community residents completed at approximately the same time in each nation are used to create comparable measures of need and assistance. Descriptive and logistic regression analyses compare need and assistance patterns across the nations and identify individual factors that explain receipt of assistance and unmet needs. RESULTS: Our results indicate that a simple story of greater use of paid formal services in Sweden and more unpaid informal use in the United States masks a more complex relationship. Assistance with ADLs seems to be more targeted in Sweden; narrow differences in assistance widen considerably when the analysis is limited to those reporting need. IMPLICATIONS: Although these two different health systems result in similar levels of overall ADL assistance, a detailed microlevel comparison reveals key distinctions. Further microlevel comparisons of access, cost, and quality in cross-national data can further aid our understanding of the consequences of health policy.