A nursing intervention to decrease depression in family caregivers of persons with dementia

A Nursing Intervention to Decrease Depression in Family Caregivers of Persons With Dementia Kathleen C. Buckwalter, 1 Linda Gerdner, 1 Frank Kohout, 1 Geri Richards Hall, 2 Ann Kelly, 2 Beverly Richards? and Marilyn Sime 4

The goal of this study was to evaluate a community-based psychoeducational-nursing intervention designed to teach home caregivers to manage behavioral problems of persons with Alzheimer's disease and related dementias (ADRD) using the Progressively Lowered Stress Threshold (PLST) model, and to compare this intervention with routine information and referrals for case management, community-based services, and support groups. Previous caregiver studies have overwhelmingly pointed to the adverse effects of caregiving on the caregivers' physical and mental health, and high prevalence rates of depression among caregivers of persons with ADRD have consistently been reported. Therefore, a primary aim was to evaluate the impact of the intervention on caregivers' affective responses, especially depression. Data from both the Profile of Moods States and the Geriatric Depression Rating Scale support the effectiveness of this intervention in decreasing depression among caregivers who received the experimental training. Additional analysis of factors associated with caregiver depression are also reported. The pivotal role of psychiatric nurses in the assessment and treatment of depression among caregivers of persons with ADRD is discussed. Copyright © 1999 by W.B. Saunders Company

HE OVERALL GOAL OF the study reported here was to evaluate the efficacy of a community-based psychoeducational nursing intervention designed to teach home caregivers to manage behavioral problems of persons with Alzheimer's disease and related dementias (ADRD) using the Progressively Lowered Stress Threshold (PLST) model, and to compare this intervention with

T

From the College of Nursing, 1University of Iowa, Iowa City, IA; the 2Department of Nursing, Mayo Clinic, Scottsdale, AZ; the 3School of Nursing, Indiana University, Indianapolis, IA; and the 4School of Nursing, University of Minnesota, Minneapolis, MN. Address reprint requests to Kathleen C. Buckwalter, Ph.D, R.N., 234 CMAB, University of lowa, Iowa City, IA 52242. Supported by NIH grant #ROI-NR03434 to K.C. Buckwalter from the National Institute of Nursing Research. Copyright © 1999 by W.B. Saunders Company 0883-9417/99/1302-0003510. 00/0

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routine information and referrals for case management, community-based services, and support groups. Despite gaps in the literature and inconsistencies in research methods used, previous caregiver studies have overwhelmingly pointed to the adverse effects of caregiving on the caregivers' physical and mental health (Bergman-Evans, 1994; Cohen & Eisdorfer, 1988; Collins, Stommel, Wang, & Given, 1994; Schulz, Visintainer, & Williamson, 1990). High prevalence rates of depression among community-dwelling caregivers of persons with dementia have consistently been reported, ranging from 30% (Kiecolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991) to as high as 83% (Drinka, Smith, & Drinka, 1987). More commonly reported are midrange, yet significant, depression prevalence rates as noted in the following studies: 38% (Baumgarten, Battista, Infante-Rivard, Hanley,

Archives of Psychiatric Nursing, Vol. XIII,No. 2 (April), 1999: pp 80-88

DEPRESSION IN FAMILYCAREGIVERS

Becker, & Gauthier, 1992), 46% (Gallagher, Rose, Rivera, Lovett, & Thompson, 1989), 55% (Cohen & Eisdorfer, 1988), and 67% (Barusch, 1988). Confirming the magnitude of this problem, recent data from the 1997 National Family Caregivers Association Report suggest that caregivers experience a 60% increase in depression as a result of the caregiving experience. Meshefedjian, McCusker, Bellavance, and Baumgarten (1998) have argued cogently for the development and testing of caregiver interventions that are targeted at preventing and treating depression in this population, to decrease the burden associated with caregiving. Therefore, a primary aim of the study was to evaluate the impact of the psychoeducational nursing intervention on caregivers' affective responses, especially depression. Related to this aim, the following hypothesis was tested: The PLST training program in symptom presentation, care, and structured activities will increase the ability of caregivers to manage behavioral symptoms associated with ADRD, and thus positively impact on their mood and affect. CONCEPTUAL FRAMEWORK: PROGRESSIVELY LOWERED STRESS THRESHOLD MODEL

The Progressively Lowered Stress Threshold (PLST) model, first published in this journal more than a decade ago (Hall & Buckwalter, 1987), proposes that persons with dementia need environmental demands modified because of their declining cognitive and functional abilities. The model describes the increasing inability of persons with dementia to cope with stress resulting from progressive cerebral pathology and associated cognitive decline. Both environmental and internal stressors are demands that cause the person with dementia to become anxious and agitated. If stressful stimuli are allowed to continue or increase, behavior becomes increasingly dysfunctional, and often catastrophic. The PLST model suggests that reducing stress by modifying environmental demands promotes functional adaptive behavior. For purposes of this study, the model was tailored more specifically to the individual needs of caregivers in the home/community setting. To assist caregivers in understanding patient behaviors and in planning care, the PLST model addresses three dimensions and their interactions: clusters of symptoms in patients, levels of patient behaviors, and staging of the disease. Symptoms of

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dementing illnesses are conceptualized to cluster into four groups: 1) intellectual losses, 2) affective or personality losses, 3) cognative or planning losses, and 4) progressively lowered stress threshold (PLST). PLST may lead to catastrophic or purposeless behaviors, violent, agitated or anxious behaviors; wandering, confused night awakening, and compulsive repetitive behaviors; and noisy verbalizations that may foster depressive reactions in caregivers who are trying, often unsuccessfully, to deal with these difficult secondary symptoms. METHODS

Research sites for this 4-year longitudinal study were originally established in rural Iowa and Minnesota. Because no minority subjects were enrolled from these sites in the first 2 years of the project, sites in Arizona and Indiana were added in years 3 and 4 in an effort to recruit from a more diverse subject pool of caregivers who met the following criteria: 1. Be non-paid (informal) caregivers 2. Caring for an individual living in the community who has memory impairment or who has been diagnosed by a physician as having ADRD 3. Live within a 2-hour drive of the study sites 4. Provide 4 or more hours of supervision and/or care weekly 5. Have not previously been exposed to any training based on the PLST model 6. Have a Global Deterioration Score of 2 or below If several caregivers were providing equal amounts of in-home care, one was randomly selected to serve as the primary caregiver for the study. Procedures

Caregivers who met the above inclusion criteria and consented to participate were randomly assigned to either the experimental PLST training program, or to the comparison group, which received routine information, community based services, and case management/support group referral. Staging of dementing illness was determined by scores on the Global Deterioration Scale (GDS) (Reisberg, Ferris, deLeon, & Crook, 1982), which describes 7 clinically identifiable and ratable stages ranging from 1 (normal, or no cognitive decline) to 6-7 (severe cognitive decline). The GDS was

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administered to both the caregiver (for inclusion criteria) and the care recipient. At the initial interview, caregivers were asked to complete a Behavioral Assessment for Low Stimulus Care Plan (BALSCP). The BALSCE developed by G. Hall (1986), is an individualized needs assessment tool that identified problems amenable to the PLST intervention, allowed the PLST model to be tailored to each client and their caregiver, and guided subsequent teaching and careplanning. Within 2 weeks after subjects enrolled in the study and completed the baseline assessment, a research associate met with each caregiver in his or her home or other place of convenience. For participants in the experimental group, the individualized plan of care based on the PLST model was presented and practiced utilizing examples with return demonstration during the in-home sessions. The care plan was reviewed, techniques taught, and written materials summarizing the care plan were provided at the second in-home session one week later. Referrals for support groups, legal counseling, and case management services were provided as indicated. Experimental subjects received a total of approximately 3 to 4 hours of in-home intervention following baseline assessment, and biweekly follow-up phone calls from a research team member for the first 6 months of the study. Subjects in the comparison group received two in-home visits of equal intervals 2 weeks apart consisting of general information about ADRD, referral for community-based services to local support groups or case management networks, a copy of The 36 Hour Day (Mace & Rabins, 1991), a generic caregiver book, and related brochures. They participated in the same phone follow-up schedule and identical data collection protocol as experimental group members and at the conclusion

of the study were offered the opportunity to participate in the experimental (PLST) training program, and to obtain related materials. All caregivers received notebooks at the first in-home visit. Contents of the notebooks differed according to the treatment protocol but both contained overall aims of the project, plans of care, information on common behavioral problems and related interventions, as well as lists of resources and brochures on topics such as home safety, hiring helpers, and activities.

Instruments Table 1 lists the instruments used to measure caregiver affect, depression, and related variables, as well as the timetable for data collection. The Profile of Moods States (POMS) and Geriatric Depression Rating Scale (GDRS) are described in more detail below. Subjective affect. Subjective affect of the caregiver was measured by the 65-item POMS (McNair, Loft, & Droppleman, 1971), a factor analytically derived inventory that measures 6 identifiable mood or affective states: Tension-Anxiety, Depression-Dejection, Anger-Hostility, Vigor-Activity, Fatigue-Inertia, and Confusion-Bewilderment, using 5-point adjective rating scales. The POMS is reliable and valid for persons with at least a 7th grade education and is a sensitive measure of the effects of experimental manipulations. Internal consistency for the six scales ranges from .84-.95, and studies support the sensitivity of the test to variations in mood. Use of the POMS with an elderly population show a similar factor structure as with the original standardized samples (Kaye, Lawton, Gitlin, Kleban, Windsor, & Kaye, 1988). Validity is supported by high correlations between the POMS and other scales measuring emotional states. The

Table 1. Instrument Description and Data Collection "timetable Tool Consent f o r m * t Geriatric depression rating scale (Iowa only)* Global deterioration scale*t Behavioral assessment for low stimulus care plant Demographic data form* Profile of mood states*

Variable

Baseline

3 mos.

6 mos.

12 mos.

depression

X X

X

X

X

stage of disease problems amenable to PLST intervention

X X

X

X

X X

demographic, caregiving related variables that may influence outcomes mood, affective status

X

X

X

X

X

X

X

X

* = data collected from caregiver. t = data collected about patient with dementia.

DEPRESSION IN FAMILY CAREGIVERS

POMS provides information about the level of psychological discomfort experienced by caregivers and whether that level changes in association with interventions. Depression. Because depression is such a common consequence of caregiving, the investigators sought to measure depression in more depth than was provided by the POMS alone by using the GDRS (Yesavage, Brink, Rose, Lure, Huang, Adey, & Leirer, 1983). The GDRS is a 30-item self-report measure of depression that takes about 10 minutes to administer. Designed especially for use with the elderly, the GDRS omits assessment of somatic items that tend to over-inflate depression scores in this population and uses a simple to administer and score yes/no format. Reliability coefficients over .90 have been reported for the GDRS in samples of community-dwelling elderly.

Data Entry, Management and Analysis All data were entered, managed, and analyzed by the University of Iowa's Research Support Network under the direction of the project statistician (Kohout). Data were entered on microcomputers using software that supported a 2-pass entry and verification procedure. Data entry kept pace with data collection, and interim analyses were conducted throughout the course of the study to compute reliabilities for instruments and to check for anomalies in the data.

Sample A total of N = 245 caregivers completed the study. Sample size projections were based on a total of 160 cases (80 per group) to achieve a power of .72 to detect an effect for the intervention that contributes as little as 3% more to explained variance. The high attrition rate for this study was anticipated given the authors' previous research with this population. In fact, sample size calculations were based on an assumed attrition rate of 30% in the first 6 months (versus a 28% actual rate). Loss of subjects can best be explained by institutionalization (N = 58) and by death (N = 14) of the care recipient. The high attrition rates also reflect the late stage of the disease trajectory at which many care recipients were entered into the study. No differential attrition rate between subjects in the two groups was noted.

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Description of the Sample Major characteristics of the sample are summarized below. Group membership. Subjects were fairly equally divided between membership in the experimental (N = 132, 54%) and comparison groups (N = 108, 44%), with slightly more participants in the experimental group. Data on N = 5, 2% of subjects was missing. Age. The total sample mean for caregivers was 64.6 years, reflecting a mix of spouse and adult child caregivers. At baseline, average age for caregivers in the two groups was significantly different (p = .02), with caregivers in the experimental group being older (x = 66.2 yrs) than those in the comparison group (x = 60.9 yrs). As would be expected, care recipients were older than their care providers, averaging 76.5 years. There were no statistically significant differences in age among care recipients in the two groups. Amount of caregiving. Caregivers in this sample provided a great deal of hands-on care, averaging 122 hours/week or 17.43 hours/day of direct care. There were no statistically significant differences in the amount of caregiving provided between caregivers in the experimental and comparison groups (X2 = .55) Caregiver relationship to care recipient. In keeping with national data on caregivers of persons with dementia, the majority of caregivers in our sample were spouses (N = 156, 64%), followed by adult children (N = 57, 23%), and "others" including grandchildren, siblings, neighbors, other kin, and nieces and nephews (N = 32, 13%). There were no differences in type of relationship between subjects in the comparison and experimental groups (X2 = .20). Gender. Although there were approximately equal numbers of male and female care recipients in the study, there were three times as many female caregivers as males, reflecting the national trend of "caregiving as women's work." As shown in Table 2, there were no statistically significant differences in gender for either caregivers or care recipients, according to group membership. Ethnicity. Despite focused recruitment efforts and diversification to data collection sites more likely to yield minority subjects (AZ, IN, Minneapolis), enrollment of minority care givers was disappointing (N = 18/245, 7%). There were no significant differences in caregivers or care recipients in

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Table 2. Gender Caregiver Gender

N

Male

Care Recipient %

N

%

62

25

124

51

Female

183

75

121

49

Total

245

100

245

100

Baseline E/C X2 = .10

Baseline E/C X 2 = .89

Iowa data collection site only. Based on evidence from other studies, a number of theoretically important variables such as nature of caregiver relationship, duration of illness, and sex by group interaction, as well as baseline scores and data collection site, were incorporated into the regression equation to control sources of extraneous variance. POMS Depression Scale

terms of ethnicity according to group membership (X2 = .65). Care recipient diagnosis. As would be expected given national epidemiological data on the dementias, the majority of care recipients in this study carried a diagnosis of Alzheimer's disease (AD) (Table 3). Fourteen percent of the sample had an unknown or missing diagnosis, which is not uncommon, especially among community dwelling elders in rural settings who lack access to formal diagnostic services. RESULTS

The following hypothesis and sub-hypothesis were tested: The PLST training program in symptom presentation, care, and structured activities will increase the ability of caregivers to manage behavioral symptoms associated with ADRD, and thus improve their mood and affect. 1. a) Caregivers who receive home care management training based on the Progressively Lowered Stress Threshold (PLST) model will report less depression than those who receive routine information, case management, and support group referral as a basis for providing home care for the ADRD patient. Data to answer address the subhypothesis (1.a) on depression were obtained from two sources at 6 and 12 months postintervention using multiple regression techniques. The first data source was the depression subscale of the POMS, 1 of 6 subscales that comprise the instrument. The second data source was the GDRS, which was administered at

AD MuRi-infarct

Table 4. POMS Depression Subscale

1 Tailed

%

159

65

11

5

Explained variance 1 2 - m o n t h data: N = 133

M i x e d dementia

16

6

25

10

Unknown

26

11

Missing

Data from the GDRS, which may be a more sensitive measure of depression in this population, fully support hypothesis la, although the sample size is smaller because this scale was administered only in Iowa. At both 6 and 12 months caregivers in

N

Other dementias

Totals

Geriatric Depression Rating Scale

6-month data: N = 174 (range of possible scores = 15-60, national norm = 7.9)

Table 3. Diagnosis of Care Recipient Diagnosis

The sub-hypothesis (la) was partially supported with data from the POMs depression subscale (Table 4). Data indicate that caregivers in the experimental group were significantly (p = .0007) less depressed than caregivers in the comparison group at 6 months on the POMS Depression subscale, however, by 12 months the difference in depression scores (although in the hypothesized direction), was no longer statistically significant. (p = 15). Further analyses determined both that the more-depressed caregivers dropped from the study between the 6 and 12 month data collection points, and that persons cared for by these more depressed caregivers were institutionalized at a greater rate, thus influencing depression scores at 12 months. This is similar to findings by Baumgarten et al. (1994), in which caregivers of patients with dementia who were admitted to an institution during the study period were more likely to experience an increase in both depressive and adverse physical symptoms. Explained variance at both 6 and 12 months was adequate (.37 and .35, respectively).

8

3

245

100

Regression coefficient f o r g r o u p (effect size)

B = -3.44

P = .0007

R2 = .37 1 Tailed

Regression coefficient f o r g r o u p (effect size) Explained variance

B = - 1.42 Rz = .35

P = .15

DEPRESSION IN F A M I L Y CAREGIVERS

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the experimental group were less depressed than their counterparts in the comparison group (.003 and .025, respectively), as shown in Table 5. Based on factors known to be associated with depression (Kurlowicz, 1993), additional analyses of the depression data were conducted, including examination of POMS and GDRS scores according to caregiver age, education, relationship to the care recipient, care recipient stage of illness, and length of time since onset of memory problems. Selected findings from this extensive analysis are summarized below. Variable: caregiver age (divided into quartiles of 20-54, 55-64, 65-74, and 75 years and older). At baseline caregivers in the 65- to 74-year-old group reported the highest levels of depression on both measures (GDRS = 9.9, POMS = 14.0). At 6 months, the highest depression scores were reported by caregivers in the 55 to 64 age cohort (GDRS = 11.0, POMS = 14.5). By 12 months, POMS depression subscale scores were highest among the youngest group of caregivers (12.0), whereas GDRS scores were slightly higher in the 65- to 74-year-old group (10.75), with the youngest caregiver cohort reporting second highest mean scores (9.66) as compared with an overall group mean of 9.18. This trend toward increased depression in younger caregivers over time is in keeping with their reports of higher burden and distress levels in response to care-recipient behaviors in this study and with findings elsewhere in the literature, which suggest that younger caregivers perceive that they have more demands placed on them (Bergman-Evans, 1994; Fitting, Rabins, Lucas, & Eastham, 1986; Neundorfer, 1991). Variable: caregiver educational level (dichotomized at the median, 12 years). This variable was examined because of concern that the psycboeducaTable 5. Geriatric Depression Scale 6-month data N = 79 (Iowa only), range of possible scores = 0-30, scores < 1 1 = not depressed 1 Tailed Regression coefficient f o r g r o u p (effect size) Explained variance

B - -3.061

P = .003

R 2 = .29

B a s e l i n e X (ex) = 6,3; b a s e l i n e X(c) = 7.0, p = .61

12-month data, N = 54 1 Tailed Regression coefficient Explained variance

B - -2.317 R 2 = .34

P = .025

tional intervention might be of more use to more highly educated participants. At baseline, less educated caregivers reported slightly more depression on both the POMS (means = 13.0 vs. 11.53) and the GDRS (means = 8.93 vs. 7.6). These group differences increased slightly by 6 months (POMS = 12.7 vs. 9.6) and (GDRS = 10.0 vs. 6.6), and held through the 12 months analysis for the POMS depression subscale (12.6 vs. 9.3). However, by the end of the study the gap in GDS scores closed somewhat (9.5 vs. 8.7) between caregivers based on level of educational attainment. Variable: care-recipient stage of illness (GDS score dichotomized as low, score of 2-4, or high, score of 5-7). Based on the literature (Deimling & Bass, 1986), it was hypothesized that the care recipient's level of disease progression might influence caregiver levels of depression. At baseline, caregivers of less impaired persons (GDS low) reported slightly higher levels of depression on the POMS subscale (13.49 vs. 11.5), but GDRS scores were very equal (8.61 vs. 8.17). By 6 months, the depression scores for both scales were slightly higher for caregivers of less impaired persons. At 12 months, differences were similar to baseline. Thus, the care-recipient stage of illness did not seem to have much impact on caregiver depression. Variable: caregiver relationship to care recipient (categorized as spouse, adult child, or other). Again, based on the literature, it was hypothesized that the caregiver's relationship to the patient might influence their mood. Indeed, at baseline, spouse caregivers reported much higher levels of depression on both depression measures (POMS = 13.8, GDRS = 9.86) compared with adult children (8.4 and 4.5) and "other" caregivers (9.7 and 3.0). This pattern of group differences persisted at both the 6 and 12 month data collection points, with spouses (who themselves may be old and frail), consistently reporting higher levels of depression than other caregivers. These findings are in keeping with those reported elsewhere (Fitting et. al., 1986; George & Gwyther, 1986; Neundorfer, 1991), including Robinson's (1989) research on wife caregivers that found a negative relationship between their total health and depression. Variable: length of care recipient illness (as dichotomized by the median of 48 months since onset of memory problems). It was hypothesized that caregivers who had provided care for a longer

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duration might experience more depression than those who had been providing care for less than 4 years. However, the baseline data revealed that it was the newer caregiver group who were slightly more depressed on both the POMS (13.7 vs. 10.8) and GDRS (9.5 vs. 7.2) than those who had been providing care the longest. This pattern of differences persisted at 6 months, and was even more pronounced at 12 months (15.1 vs. 7.1) on the POMS depression subscale. This finding, supported by the longitudinal studies of Schulz and Williamson (1991), suggests that "long term" caregivers may have successfully adjusted to the rigors of caregiving, and had learned to cope with the demands of this task such that they were able to maintain a more positive mood over time.

Additional Analyses Related to Hypothesis #1--Caregiver Affect

Subjective affect of the caregiver was measured by scores on the other Profile of Mood States subscales of Tension-Anxiety, Anger-Hostility, Vigor-Activity, Fatigue-Inertia, and ConfusionBewilderment, as well as a Total Mood summary score. Despite randomization efforts, at baseline (BL) caregivers in the experimental group were significantly more angry (p = .01) than caregivers in the comparison group, and their total mood disturbance score was significantly higher (p = .05) using two-tailed t-tests. These differences were controlled for statistically in subsequent multiple regression analyses reported by subscale below. Tension-anxiety: (range o f scores = 4-31, combined group means = 9.96 at BL, 8.96 at 6 months, 8.96 at 12 months). At 6 months, tension scores

were significantly (p = .006) lower for subjects in the experimental group than comparison group caregivers. The regression coefficient for group was - 3 . 4 8 and the R 2 value was .27. The difference persisted at 12 months, where again tension scores were significantly (p = .009) lower for subjects in the experimental group than comparison group caregivers. The regression coefficient for group was -4.05, and the R 2 value was .29. Anger-hostility: (range o f scores = 12-48, means = 8.44 at BL, 7.39 at 6 months, 6.79 at 12 months). Caregivers in the experimental group

experienced significantly less anger than comparison group members at 6 months (p = .02). The regression coefficient for group was -2.95, and the R 2 value was .32. At 12 months, the group differ-

BUCKWALTER ET AL.

ences were again significant (p = .016), with a regression coefficient of - 3 . 7 0 and R 2 value of .36. Fatigue-inertia: (range o f scores = 7-28, means = 8.94 at BL, 8.76 at 6 months, 8.22 at 12 months). At 6 months, caregivers in the experi-

mental group reported experiencing significantly less fatigue than caregivers in the comparison group (p = .0029). The regression coefficient for group was -3.32, with a R 2 value of .27. Significant differences on this subscale persisted at 12 months (p = .038), with a regression coefficient for group of -3.07, and R z value of .35. Confusion-bewilderment: (range o f scores = 5-23, means = 6.39 at BL, 6.27 at 6 months, 6.04 at 12 months). At 6 months, caregivers in the

experimental group reported significantly less confusion (p = .0001) than comparison group caregivers (regression coefficient for group = - 3 . 5 0 , R 2 = . 2 5 ) . At 12 months, there were also significant differences for group on this subscale (p = .0093), with a regression coefficient for group of - 2 . 9 2 and a R 2 value of .23. Vigor-activity: (range o f scores = 8-32, means = 16.61 at BL, 16.46 at 6 months, 16.40 at 12 months). This was the only POMS subscale

with no significant differences between experimental and comparison group subjects at either 6 months (p = .62) or 12 months (p = .32). Why this should be the case is unclear. One possibility is that some of these subscales (for which calculations are quite different than the other five POMS subscales) were misscored and went undetected by the research team, despite a rigorous, multi-person spot check of data. P O M S total score. At 6 months, differences between experimental and comparison subjects on this summary scale approached significance ( p - - . 0 8 ) , but were less apparent at 12 months (p = .22). Nonsignificant difference scores on the Vigor subscale may have impacted these Total Score results. Thus, with the exception of the Vigor-Activity subscale, data from the Profile of Mood States lend support to the portion of Hypothesis #1 related to improved caregiver affect in subjects receiving the PLST training program. Although the R 2 values are not large, the regression coefficients for the experimental group for many of the subscales are substantial, given the range of scores and means for these subscales. These findings are in keeping with other aspects of this hypothesis that indicate improved caregiver mood, as discussed below.

DEPRESSION IN FAMILY CAREGIVERS

Discussion: Caregiver Depression Given the high prevalence rates of depression among community-dwelling caregivers of persons with dementia, the positive impact of the PLST intervention on caregiver depression is significant. This is true not only in terms of quality of life issues, but also in light of research showing that depression among caregivers is associated with the intensity of their reactions to the patients' memory and behavior problems (Kiecolt-Glaser, Dyer, & Shuttleworth, 1988; Pearson, Teri, Wagner, Truax, & Logsdon, 1993), and a variety of other adverse outcomes such as increased physical burden (Cairl & Kosberg, 1993; Draper, Poulos, Cole, Poulos, & Erlich, 1992), subjective burden (Drinka et al., 1987; Gaynor, 1990), and use of psychotropic medications (Baumgarten et al., 1992; Clipp & George, 1990). As noted by Boss, Caron, Horbal, and Mortimer (1990), feelings of loss of personal control can exacerbate depression. Certainly caring for persons with dementia, a disease characterized by an unpredictable and changing clinical course, can easily lead to perceived lack of control. The PLST-based intervention tested in this study may have impacted on caregivers' depression scores by enhancing their sense of personal control through increasing their understanding of the disease and dementia-related care strategies. The findings of this study are consistent with those reported by Cruz (1997) in a comparative correlational study using a subset of this data. Cruz investigated caregiver age, gender, relationship to care recipient, subjective burden, social support, use of community resources, use of psychotropic medications, care recipient's stage of dementing illness, and number and type of health care problems of the care recipient as possible predictors of depression among caregivers. Her study also examined the longitudinal effects of the PLST intervention on changes in predictors of depression in the treatment and comparison groups at baseline and 12 months, in (N = 57) subjects. Regression analysis indicated that subjective burden and relationship (spousal) to the care recipient were the best predictors of caregiver depression, accounting for 27% of the variance. Analysis of variance with repeated measures indicated a significant increase in subjective burden levels for both groups from baseline to 12 months with the comparison group having greater increases in burden levels than caregivers in the experimental group. Although no

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statistically significant differences were found between groups on caregiver depression at 12 months, there was a significant difference within groups across time, with the comparison group reporting greater increases in depression levels. The findings of Cruz further support a modest positive effect of the PLST intervention on both caregiver's levels of subjective burden and depression. Implications for Psychiatric Nursing Psychiatric nurses are likely to encounter depressed caregivers in a variety of practice settings, many of whom go undetected and untreated until a crisis occurs. This is particularly unfortunate in light of empirical evidence validating the effectiveness of psychosocial and educational interventions with this population (Knight, Lutzky, MarcofskyUrban, 1993). Thus, psychiatric nurses can play a pivotal, multifaceted role in the assessment and treatment of caregiver depression. Opportunities for psychiatric nursing involvement include the identification of high-risk caregivers; offering preservice screening (Cairl & Kosberg, 1993); encouraging the use of mental health services to diminish the emotional toll of caregiving; providing referrals for support groups and services such as respite and adult day care; consulting with and educating both caregivers and gerontological colleagues about depression and its management; delivering independent and collaborative interventions for caregivers such as the psychoeducational intervention tested in this study, skills training (Bourgeois, Schulz, & Burgio, 1996), behavioral treatments (Teri, Logsdon, Wagner, & Umoto, 1994), and direct counseling; providing home-based services for this population; developing problem-focused programs that help caregivers to cope (Wright, Lund, Caserta, & Pratt, 1991) and that empower them (Schulz, O'Brien, Bookwala & Fleissner, 1995); and monitoring areas of change and progress in coping with the stress associated with caregiving. REFERENCES

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