Bridging Disciplinary Boundaries (January 11 - 14, 2007)

PURPOSE: Caring for a family member with Alzheimer's disease or a related dementia (ADRD) is a known risk factor for depression. Pearlin and colleagues' well established theoretical model of the dementia caregiving stress process specifies that the impairments and behavioral problems of the person with ADRD (primary objective stressors) and primary subjective stressors such as burden, along with secondary stressors and appraisals, lead to negative outcomes such as depression. Researchers have begun to explore other aspects of this process such as the losses and grief experienced by family caregivers, and the prior or current relationship with the care recipient. This study examines the associations of personal and relational losses and the quality of the relationship to ADRD caregivers' depressive symptoms.

METHOD: Data were from a cross-sectional sample of caregivers who completed questionnaires at an Alzheimer's disease research center during their first visits accompanying a family member with ADRD. A theoretical path model was constructed based on prior research about the caregiving stress process and recent thinking on losses and relationship. Hierarchical multiple regression analyses were conducted to identify the direct and indirect effects in the model, with depressive symptoms (CES-D) as the final outcome variable. Control variables included caregiver age, gender, relationship status, and the quality of the relationship (Q of R) prior to onset of ADRD. The Blessed Dementia Rating Scale and the Mini-Mental State Exam (MMSE) represented care recipient impairments. Personal Mastery and Expressive Support were entered as resource variables. Then, in order, Loss of Intimate Exchange, Loss of Self, Current Q of R, Role Overload and Role Captivity each served as outcome and predictor variables in the path model.

FINDINGS: In the final caregiver sample with non-missing data (N = 428), 88.3% were white, while 65.9% were female. Mean CES-D score was 11.37. In the path model, care recipient impairments accounted for significant direct effects on Loss of Intimate Exchange, current Q of R, and Overload, in the expected directions. Loss of Intimate Exchange had significant direct effects worsening Loss of Self, Q of R and Overload, while Loss of Self had direct effects worsening Overload, Role Captivity, Q of R, and CES-D. Lowered current Q of R directly worsened Role Captivity and CES-D. The final model explained 45.2% of the variance in CES-D scores; 9.8% of the variance came from personal and relational losses and Q of R.

IMPLICATIONS: This theoretical model, although limited by the cross-sectional nature of the data, provides new evidence about the potential importance of losses and relationship quality to caregivers' depression. The model can now be tested longitudinally. Much of the intervention development to date with caregivers of persons with ADRD has focused on stress, burden and instrumental tasks such as resource provision and behavioral management. However, it appears that reactions to losses incurred and caregivers' subjective experience of the relationship with the care recipient are important parts of this picture. Acknowledging these losses and relationship issues should be regular components of social work intervention approaches with family caregivers.