Do caregiver management strategies influence patient behaviour in dementia?
de Vugt ME, Stevens F, Aalten P, Lousberg R, Jaspers N, Winkens I, Jolles J and Verhey FR;
Commented by , 23 Feb 2004
Objectives of the Study
To identify specific caregiver strategies, then analyse whether these are predictors of patient behavioural problems and caregiver distress.
Methods
Subjects
This study was part of the Maastricht Study of Behaviour in Dementia. Subjects were 99 informal caregivers of ambulatory patients with dementia diagnosed according to DSM-IV criteria, referred from the Memory Clinic. Consenting subjects had contact with the patient (living at home) at least once per week. Patient and caregiver assessments were conducted by independent experienced psychologists.
Outcome Measures
Patient behavioural problems were measured with the Neuropsychiatric Inventory (NPI); cognition by the Mini-Mental State Examination (MMSE); and activities of daily living by the Interview for Deterioration in Daily living activities in Dementia (IDDD).
Caregivers completed a semi-structured interview which was tape-recorded and analysed qualitatively. Caregiver competence was measured with the Short Sense of Competence Questionnaire (SSCQ), and depression by the Montgomery-Asberg Depression Rating Scale (MADRS).
For each of the twelve BPSD symptoms on the NPI, caregivers rated the level of distress they experienced on a scale from 0 (none) to 5 (extreme). Analyses were performed at baseline, 6 months and 1 year.
Statistical Analysis
Principal component analysis was used to identify behavioural sub-syndromes measured by the NPI. This resulted in three components:
- Hyperactivity – including disinhibition, agitation, aberrant motor behaviour.
- Mood/Apathy – including depression, apathy, eating disturbance and night disturbance.
- Psychosis – including delusions and hallucinations.
Differences in BPSD were then analysed using repeated measures analysis of variance (MANOVA).
Results
Qualitative analysis revealed three types of caregiver management strategy, based on whether the caregiver accepted the caregiving situation and understood the dementia-related problems. Caregivers were designated adapting (= accepting) or non-adapting (n = 17), and adapters were further subdivided into "nurturers" (n = 30), and "supporters" (n = 52). These definitions are described in detail in the paper.
Relatively more women than men used a nurturing strategy (25 vs. 5), or a non-adapting strategy (13 vs. 4). No difference in management strategy was found between spouses and offspring. Significant findings were that non-adapting caregivers reported more patient hyperactivity symptoms; nurturing caregivers (who tended to be women) reported lower levels of patient activity.
Higher levels of BPSD were found in caregivers who used a non-adapting strategy rather than a supporting strategy. MANOVA of the three sub-syndromes of BPSD again suggested that non-adapters reported more hyperactivity symptoms increasing over time. Mood/apathy and psychosis showed no overall differences in patient behaviour relative to caregiver type.
Caregivers who used a supportive strategy had a significantly higher sense of competence on the SSCQ, than non-adapting caregivers.
Discussion
This rather over-complicated paper produced two important, if common sense, findings.
Firstly, the minority of caregivers who used non-adaptive strategies (characterised by lack of understanding of the patient and non-acceptance of the situation), did badly in terms of their own well-being and sense of competence. Secondly, non-adapters seemed to engender more hyperactivity (disinhibition, irritability, agitation, euphoria and wandering) in the people they were caring for.
For carers who were classed as ‘adapters’, there were pros and cons in outcomes of adopting either a nurturing or supporting style.
Gender, education and personality are obvious determinants of caregiver strategies. However, this paper raises the possibility that if non-adapters can be helped to a position of acceptance/adaption, outcome for carer and dementia sufferer can potentially improve.