Browse through our Medical Journals...

DEPRESSION IN CARERS OF PATIENTS WITH DEMENTIA

Aadil Jan Shah,Senior SHO Psychiatry, Gwent Health Care NHS UK,
Ovais Wadoo,SHO Psychiatry,Sheffield Health Care NHS UK.

Review Article

INTRODUCTION

Dementia is a progressive disease and those who suffer with dementia gradually lose the ability to live independently without the assistance of others. The majority of patients are cared for by family caregivers and these individuals are placed in a situation of escalating personal demands.
Caring for an elderly person with dementia is a major life challenge and it entails emotional, physical, social and financial burden (Morris 1998).It also has been described as one of the most difficult situations encountered by caregivers(Teusing JP,Mahler S.,1984).
Caregivers of dementia patients can experience various emotional problems during the course of the illness (Rabins PV.,1984).One such disorder, that is frequently overlooked and not treated, is carers depression (Harwood,et al,1998).It is well documented that family caregivers of persons with dementia have significantly more depressive symptoms than age and gender-matched non caregivers(Gallagher,et al,1990).Caregivers of persons with dementia report more emotional strain and depressive symptoms than caregivers of persons who are not demented (Hooker,et al,1998).Prevalence rates for depressive symptoms among caregivers of persons with dementia are reported to range from 28% to 55%(Schulz,et al,1995)
Zarit and colleagues were among the first researchers who highlighted the burden of providing care to a relative with dementia (Zarit et al.1980).Following this study, there has been an explosive growth of care-giving research, focussing on the negative effects of providing care on carers and on interventions to reduce or prevent these effects (Schulz et al.1995).The stress of carers is an important issue for public health care, because of their central role in the care of persons with dementia and the negative health consequences they may experience (Duijnstee,1992). Its importance gains prominence,due to the expected increase in numbers of elderly persons with dementia and their family carers (RGO 2002).
High levels of depression are found in individuals providing care to persons with dementia or Alzheimer's disease. Caring for an individual with Alzheimer's disease or a related dementia can be challenging and, at times, overwhelming. Such stress and frustration with its impact on carers physical and mental health can set a scene for potential abuse.
This essay presents a study of the literature on this mental health issue, mainly focusing on the factors responsible for caregiver’s depression, ethnic, cultural and gender differences, enhancing caregiver health strategies used for coping and related abuse.
A computer literature search was done covering the period 1982 to 2005 on PsychINFO and CINAHL database. Key words used were (combinations of): depression, dementia, Alzheimers disease, Caregivers, Caregiver burden. I also used Google search and text books as reference.

THE CORE PROBLEM AND ITS DEMANDS

Dementia is not merely a memory problem as indicated by the World Health Organisation definition 1986 :
Dementia is the global impairment of higher cortical functions, including memory, the capacity to solve the problems of day-to-day living, the performance of learning perceptuo-motor skills, the correct use of social skills and control of emotional reactions, in the absence of gross 'clouding of consciousness’.
Dementia presents a significant burden for both formal and informal care sectors. There are estimated 700,000 people with dementia in United Kingdom and of these up to 55% or 385,000 have dementia attributable to Alzheimer’s disease (AS 2003).
The prevalence of Alzheimer's disease is projected to more than triple in next 50 years (Hebert et al.,2001),generating substantial burdens on both the formal health care system and family caregivers who typically provide most of the direct care. Caring for a relative with dementia appears to be associated with adverse effects on caregivers health and some have referred them as "hidden victims" of Alzheimer's disease (Zarit,Orr & Zarit,1985).
Most dementing illnesses are progressive, and early symptoms and problems differ markedly from those in later stages. This may simply be a matter of degree. Other symptoms and problems usually develop later in the course of the illness.
In the moderate stage of dementia, the dementing person often requires some level of support from other individuals to enable them to maintain their function. It is often in this stage that carer’s begin to realize the full extent of the various demands upon them. While the deteriorating memory function is a problem, it is usually not the main feature that impacts upon the carer. It is more often the personality and behavioral changes that cause the most concern, having the greatest effect on those carers who live with the dementing person (Draper, 2004).

SUPPORT SYSTEMS

Support systems may be informal and formal.
Informal carers are family members who care for their demented relatives. Families remain the first, most reliable and most acceptable source of assistance. There are about 5.7 million people providing some hours of informal care (ONS 1998), the majority of which will be caring for elderly or disabled people. Of these, about 800,000 people will provide unpaid care for 50 hours a week or more. A sizeable proportion of these informal carers will be caring for a person with dementia.
Most families would probably prefer to look after their disabled relatives for as long as possible at home. However, because dementia is such a slowly progressive condition, by comparison with illnesses such as cancer, the time frame over which care needs to be provided is very long. Without a strong community care system, most families and other carers are hamstrung in their efforts to look after the person with dementia at home (Draper, 2004). Furthermore, informal carers often facilitate the linkages with formal providers, such as physicians, hospitals, community long-term care services, and nursing homes (Pearlin,1993).
Formal or professional caregivers include trained nursing staff, hospital staff, professional staff involved in home support, and untrained care staff within residential and nursing home facilities.
Most people with dementia will be placed into residential or nursing care in the moderate—severe stage of their illness, despite the efforts of family carers and community support services. Placement into a residential or nursing care facility is often a very stressful process for both the dementing person and the carers (Gruetzner, 2001).

HIGH LEVEL BURDEN LEADING TO DEPRESSION

Caregivers provide assistance with activities of daily living, dealing with incontinence, feeding and mobility. The majority (73%) of Alzheimer’s disease caregivers age 65 and over provide high levels of care. These caregivers are twice as likely to report physical strain and high levels of emotional stress as a direct result of care giving responsibilities. Consequences of caring for someone with dementia may also include the loss of companionship and support of a life partner (Moritz 1989) and the detrimental effects of caring on the carer's health (Chenoweth 1986; Haley 1987).
Due to high burden and responsibilities caregivers experience poorer self reported health, engage in fewer health promotion actions than noncaregivers, and report lower life satisfaction(Acton,2002;Amirkhanyan & Wolf,2003;Burton et al,1997;Danhauer et al.,2004,Ory et al.,1999;Schulz et al.,1995).
Family caregivers who have a significantly depressed mood may be adversely affected in their ability to perform desirable health maintenance behaviour or self care behaviours in response to symptoms(Yvonne&Mary,2005). Family caregivers experience more physical and mental distress than non caregivers in the same age group(Amirkhanyan & Wolf,2003;Schulz et al.,1995).
Informal caregivers of individuals with AD (Alzheimer’s Disease) are one of our health care system's greatest resources,and their task is not an easy one being fraught with psychological stress and physical exhaustion(Cohenetal,1990; Grafstrom,Fratiglioni,Sandman,&Winblad,1992;Vitaliano,Russo,Young, Teri &Maiuro,1991).
The vehicles of psychological stress has been conceptualized as adjustment to change (Holmes and Rahe, 1967), daily hassles (Kanner et al., 1981), and role strains (Pearlin, 1983).Lazarus and Folkman (1984) define stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well being”.
The burden and depressive symptoms sustained by caregivers of AD patients have been the two most widely studied care giving outcomes.
The association between feelings of burden and the overall caregiver role is well documented (Deimling, Bass, Townsend, &Noelker,1989 ;George and Gwyther, 1986;Pratt, Wright,&Schmall,1987;Zarit, Todd,&Zarit ,1986).Several studies suggest that caregivers of dementia patients are significantly more likely to be depressed than are noncaregiver controls (Dura,Stukenberg,& Kiecolt-Glaser,1991;Haley et al., 1987b;Kiecolt-Glaser et al., 1991;Russo,Vitaliano, Brewer,Katon,& Becker,1995 ). Reports indicate that depressive symptoms are twice as common among caregivers than noncaregivers (Baumgarten et al., 1992;Canadian Study of Health and Aging Working Group, 1994b).
Several studies suggest that many caregivers are at risk of experiencing clinical depression (Gallant & Connel., 1997; Schulz &Williamson, 1991; Williamson & Schulz, 1993). Nearly half of the caregivers in some studies were reported to meet diagnostic criteria for depression when structured clinical interviews were used (Cohen & Eisdorfer,1998;Gallangher,Rose, Rivera, Lovett, &Thompson, 1989).There is also some evidence to suggest that a diagnosis of depression can be causally related to the caregiving situation. Dura et al 1991, found that nearly one quarter of caregivers met the criteria for depression whilst in the caregiving role, although they had never been diagnosed with depression prior to their assumption of this role. The societal implications of this are underscored by reports indicating that the stressed caregiver is more likely to institutionalize the care recipient (Cohen et al.,1993; Colerick & George, 1986; Haupt & Kurz, 1993).
Covinsky et al.concludes appropriately, that"efforts to identify and treat caregiver depression will need to be multidisciplinary,consider the cultural context of the patient and caregiver, and focus on multiple risk factors simultaneously."

RISK FACTORS LEADING TO CARER’S DEPRESSION

Prevalence of depression among caregivers of people with dementia has been estimated at between 40 and 60% (Redinbaugh et al.,1995) which contrasts sharply with 8% reported in non-caregivers of similar age (Blazer and Williams, 1980). Recognition of risk factors or characteristics that may facilitate or are associated with the disease process is therefore crucial.

Patient Characteristics

There is overwhelming support for the claim that a higher frequency of behavioural problems presented by the patient is associated with an elevated level of caregiver depression and burden (Bedard, Molloy, Pedlar, Lever, &Stones, 1997). The frequency with which behavioural disturbances are manifested by the patient has been identified as the strongest predictor of caregiver distress and plays a significant role in the caregivers decision to institutionalize the patient (Cohen et al.,1993)
The literature consistently demonstrates that the frequency of behavioural problems is a more reliable predictor of caregiver burden and depression than are the functional and cognitive impairments of the individual (Coen et al.,1997; Pruchno & Resch, 1989a; Williamson & Schulz , 1993). Carers face unfamiliar and unpredictable situations, which increases stress and anxiety. Anxiety may be increased by behavioural problems of the demented patients who cannot be successfully managed on a consistent basis. Anxiety is associated with depression, stress, and physical ill health.
BPSD(Behavioural and Psychological Symptoms of depression) are associated with patient distress (Ballard et al.,1995a;Gilley et al.,1991),and are perceived by caregivers as the most difficult symptoms to manage (Rabins et al.,1982).BPSD adversely affect the patient caregiver relationship (Deimling & Bass,1986).Caregiver distress is particularly associated with aggressive behavioural disturbance (Clyburn,Stones,Hajistavropoulos,&Tuokko,2000). BPSD therefore results in the increased level of caregiver burden leading to depression. Not all changes of behaviour are a problem. Often an explanation that the behavioural change is part of the dementia allows the carer to tolerate it. At other times the behaviour itself is not abnormal, it is just occurring in the wrong place or at the wrong time (Draper, 2004).
Family caregivers of the persons with dementia assist with tasks of daily living over an extensive period of time. Physical and functional impairments in dementia patients may increase the difficulty of providing physical care and may be more distressing, for older family caregivers, particularly spouse caregivers (Connell,Janevic&Gallant,2001).
Findings regarding the relationship of functional impairment and negative caregiver outcomes have been inconclusive. Some studies document a weak association of objective measures of patient functional status and caregiver burden/depression (Kiecolt-Glaser et al., 1991; Russo et al., 1995), whereas others report a stronger relationship (Baumgarten et al., 1992; Gallant & Connell, 1997).

Joshua R.Shua-Haim and colleagues identified three patient factors were found to have a strong association with Alzheimers caregiver depression, which are:1)Depression in dementia patient;2)ADL functional scores of 12 or greater; and 3)the presence of hallucinations.

Caregiver Characteristics

Risks for carer depression are related to gender, age, health status, ethnic and cultural affiliation, lack of social support, as well as certain other characteristics related to the caregiver (Gruetzner, 2001).

Gender: Women have higher rates of depression than men in the care giving role (McGrath et al., 1992). These gender differences in levels of depressive symptoms and depression may be due to variations in stress exposure, coping responses used, the role of social support (Billings and Moos,1984) and biological factors (McGrath et al., 1992). The literature on gender differences in the psychological well being of caregivers points to the increased risk for females in terms of depressive symptomatology.
Schulz and Williamson (1991) found that 39% of female caregivers, compared to16% of male caregivers, qualified as being at- risk for clinical depression on The Center for Epidemiologic Studies-Depression Scale (CES-D). AD caregivers reporting symptoms of depression have ranged from 28% to 55% and female caregivers were more likely to experience depressive symptoms than male caregivers (Schulz et al., 1995).
In a systematic review of gender differences and caregiving, Yee and Schulz (2000) showed that women caregivers reported more psychiatric symptoms than men caregivers, including greater depression (Beach, Schulz, Yee, & Jackson(2000), burden (Lutzsky & Knight,1994), and anxiety. However, few studies have examined the relationship between gender and intervention effects. In a randomized controlled trial (Gitlin et al, 1999) found that women were more likely than men to comply with a home environmental modification intervention, implement recommended strategies, and derive greater benefits.
Thus,In general, female carers seem to suffer higher levels of distress than male carers. How can this be explained? Certainly, women in societies are more likely to be thrust into the caregiving role than men. Female carers are also more likely to be ‘hands-on’, that is, they tend to do everything themselves rather than delegate to others. Male carers tend to have more of a ‘managerial’ style that allows them to distance themselves from the stressful situation to some degree by delegating tasks (Draper, 2004).

Age: Age-associated impairments in physical competence make the provision of care more difficult for older caregivers. Lawton et al. (1992) found a positive association of age and caregiver burden in Whites, but a negative association for African Americans, suggesting that older African Americans are less likely to experience caregiving as physically burden-some. Similarly, Cox (1995) found a negative association of age and burden in African American caregivers, but no significant association in Whites.

Health: Caregiver health has also been identified as a significant predictor of caregiver depression (Lawton, Moss, Kleban, Glicksman, & Rovine, 1991). This association with depression suggests that caregivers with lower levels of physical health are more vulnerable to the psychological consequences of caregiving.
Studies have reported poorer physical health among caregivers than age -matched peers,and such health problems are linked to an increased risk of depression (Baumgarten et al., 1992; Stone et al., Haley et al., 1987)
Not only have caregivers reported having poorer perceived health(Schulz R et al.,1995) and a greater number of physical symptoms, but it has also been demonstrated that caregivers mount poorer immune responses to viral challenges(Glaser R,Kiecolt-Glaser JK.,1997), evidence slower rates of wound healing(Kiecolt-Glaser JK et al.,1995) and have significantly higher levels of plasma insulin(Vitaliano PP et al.,1996) than do age matched control subjects. Longitudinal studies also demonstrated that caregivers are at a greater risk than non care giving age matched controls for developing mild hypertension and have an increased tendency to develop a serious illness(Shaw WS et al.,1997) as well as increased risk for all-cause mortality(Schulz R,Beach SR.,1999).
Men and women who suffer depression have greater cardiovascular risks. Many carers do not pay sufficient attention to their needs for a healthy diet, sufficient sleep, and regular exercise. These practices are also important for successful stress management. They have a protective role in reducing the risk of depression and other health problems. Carers who do not attend to their own health needs have a greater chance of developing health problems, which leads to an increased risk of depression (Gruetzner, 2001).Other investigators have found that family caregivers who did not take care of their own health reported higher levels of caregiving stress and more problematic behaviours with the care recipients (Shaw et al., 1997).

Ethnic and Cultural affiliation: Ethnicity has substantial impact on the caregiving experience (Gruetzner, 2001).
Explanations for lower burden and less depression reported by Black carers as compared to those of their White counterparts have yet to be clarified. Probable explanations suggested were that the distress of caregiving may be viewed by Black carers as relatively minor, as they may be more likely to view the symptoms of dementing illnesses as part of the normal ageing process, and they may receive more help from other informal social support systems (Choi, 1998). Gender differences with respect to psychological well being of ethnic minority caregivers has not been sufficiently addressed in the literature, although work by Miller et al. suggest no gender differences between African Americans and Anglos (Miller et al., 1995).
Cultural differences may affect caregiver’s attitudes about treatment. In a study of primary care patients, Cooper found that acceptance of antidepressant medication was significantly lower among African-American and Hispanic patients than among whites, while more than 90% of African Americans believed that "prayer can heal depression”. Cooper LA, et al., 2003.
Comprehensive reviews of the literature have identified differences in the stress process, psychological outcomes, and service utilization among caregivers of different racial and ethnic backgrounds (Connell & Gibson, Janevic & Connell,2001).Studies consistently show important differences in perceived burden and depression among African American, White, and Hispanic family caregivers (Calderon &Tennstedt, 1998; Haley et al., 1996). Studies suggest that African American caregivers report fewer depressive symptoms and lower burden than White or Hispanic caregivers (Connell & Gibson, 1997).Caucasian caregivers tend to report greater depression and appraise caregiving as more stressful than African American caregivers (Farran, Miller, Kaufman, & Davis, 1997; Haley et al., 1996). However, Hispanic caregivers report greater depression and behavioural burden than Caucasians and African Americans (Harwood et al., 1998).
A significant limitation of above studies is the lack of attention to the potential impact or role of racial and ethnic identity on caregiving and how that may affect responses to intervention (Aranda & Knight, 1997; Connell & Gibson, 1997). Culture is known to influence the construction of illness perceptions (Kleinman, Eisenberg, & Good, 1978; Lockery, 1991). The failure to address multicultural issues in intervention research has led to significant gaps in knowledge about psychological problems such as depression and its treatment in the various ethnic subgroups (Sue, Bingham, Porsche-Burke, & Vasquez, 1999).It seems reasonable to expect that racial and ethnic identity may shape cultural beliefs about dementia, which in turn may affect how families respond to the challenges of long-term caregiving and interventions designed to support these efforts (Haley, Han ,& Henderson, 1998).

Social support: Social support has profound effects on caregiver outcomes. Reports invariably indicate that more social support corresponds to less depressive symptomatology (Baumgarten et al., 1992; Schulz & Williamson, 1991) and lower perceived burden (Gallant & Connell, 1997). Social support and caregiver burden have been found to mediate depression in caregivers (Clyburn et al.,2000).
Social support has other important functions in that, carers may find out about services from people who have used them before and form a network with others in similar situations. (Gruetzner, 2001).

Other Characteristics: Loss of self identity is associated with carer depression. Carers face three processes that lead to this problem : chronic stress, role engulfment, and the loss of the patient with dementia. Role engulfment is common because carers no longer have the time or energy to engage in other activities. Prior to caregiving these activities had been important sources of support.
Another category of risk predictors for carer depression involves characteristics of the caregiving context , this includes the caregiver's relationship to the care recipient and the living arrangements. The literature provides substantial evidence that the caregiving experience is most difficult for spousal caregivers (Pruchno & Resch, 1989a). Spousal caregivers experience more depressive symptoms than other caregivers (Baumgarten et al.,1992; Cohen et al.,1990).
Findings concerning the relationship between patient residence and caregiver outcome are inconsistent. Several studies have indicated that caregivers who lived with their parents had higher burden or depression scores than those who lived apart from the care recipient (Grafstorm et al.,1992 et al., 1997). Others, however, have found no significant association between living arrangements and caregiver distress (Dura et al.,1991).

COPING STRATEGIES AND OTHER INTERVENTIONS IMPACTING ON STRESS

There is increasing interest in examining the factors that help caregivers successfully manage their role, while minimizing the effect on their mood and general well-being (Quayhagen &Quayhagen, 1988).Much of this research has been done within the general framework of stress and coping theory (Lazarus &Folkman, 1984),examining coping styles of caregivers and the relationship between types of coping styles and reported symptoms of depression (Fingerman, Gallagher-Thompson, Lovett,& Rose,1996;Pruchno &Resch,1989;Williamson &Schulz,1993).
A variety of interventions have been developed which support caregivers. Interventions include: training and education programes, information-technology based support and formal approaches to planning care, which take into account the specific needs of carers,sometimes using specially designated nurses or other members of the health care team(Woods.,2003).

Education
Ballard et al have demonstrated that a higher level of carer education regarding dementia increase carer's feelings of competency.This was more likely to have reduced their expectations of their dependents abilities. Previous studies which have looked at these coping strategies and feeling of competence have shown that unrealistic expectations of a dependant with dementia increase a carer's risk of depression (Coppel et al., 1985), and conversely a reduction of carer's
expectations is associated with lower rates of depression (Saad et al., 1995). Caregivers who maintain positive feelings towards their relative have a greater level of commitment to caring and a lower level of perceived strain (Horowitz and Shindelman, 1983);furthermore carers who experience feelings of powerlessness, lack of control and unpreparedness have higher levels of depression (Coppel et al., 1985). The most effective treatments in depression of carers appear to be a combination of education and emotional support (Lawton, 2000).

Spirituality
Spiritual support can also be considered a coping resource and has been studied in older African Americans (Chatters et al., 1992; Levin et al., 1995) and older Mexican Americans (Levin et al., 1996).Previous work examining the role of spiritual support observed that African American caregivers report higher spiritual rewards for caregiving (Picot et al., 1997), and reliance on prayer and church support (Dilworth-Anderson and Anderson, 1994).
Religious coping plays paramount role, and it is often present at higher levels for African Americans and Hispanics. For REACH caregivers, Coon et al.(2004) and Haley et al. (2004) find that religious coping is greater for Hispanic and African American than for White caregivers. Religious involvement is frequently associated with more access to social support as well (Walls & Zarit, 1991).

Problem solving

Anecdotal literature (Haley et al.,1987) suggests that caregivers who use more active coping strategies, such as problem solving, experience fewer symptoms of depression than do those who rely on more passive methods . Supporting this work, Saad and colleagues(1995) reported significant associations between positive strategies for managing disturbed behaviour and active strategies for managing the meaning of the illness , and reduced levels of caregiver depression. Nolan and colleagues (1997) suggest that an important role for health -care professionals is in helping caregivers enhance their coping skills, supporting existing skills and facilitating the development of new ones.

Positive aspect to the role
Caregiving has some positive associations for caregivers , including pride in fulfiling spousal responsibilities,enhanced closeness with a care receiver, and satisfaction with one's competence (Kramer, 1997).These perceived uplifts of caregiving were associated with lower levels of caregiver burden and depression in a meta-analysis (Pinquart & Sorensen ,2003). Perceived uplifts are more common among caregivers of color than among Whites (Coon et al.,2004 ; Haley et al., 2004).

Social and professional support
High quality of informal relationships and presence of informal support is related to lower caregiver depression (Cox, 1995) and less deterioration in emotional health for African American caregivers, but not for Whites (Allen, 1993).Support of caregivers by others help to alleviate stress if the supporter is understanding and empathic(Haley et al.,1987).Highly stressed persons may not be able to benefit from attempted social support of others as much as moderately stressed persons (Rivera et al.,(1991).
Caregivers need to have the opportunity to learn more effective ways of coping with stress, In order to reduce anxiety and their reliance on treatments (Gruetzner, 2001).Bourgeois et al., report that caregivers behavioural skills and effective self management training program results in a lower frequency of patient behavioural problems and helps to improve the caregivers mood. Stevens and Burgio (2000) designed a caregiver intervention that teaches caregivers behavioural management skills to address problem behaviours exhibited by individuals with AD,in addition to problem solving strategies to increase pleasant activities for the caregiver.
Psychotherapy may be of some benefit in patients with early dementia but, due to cognitive loss, some adaptation of the technique is required and the involvement of carers is often necessary (Cheston.,1998).Cognitive-behavioural family intervention can have significant benefits in carers of patients with dementia and has a positive impact on patient behaviour.(A.Marriott et al.,2000).
Passive coping styles have been associated with greater burden. Persons who use an escape-avoidance type of coping are known to have more depression and interpersonal conflicts (Gruetzner, 2001).
Among caregivers with depressive symptoms ,19%used antidepressants,23% antianxiety drugs, and 2% sedative hypnotics. African-American caregivers were less likely than Whites to be taking antidepressants(B Sleath et al.,2005).
In a study by Helen C.Kales et al.,2004, use of herbal products/supplements was found in 18% of elderly subjects with depression and/or dementia and in 16% of their care givers.

ROLE OF RESPITE

Respite care is seen by many carers as a very important service in caring for patients with dementia. Information about various respite options, and the availability of affordable, reliable and flexible programs which can manage behavioural problems, appear to be high priorities in enhancing carer well-being (Bloch, 1998). Burdz et al. (1988) examined the effect of respite care and defined it as temporary institutionalisation (in both cases for a period of two weeks) of the person with dementia in a nursing home and in a hospital .
In the Burdz et al. study, respite care proved to have a positive effect on the burden experienced by the caregivers, and it also had a positive effect , against all expectations , on the cognitive and physical functioning of the persons with dementia. Sutcliffe and Larner (1988) studied the effect of individual support for the carers at home (information and emotional support combined with relaxation exercises). The group receiving emotional support improved significantly on mood, whereas the control group deteriorated significantly. Zarit et al. (1998) report the findings of an evaluation of the psychological benifits of the use of adult day care by family caregivers assisting a relative with dementia.It was concluded that use of day care results in lower levels of caregiver-related stress and better psychological well-being.

ABUSE

Abuse, may include physical, psychological, sexual and financial maltreatment,
may be the result of the actions of others (e.g., caregivers) or may result
from neglect by others or by self (Dyer et al., 2000).
Caregivers depression, while providing care to a family member suffering from
dementia may lead to both verbal or physical abuse. Variety of studies have
identified risk factors for abuse of the elderly by family members and other
caregivers (Dyer et al., 2000; Lachs et al., 1997).
Such factors include excessive physical and psychological demands associated
with caregiving; advanced age, poor health, physical frailty and impaired
activities of daily living (ADL) on the part of the care recipient; alcohol
and other substance abuse by caregivers; the caregiver and care recipient living
together; caregiver psychopathology; and a family history of abusive behaviour.
In addition, a number of investigators have found that mental health factors such
as caregivers depression while caring for a person with dementia increase the
risk of abuse within a caregiving relationship (Dyer et al.,2000; Paveza et al.,
1992).
Caregivers themselves may face verbal or physical abuse directed at them by
the patient with dementia. In some cases, Alzheimer's disease or other forms of
dementia may cause the patient to be uncharacteristically aggressive. In other
cases, verbal abuse or physical violence may have been typical of family
interactions before the illness(A C Coyne et al.,1996), and may be exacerbated
by the illness.
A House of Commons report published on BBC (British Broadcasting
Corporation) in 2004 states that 67% of elderly abuse occur in
their own home,12%in nursing homes & 10% in residential care.
There appears to be a relationship between abuse of a family member and
caregiver burden and depression. Caregivers who report directing abuse

toward patients are often more stressed or burdened by caregiving

responsibilities and depression than individuals not engaging in abuse.
Interventions to reduce burden and treat depression should serve to limit abuse
(Paveza et al 1992).

Abuse prior to the onset of dementia appears to be associated with a greater

likelihood of abusiveness between caregivers and care recipients once dementia

occurs. Although such a cycle of abuse (Steinmetz, 1988) is difficult to break,

interventions such as supportive counselling and individual or family

psychotherapy for caregivers, respite or in-home care services for patients, and

alternative living situations for all parties concerned may be helpful (Burkhart,

1990).

CONCLUSION

The impact of caring for a relative with dementia brings the risks of mental ill health to the carer in the form of emotional stress, depressive symptoms or clinical depression. The ramifications of this may include negative effects on the quality of life for the carer and sufferer and the standard of care delivered to support the sufferer. On the higher level ,carers depression is a serious public health problem leading to substantial costs, in varying regards, to society e.g., early entry to long term care.
The challenge to health and social care providers is to properly recognize this symbiotic union and to support it effectively. Quality care needs to be delivered to both units in this union, the sufferer and the carer, if a meaningful package of care is to be allocated. Vigilance is required from those professionals involved in dementia care to reduce carer burden and detect early signs of compromise in carers mental health.
Personal education for carers in the form of advice about dementia itself and the warning signs of carer stress, such as denial, anger, social withdrawal, anxiety , depression, exhaustion, sleeplessness etc. is beneficial.
The needs of carers are increasingly recognized across agencies and, in the United Kingdom, integral to the Unified Assessment Process in the statement that carers are entitled to an individual assessment in their own right. The Draft National Service Framework for Wales 2005, which is a multi agency stakeholder document, points to the vulnerability of carers and states that specialist services for people with dementia should include " interventions for carers, for example structured advice/training, counselling services or short breaks".Caring for the carer is as important as caring for the individual with dementia for a successful outcome in difficult circumstances.

REFERENCES :

Acton, G.A.(2002). Health-promoting self-care in family caregivers.Western Journal of Predictors of institutionalisation among caregivers of patients with Alzheimers disease Nursing Research, 24, 73-86.
Alison Marriott, Catherine Donaldson, Nicholas Tarrier and Alistair Burns (2000). Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer's disease: British Journal of Psychiatry.
Allyson Waite, Paul Bebbington, Martin Skelton-Robinson and Martin Orrell (2004) Social Factors and Depression in Carers of People With Dementia: International Journal of Geriatric Psychiatry 2004: 19;582-587.
Alten, G.J.(1993). Racial variations in caregiver stress and burden among informal caregivers of impaired elderly persons.University of Florida, Gainesville.
Amirkhanyan, A.A., & Wolf, D.A.(2003). Caregiver stress and noncaregiver stress: Exploring the pathways of psychiatric morbidity. Gerontologist, 43, 817-827.
Andrew C. Coyne, Mildred Potenza, Lisa J. Berbig .Abuse in families coping with dementia- special populations: Families coping with Dementia.(1996).
Aranda, M., & Knight, B.(1997). : AThe influence of ethnicity and culture on the caregiver stress and coping process sociocultural review and analysis. The Gerontologist, 37, 342- 354
Ballard, C.G., Saad,K., Patel, A., Gahir,M., Solis, M., et al. (1995a). The prevalence and Phenomenology of psychotic symptoms in dementia sufferers. International Journal of Geriatric Psychiatry, 10, 477-485.
Baumgarten, M., Battista, R.N., Infante-Rivard,C.,Hanley, J.A., Becker, R.,& Gauthier, S.(1992).The Psychological and Physical health of family members caring for an elderly person with dementia. Journal of Clinical Epidemiology, 45,61-70.
Beach, S.R., Schulz, R.,Yee, J.L., & Jackson, S. (2000). Negative and positive health effects of caring for a disabled spouse: Longitudinal findings from the Caregiver Health Effects Study. Psychology and Aging, 15, 259-271.
Betsy Sleath, Joshua Thorpe, MPH, Lawrence R. Landerman, Phd, Marti Doyle, MA, and Elizabeth Clipp, PhD (2005). African-American and white caregivers of older adults with Dementia:Differences in Depressive Syptomatology and Psychotropic Drug Use : By the American Geriatrics Society .
Billings, A., and Moos, R.(1984).Coping, stress, and social resources among adults with unipolar depression. J. Pers.Soc. Psychol. 46: 877-891.
Blazer D, Williams CD. 1980. Epidemiology of dysphoria and depression in an elderly population. Am J Psychiatry 137: 387-394.
Bloch, S., Herrman, H. & Murphy, B. 1998. Family Caregivers: Disability, Illness, and Ageing. Allen & Unwin.
Bookwala, J., Yee, JL., & Schulz, R. (2000). Caregiving and detrimental mental and Physical health outcomes. In G.M. Williamson,P.A. Parmelee, & D.R. Shaffer (Eds.), Physical illness and depression in older adults: A handbook of theory, research, and , practice ( pp.93-131).
Brad Adams, Maria P. Aranda, Bryan Kemp, Kellie Takagi (2002). Ethnic and Gender Differences in distress Among Anglo American, African American, Japanese American, and Mexican American Spousal Caregivers of Persons With Dementia: Journal of Clinical Geropsychology.
Burdz, M.P., Eaton, W.O. and Bond, J.B.(1988) 'and the Effect of respite care on dementia and nondementia patients in caregiver', Psychology and Aging 3, 1:38-42.
Burkhart J (1990), Elder abuse and neglect concern AMA-RPS. JAMA 264(15):1917. Coyne AC, Reichin man WE, Berbig LJ (1993), The relationship between dementia and elder abuse. Am J Psychiatry 150(4):643-646.
Burton, L.X., Newson, J.T., Schulz, R.,Hirsch ,C.H.,& German,P.S.(1997). Preventive health behaviors among spousal caregivers. Preventive Medicine,26, 162-169.
Calderon, V., & Tennstedt, S.(1998). : Results of a qualitative study. Journal of Gerontological Social Work, 30, 159-178.
Canadian Study of Health and Aging Working Group. (1994a).Canadian Study of Health and Aging: Study methods and prevalence of dementia. Canadian Medical Association Journal, 150, 899-913.
Candida Graham, Clive Ballard and Pak Sham (1997) .Carers' Knowledge of Dementia And Their Expressed Concerns: International Journal of Geriatric Psychiatry.
Candida Graham, Clive Ballard and Pak Sham (1997) .Carers' Knowledge of dementia, Their Coping Strategies and Morbidity: International Journal of Geriatric psychiatry.
Chatters, L.M., Levin, J.S., and Taylor, R.J.(1992).Antecedents and dimensions of religious involvement among older black adults. J. Gerontol.Soc.Sci.47: S 269-S278.
Chenoweth B, Spencer B. Dementia: The experience of family caregivers. Gerontologist 1986; 26: 267-72.
Choi, N.G., Monk, A. & Mui, A.C. 1998. Long-Term Care and Ethnicity. Auburn Care of Older Adults. Lawrence Erlbaum Associates
Clive Ballard, Kathleen Lowery,Ian Powell, John O'Brien, and Ian James(2000).Impact of Behavioral and Psychological Symptoms of Dementia on Caregivers: International Psychogeriatrics, Vol.12, Suppl.1 , 2000, pp. 93-105.
Clive Ballard,Kathleen Lowery,Ian Powell,John O'Brien,and Ian James.Impact of Behavioral and Psychological Symptoms of Dementia on Caregivers.International Psychogeriatrics,Vol12,Suppl.1,2000.
Clyburn L, Stones M, Hadjistavropoulos T, et al.:Predict depression in caregiver burden and in Alzheimer's disease.J Gerontol B Psychol Sci Soc Sci.2000;55:S2-S13.
Cohen,D.,&Eisdorfer,C.(1988).Depression in family members caring for a relative with Alzheimer's disease.Journal of the American Geriatric Association,36,885-889.
Cohen,D;Luchins,D;Eisdorfer,C;Paveza,G;Ashford,J.W;Gorelic,P;Hirsehman,R; Freels,S;Levy,P;Semla,T;&Shaw,H.(1990).Caring for relatives with Alzheimers Disease:The Mental Health Risks to Spouses,Adult children and other family caregivers.Behaviour,Health,and Ageing,1,171-182.
Colerick,E.J;&George,L.K.(1986)Depression among Alzheimer's caregivers:Identifying risk factors.American Journal ..Journal of the American Geriatrics Society,34,493-498.
Connel, C.M., Janevic, M.R., & Gallant, M.P.(2001).The costs of caring: Impact of dementia on family caregivers. Journal of Geriatric Psychiatry and Neurology, 14, 179-187.
Connell, C. M.,& Gibson, G.D.(1997). Racial, ethinic, and cultural differences in dementia caregiving: Review and analysis. The Gerontologist, 37,355-364.
Coon, D.W., Rubbert, MP., Solano,N., Mausbach,B., Kraemer, H., Arguelles, T., et al.(in press).Well-being, appraisel, and coping in Latina and Caucasian female dementia caregivers:Finding from the REACH study. Aging and Mental Health, 8(4), 330-345.
Cooper LA, Gonzales JJ, Gallo JJ, et al.The acceptability of treatment for depression among African-American,Hispanic, and White primary care patients.Med Care. 2003;41:479-89.
Coppel, D.B., Burton, C., Becker, J. and Fiore, J. (1985) Relationships of cognitions associated with coping reactions to depression in spousal caregivers of Alzheimer's disease patients. Cog. Ther. Res. 9, 253-266.
Corcoran, J. 2003. Clinical Applications of Evidence-Based Family Interventions.
Covinsky KE, Newcomer R, Fox P,et al.Patient and caregiver characteristics associated with depression in caregivers of patients with dementia. J Gen Intern Med.2003 ;18:1006-1014.
Cox, C. (1995) Comparing the experience of Black and White Caregivers of dementia patients. Social Work, 3, 343-349.
Danhauer, S.C.,McCann, J.J., Gilley,D.W., Beckett, L.A., Bienias, J. L., & Evans, D.A.(2OO4).Do behavioural disturbances in persons with Alzheimer's disease predict caregiver depression over time? Psychology and Aging, 19, 198-202.
Deimling,G.T;Bass,D.M;Townsend,A.L;and Noelker,L.S.(1989).Care Related stress:A comparison of spouse and adult child caregivers in shared and seperate households.Journal of Ageing and health.1,67-82.
Dilworth-Anderson, P., and Anderson, N.B.(1994).Dementia caregiving in Blacks:A contextual approach to research. In Lebowitz, B., Light, E., and Neidereche, G. (eds.), Mental and Physical Health of Alzheimer's Caregivers, Springer, New York , pp.385-409.
Dilworth-Anderson, P., Williams, I.C.,& Gibson, B.E.(2002).: Issues of race , ethnicity, and culture in caregiving research :A 20-year review (1980-2000).The Gerontologist, 42, 237-272.
Draper, B. 2004. Dealing With Dementia: A Guide to Alzheimer's Disease and Depression in Caregivers of Patients with Dementia.
Duijnstee, M.(1992) 'Caring for a demented family member at home: objective observation and subjective evaluation of the burden' in G.Jones and B. Miesen (eds) Care Giving in Dementia 1:359-79.
Dura,J.R;Stukenberg,K.W;and Kiecolt-Glaser,JK.(1991).Anxiety and depressive disorders in adult children caring for demented parents.Psychology and ageing.6,467-473.
Dyer CB, Pavlik VN, Murphy KP, Hyman DJ (2000), The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc 48(2):205-208.
Farran, C.J., Miller, B.H., Kaufman, J.E., & Davis, L. (1997). Race, finding meaning, and caregiver distress.Journal of Aging and Health, 9, 316-333.
Fingerman, K.L., Gallagher-Thompson, D., Lovett, S., & Rose, J. (1996). Internal resourcefulness, task demands, coping, and dysphoric affect among caregivers of the frail elderly. International Journal of Aging &Human Development, 42, 229-248.

Fisk, A.D. & Rogers, W.A. 2002. Human Factors Interventions for the Health for carers of people with dementia.Formal Helpers Lawrence Erlbaum Associates.
Gallagher,D.,Rose,J.,Rivera,P.,Lovett,S.,&Thompson,L.W.(1989).Prevalence of depression in family caregivers.The Gerontologist,29,449-456.
Gallant, M.P., & Connel, C.M.(1997).Predictors of decreased self-care among spouse caregivers of older adults with dementing illnesses. Journal of Aging and Health,9, 373-395.
George,L.K.,&Gwyther,L.P.(1986).Caregiver well being:A multidimensional examination of family caregivers of demented adults.The Gerontologist,26,253-259.
Gilley, D.W., Whalen, M.E., Wilson,R,S.,& Bennett,D.A.(1991).Hallucinations and associated factors in Alzheimer's disease. Journal of Neuropsychaitry and Clinical Neuroscience,3, 371-376.
Gitlin, L.N., Corcoran, M., Winter, L., Boyce, A., & Marcus, S. (1999).Predicting participation and adherence to a home environmental intervention among family caregivers of persons with dementia .Family Relations , 48, 363-372.
Glaser R,Kiecolt-Glaser JK:Chronic stress modulates the virus specific immune response to latent herpes simplex virus Type 1.Ann Behav Med 1997;19:78-82.
Grafstrom,M.,Fratglioni,L.,Sandman,P-O.,&Winblad,B.(1992).Health and social consquences for relatives of demented and non demented elderly.A population based study.Journal of Clinical Epidemiology;45,861-870.
Gruetzner, H.M. 2001. Alzheimer's: A Caregiver's Guide and Sourcebook. Wiley.
Haley, W, E., Levine, E, G., Brown, S, L., Bartolucci, A, A. (1987). Stress appraisal, coping and social support as predictors of adptational outcome among dementia caregivers.Psychology and Aging, 2, 323- 330.
Haley, W. E .,Han B., & Henderson, J.N.(1998). Aging and ethnicity: Issues for clinical practice. Journal of Clinical Psychology in Medial Settings ,5, 393- 409.
Haley, W.E., Gitlin, L.N., Wisniewski, S. R., Mahoney, D.F., Coon, D.W.,Winter, L., et al. (2004). Well-being, appraisal, and coping in African- American and Cuacasian dementia caregivers: Findings from the REACH study. Aging & Mental Health, 8(4), 316-329.
Haley, W.E., Roth, D.L., Coleton, M.I., Ford, G.R., West,C.A.C., Collins, R.P., and Isobe, T.L.(1996). Appraisal, coping , and social support as mediators of well-being in black and Anglo family caregivers of patients with Alzheimer's disease. J.Consult. Clin. Psychol.64: 121-129.

Haley,W.E., Roth, D.L., Coleton, M. I., Ford, G.R., West, C., Collins.Mediators of well-being in Black and White family caregivers of patients with Alzheimer's disease .Journal of Consulting and Clinical Psychology, 64, 121-129.
Haley,W.E.,Levine,E.G.,Brown,S.L.,Berry.J.W.,&Hughes,G.H.(1987b).Psychological,social and health consquences of caring for relatives with senile dementia.Journal of American Geriatrics Society,35,405-411.
Harwood DG, Barker WW, Cantillon, et al.:Depression symptomatology in the first-degree family caregivers of Alzheimer disease patients: A cross-ethnic comparison. Alzheimer Disease & Associated Disorders. 1998; 4: 340-346.
Haupt,M.,&Kurz,A.(1993).Predictors of nursing home placement in patients with Alzheimer's disease.International Journal of Geriatric Psychiatry,8,741-746.
Hebert, L.E., Beckett, L.A., Scherr, P.A.,& Evans, D.A.(2001).Annual incidence of Alzheimer disease in the United States projected to the years 2002 through 2050. Alzheimer Disease and Associated Disorders,15, 169-173.
Helen C. Kales, MD, Frederic C. Blow, PhD, Deborah E.Welsh, MS, and Alan M.Mellow,MD, PhD (2004). Herbal products and other Supplements: Use by Elderly Veterans With Depression and Dementia and Their Caregivers: J Geriatr Psychiatry Neurol 2004;17:25-31)
Holmes, T .H., and Rahe,R.H.(1967).The social readjustment rating scale.J.Psychosom.Res. 11:213-218.
Horowitz, A. and Shindelman, L.W.(1983) Reciprocity and affection: Past influences on current caregiving. J. Gerontol. Soc. Work 5, 5-20.
Joshua R.Shua-Haim,Todd Haim,Yong Shi,Yen-Hong Kuo,Juanita M.Smith.The Clinical .Juillerat, A.C., Van Der Linden, M. & Mulligan, R. 2003.
Kanner,A. D.,Coyne, J.D.,Schaefer, C., and Lazarus,R. S.(1981).Comparison of two modes of stress measurement:Daily hassles and uplifts versus major life events.J.Behav.Med.4:1-39.
Kiecolt-Glaser JK,Dura JR,Speicher CE et al.Spousal caregivers of dementia victims.Longitudinal changes in immunity and health.Psychosomatic Med 1991;53:345-362.
Kleinman, A., Eisenberg, L., & Good, B.(1978).Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88, 251- 258.
Kramer, B.J.(1997).Gain in the caregiving experience: Where are we ?What next? Gerontologist, 37, 218-232.

Lachs MS, Williams C, O'Brien S et al. (1997), Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist 37(4):469-474.
Lawton, M.P. 2000. Interventions in Dementia Care: Toward Improving Quality of Caregiving.
Lawton,M.P., Rajgopal,D., Brody,E., & Kleban,M.H. (1992).The dynamics of caregiving for a demented elder among Black and White families.Journal of Gerontology:Social Sciences ,47, S156-S164.
Lazarus,R. S., and Folkman,S.(1984).Stress,Appraisal,and Coping,Springer Publishing Company,New York.
Leah D. Clyburn, Michael J. Stones, Thomas Hadjistavropoulos, and Holly Tuokko (2000) Predicting Caregiver Burden and Depression in Alzheimer's Disease: The Journals of Gerontology.
Levin, J.S.,Chatters,L.M., and Taylor, R.J.(1995). Religious effects on health status and life satisfaction among Black Americans. J.Gerontol. Soc. Sci.50B: S154-S163.
Lockery, S. (1991).Caregiving among racial and ethinic minority elders.Generations, 15, 58-62.
Lutzsky, S. M.,& ,Knight,B . G.(1994).Explaining gender diferrences in caregiver distress: The roles of emotional attentiveness and coping styles.Psychology and Aging, 9, 513-519.
Lynn C.Waelde and Larry Thompson, Dolores Gallagher- Thompson (2004). A Pilot Study of a Yoga and Meditation Intervention for Dementia Caregiver Stress: Journal of clinical Psychology, Vol. 60
Mc Grath, E., Puryear Keita, G., Stricland, B.R., and Felipe Russo, N.(1992). Women and Depression: Risk Factors and Treatment Issues, American Psychological Association, Washington, DC.
Megumi Takahashi, MD, PhD, Katsutoshi Tanaka, MD, PhD and Hitoshi Miyaoka, MD, PhD (2005) .Depression and associated factors of informal caregivers versus professional caregivers of demented patients: Psychiatry and Clinical Neurosciences.
Miller, B.,Campbell, R. T., Farran, C. J., Kaufman, J.E., and Davis, L.(1995).Race, Control, mastery, and caregiver distress. J Gerontol. 50B: S374- S382.
Morris RG, Morris LW, Britton PG. 1998. Factors affecting the emotional well-being of caregivers of dementia sufferers.Br J Psychiatry 153; 147-156.

Mortiz DJ, Kast SV, Berman LF. The health impact of living with a cognitively impaired elderly spouse: Depressive symptoms and social functioning. Journal of Geronotology 1989;44: 517-27.
Office of National Statistics. Informal Carers: Results of an independent study carried out on behalf on the Department of Social Security as part of the 1995 General Household Survey. The Stationary Office Ltd, 1998.
Ory, M.G., Hoffman, R.R., 3rd, Yee, J. L., Tennstedt, S., & Schulz, R.(1999).Prevalence and impact of caregiving: A detailed comparison between dementia and nondementia caregivers.Gerontologist,39, 177-185...
P.Cuijpers (2005). Depressive disorders in caregivers of dementia patients: A systematic review: Aging and Mental Health.
Paveza GJ, Cohen D, Eisdorfer C et al. (1992), Severe family violence and Alzheimer's disease: prevalence and risk factors. Gerontologist 32(4):493-497.
Pearlin, L.I., Schaie, W. & Zarit, S.H. 1993. Caregiving Systems: Informal and Formal Helpers. Lawrence Erlbaum Associates.
Pearlin,L.I.(1983).Role strains and personal stress.In Kaplan,H.B.(ed.),Psychosocial stress:Trends in Theory and Research,Academic Press,New York, pp.3-32.
Picot, S.J, Debanne, SM., Namazi, K.H., and Wykle, M.L.(1997). Religiosity and perceived rewards of Black and Anglo caregivers. Gerontologist 37: 89-101.
Pinquart, M., & Sorensen, S. (2003). Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: A meta-analysis. Journal of Gerontology: Psychological Sciences & Social Sciences, 58B, 112-128.
Pratt,C.,Wright,S.,&Schmall,V.(1987).Burden,coping and health status:A comparison of family caregivers to community dwelling and institutionalized Alzheimer's patients.Journal of Gerontological Social Work,10,99-112.
Pruchno, R. A., & Resch, N. L (1989).Mental health of caregiving spouses: Coping as mediator, moderator, or main effect ? Psychology and Aging, 4, 454- 463.
Pruchno, R., & Resch, N.L.(1989).Abberant behaviours of Alzheimer's disease: Mental health effects on spouse caregivers. Journal of Gerontology ,44, S177-S182.
Pruchno, R.A., & Potashnik, S.L.(1989) .Caregiving Spouses: Physical and mental health in perspective. Journal of the American Geriatrics Society, 37, 697-705.
Quayhagen. M.P.,& Quahagen. M. (1998).Alzheimer's stress: Coping wih the caregiving role. The Geronotologist, 28, 391-396.
Rabins PV: Management of dementia in the family context. Psychosomatics.1984; 25: 369-375.
Rabins, P.V., Mace., N.L., & Lucus, M.J.(1982). The impact of dementia on the family. Journal of the American Medical Association, 248, 333-335.
Redinbaugh EM, Mc Callum RC, Kiecolt-Glaser JK.1995. Recurrent syndromal depression in caregivers. Psychol Aging 10: 358-368.
RGO Health Council of the Netherlands(2002) Dementia, The Hauge: Health Council of the Netherlands 2002/04.
Richard Schulz,Ph.D, Lynn M.Martire, Ph.D (2004) .Family Caregiving of Persons With Dementia. Prevalence, Health Effects, and Support Strategies: Am J Geriatr Psychiatry 2004; 12:240-249.
Russo,J.,Vitaliano,P.P.,Brewer,D.D.,Katon,W.,&Becker,J.(1995).Psychiatric disorders in spouse caregivers of care recipients with Alzheimer's disease and matched controls:A diathesis-stress model of psychopathology,Journal of abnormal psychology,104,197-204.
Saad, K.,Hartman, J.,Ballard, C., Kurian, M.,Graham, C.and Wilcock, G.(1995) Coping in the Carers of dementia sufferes. Age Ageing 24 , 495-498.
Schulz, R., and Williamson, G.(1991).A Two-year longitudinal study of depression among Alzheimer's caregivers. Psychol. Aging 6:569-578
Schulz, R., O'Brien, A.T., Bookwala, J.,& Flessiner, K.(1995). Psychiatric and physical morbidity effects of dementia caregiving : Prevalence, correlates, and causes. Gerontologist, 35, 771-791.
Shaw WS,Patterson TL,Semple SJ,et al:Longitudinal analysis of multiple indicators of health decline among spousal caregivers.Ann Behav Med 1997;19:101-109.
Silvia Sorensen and Martin Pinquart (2005) Racial and Ethnic Differences in the Relationship of Caregiving Stressors, Resources, and Sociodemographic Variables to Caregiver Depression and Perceived Physical Health: Aging and Mental Health, September 2005; 9(5):482- 495.
Steinmetz SK (1988), Duty Bound: Elder Abuse and Family Care. Newbury Park, Calif.: Sage Publication
Stone R, Cafferata GL, Sangl J.1987.Caregivers of the frail elderly:a national profile.Gerontologist 27:616-626.
Sue, D. W.,Bingham,P.,Porsche-Burke,L.,&Vasquez,M.(1999).The Diversification of Psychology:A multicultural revolution. American Psychologist, 54,1061-1069.

Sutcliffe, C. and Larner, S.(1998) ' Counseling carers of the elderly at home : a preliminary study', British Journal of Clinical Psychology 27:177-8.
Suzanne C. Danhauer , Judith J. Mc Cann and David W.Gilley, Laurel A. Beckett, Julia L. Bienias and Denis A. Evans(2004). Do Behavioural Disturbances in Persons With Alzheimer's Disease Predict Caregiver Depression Over Time: Psychology and Aging.
Teusing JP, Mahler S : Helping families cope with Alzheimer's disease. Hosp & Community Psychiatry. 1984; 35: 152-156.
Vitaliano,P.P.,Russo,J.,Young,H.M.,Teri,L.,&Maiuro,R.D.(1991).Predictors of burden in spouse caregivers of individuals with Alzheimers disease.Psychology and Ageing,6,392-402.
Williamson, G.M.,& Schulz, R. (1993). Coping with specific stressors in Alzheimer's Disease caregiving. The Geronotologist, 33, 747-755.
Woods RT, Wills W, Higginson IJ, Hobbins J, Whitby M. Support in the community for people with dementia and their carers: a comparative outcome study of specialist mental health service interventions. International Journal of Geriatric Psychiatry 2003; 18:(4):298-307.
Yee, J.L., & Schulz, R.(2000).Gender differences in psychiatric morbidity among family caregivers.A review and analysis.The Gerontologist, 40, 147-164.
Yvonne Yueh-Feng Lu and Mary Guerriero Austrom (2005). Distress Reponses and Self- Care Behaviours in Dementia Family Caregivers With High and Low Depressed Mood: J Am Psychiatr Nurses Assoc, 2005; 11(4), 231-240.
Zarit SH, Reever KE, Bach-Peterson J: Relatives of impaired elderly: Correlates of feeling to burden. The Gerontologist. 1980; 20: 649-655.
Zarit, S. H., Todd, P.A and Zarit, J. M (1986) Subjective burden of husbands and wives as caregivers: A longitudinal study. Gerontologist 26, 260-266.
Zarit, S.H., Stephens, M.A., Townsend, A. and Greene, R. (1998) 'Stress reduction for family caregivers: effects of adult day care use ', J. Gerontol. B Psychol. Sci.Soc.Sci. 53, 5:S267-77.
Zarit,S.,Orr,N.,&Zarit,J.(1985).The hidden victims of Alzheimer's disease:Families under stress.New York:New York University Press.

Click on these links to visit our Journals:
Psychiatry On-Line
Dentistry On-Line | Vet On-Line | Chest Medicine On-Line
GP On-Line | Pharmacy On-Line | Anaesthesia On-Line | Medicine On-Line
Family Medical Practice On-Line

Home • Journals • Search • Rules for Authors • Submit a Paper • Sponsor us