Introduction

Providing daily care to demented family members is a physically and emotionally exhausting task. Families provide this care out of love, concern, fear of institutionalization, financial pressures, and/or guilt. No matter what the motivation, it is an enormously difficult job which causes new stresses on the caregiver as the dementia victim passes through different stages of the illness. A large volume of previous research has shown that the physical and emotional health of community-dwelling family caregivers is negatively effected. Among the consequences is depression which is alarmingly common among these caregivers, and it often severe.

Previous studies have shown that unsafe and inappropriate behaviors are one of the most difficult aspects of the disease for caregivers, and cause tremendous emotional stress. Behavioral management strategies and techniques have improved markedly over the past several years but the research for the application of this new information has been focused on institutional settings. This study attempts to determine the ability of nurses to reduce this stress by teaching caregivers to understand, prevent, and reduce problematic behaviors by applying a model of care called the Progressively Lowered Stress Threshold Model (PLST) (Hall and Buckwalter, 1987).

Method

Beginning with a study sample of over 300 community-dwelling family caregivers, 245 caregivers completed the study. Attrition was expected and occurred must often because of the death or institutionalization of the patient. Most of the caregivers were women (3 to 1 ratio) and were elderly themselves. Two-thirds were the patients' spouses and one-quarter were the patients' adult children. The remaining 13% were the patients' grandchildren, siblings, neighbors, and other family members.

Although the study's inclusion criteria accepted any informal caregiver who provided as little as four hours of direct care or supervision each week, these caregivers provided direct care an average of 122 hours a week or nearly 17.5 hours each day.

Participants were randomly assigned to one of two groups. The control group received the usual literature about the disease, and referrals to resources and services available in their communities. Those assigned to the study group received individualized care plans based on PLST, instruction to implement the plan including role playing and return demonstration, plus the same literature and referrals as the control group.

Participants were assessed for mood and depression at the beginning of the study, and then at three-month intervals over the following year. The tools used were the validated and commonly used Profile of Moods States (POMS) (McNair, et al., 1971) and the Geriatric Depression Rating Scale (GDRS) (Yesavage, et al., 1971).

Results

At six months, the caregivers in the study group appeared to benefit from the additional interventions by experiencing less depression than the control group. But by the end of the year, the difference was no longer significant. The similarity for the incidence and severity of depression between the two groups appears to be unrelated to the intervention. In reviewing their data, it was found that caregivers' whose depression was most severe were more likely to institutionalize the patient or to drop out from participating in the study.

Based on the POMS scores, participants in the study group experienced less tension, anxiety, anger, fatigue, and confusion than caregivers in the control group.

Comment

The study sample is representative of the thousands of family caregivers at home. Although one particular model of care for demented elders was used in this study, this is not a study which compares one behavior management strategy against another. It seems reasonable that if any plan of care for behavior management is taught to the caregivers, a great deal of stress would be relieved and depression reduced in frequency and severity. From previous research and again found in this study, we know that the most likely time for family to struggle with depression is when they first assume the role of caregiving. If these caregivers can be provided with the information and skills to reduce, if not prevent, problematic behaviors, the incidence and severity of depression among caregivers could be greatly reduced.