Based on the vulnerability model of depression, this study tested the hypothesis that caregivers with prior depression are more likely to be depressed during caregiving than caregivers without prior depression. We further hypothesized an interaction effect in which caregivers with prior depression would be affected more by care-recipient dependency in activities of daily living and care-recipient depressive symptoms than those without prior depression. In a sample of 111 caregivers of persons with Alzheimer's disease, in an additive regression model, neither 'prior depressive symptoms' nor the clinically more serious 'prior depressive syndrome' was related to depressive symptoms during caregiving. In an interaction model, for caregivers with either 'no prior depression' or 'prior depressive symptoms,' the greater the care-recipient dependencies in instrumental activities of daily living (IADL), the greater were the depressive symptoms during caregiving. For caregivers with a 'prior depressive syndrome', however, the greater the IADL dependency, the fewer were the depressive symptoms during caregiving. This unexpected finding suggests that caregivers with a history of clinically significant depression are not necessarily more prone to depressive symptoms when caregiving responsibilities, at least for instrumental activities, are high. This result questions the vulnerability model of depression when applied to older caregivers.

OBJECTIVES:Studies of caregivers illustrate a classic sampling dilemma: maximizing recruitment without compromising study validity. Because caregivers are defined in relation to a care recipient, sampling methods are often determined by pragmatic decisions such as access, efficiency, and costs. However, overlooking validity may result in selection bias, misclassification of caregiver status, and the confounding of results. Validity and pragmatic concerns were compared in four caregiver studies that used different sampling frames: community based, Alzheimer's disease registry, and ancillary studies to existing epidemiologic studies.METHODS:Systematic comparison of validity and of pragmatic aspects of sampling frames, recruitment methods, and participation rates, with attention to caregiver identification, inclusion criteria, and sample restriction.RESULTS:All studies used task-based inclusion criteria. Caregiver participation rates ranged from 81% to 96%, with higher rates in community-based and registry-based studies than in ancillary studies. The latter studies benefited from unbiased selection of noncaregivers.DISCUSSION:Regardless of sampling frame, standard task-based inclusion criteria to define caregivers may enhance validity.

OBJECTIVES: To derive a clinically relevant age-independent physiologic failure scoring system and to use this system to examine aspects of the association of physiologic failure, age, and comorbidity with inpatient mortality.DESIGN: Retrospective, secondary analysis of a derivation and validation cohort selected from the Cleveland Health Quality Choice Coalition data set.SETTING: Thirty hospitals in greater Cleveland.PARTICIPANTS: Thirty-one thousand nine hundred seventy-six inpatients aged 50 and older discharged in 1993 with a diagnosis of congestive heart failure, pneumonia, or stroke.MEASUREMENTS: The Inpatient Physiologic Failure Score (IPFS) was developed and used to calculate physiologic failure. Forty-four candidate variables were examined for their association with inpatient mortality, and 12 were selected. A point value (2, 3, 4, or 6) based on adjusted odds ratio was assigned for an abnormal result for each of the 12 common physiologic variables. Each patient's abnormal physiology points were summed to produce a physiologic failure score (range 0-39). Comorbidity was quantified using the Patient Management Category Severity Scale. The association between mortality and increasing physiologic failure, increasing age and comorbidity, and distribution of physiologic failure with increasing age and comorbidity were examined. A threshold age was sought. Models for predicting inpatient mortality were developed.RESULTS: Twelve physiologic variables constitute the IPFS. Increasing physiologic failure, age, and comorbidity were associated with increasing mortality. Increasing physiologic failure was not associated with increasing age or comorbidity. We did not find a threshold age. The area under the receiver operating characteristic (ROC) curve for predicting inpatient mortality for IPFS was 0.730, and for comorbidity was 0.741 (not significant). The area under the ROC curve for a mortality prediction model based on age was significantly less (0.603). Accounting for patient age did not significantly improve the predictive ability of the IPFS model (area = 0.752, P < .05). The complete model best predicted mortality (0.829).CONCLUSIONS: The IPFS represents a clinically relevant method for scoring physiologic failure. Physiologic failure, age, and comorbidity are independently and differently associated with inpatient mortality. Physiology fails independent of age and comorbidity.

The “reserve” hypothesis suggests that education should affect the clinical expression of Alzheimer's disease (AD), but results from studies examining this idea are not consistent. In a single study, we evaluated the effects of educational attainment on three aspects of the clinical expression of AD: age at symptom onset, rate of cognitive decline, and survival. Subjects were 258 persons with mild-or moderate-stage Alzheimer's, drawn from our AD Research Registry. With statistical adjustment for confounding variables present in a clinic-based design, we found that higher educational attainment was associated with slightly earlier reports of symptom onset and a slower rate of cognitive decline on the Mini-Mental State Exam (MMSE). Education did not affect time of survival until death. We conclude that, for subjects in our sample, education had modest effects on aspects of the clinical expression of AD. These effects were not fully consistent with predictions derived from the “reserve” hypothesis.

Whereas a growing commitment to incorporating caregiver attitudes, beliefs, and perceptions into research and practice related to service use has emerged, less attention has been paid to the link between these subjective caregiver characteristics and the caregiving experience more gent rally. In a sample of 120 family caregivers of persons with Alzheimer's disease, we found that independent of actual receipt of help and caregiver perceptions about their own health and that of the care recipient, normative beliefs about receiving hell, were significantly related to caregiver mental and physical burden, role captivity and overload practitioners may be able to improve the caregiving experience by taking caregivers' normative beliefs into account throughout the caregiving trajectory and by helping individuals and families modify maladaptive beliefs.

Research that has examined the linkages between social resources and health outcomes has been hindered by a lack of clarity in the conceptualizations of key social resources such as social ties and social support, This article presents evidence that social ties and social support are separate constructs and should be treated as such, In a study of 203 family caregivers, measures of social resources were only moderately to weakly intercorrelated. The social resource measures behaved differently as predictors of caregiver burden, physical well-being, and emotional well-being in a path analysis, and the subjective perception of adequacy of social ties was more germane to explaining health outcomes than was an objective number of social ties, Researchers must clearly and consistently operationally define measures used to examine relationships between social resources and health outcomes if these enigmatic connections are to be fully understood.

Caregivers of persons with Alzheimer's disease (AD) are confronted with novel decision-making tasks that leave them at risk for social isolation. ComputerLink is a computer network providing information, communication, and decision-support functions for caregivers of persons with AD. One hundred two AD caregivers participated in a randomized field experiment to evaluate the effects of ComputerLink on confidence in decision making, decision-making skill, and social isolation. During the 1-year study period, AD caregivers averaged two encounters per week with ComputerLink for sessions lasting an average of 13 minutes. Access to ComputerLink enhanced caregivers' decision-making confidence. Decision-making skill was unaffected. ComputerLink access did not lead to changes in social isolation as measured by standard instruments. The decision-support function was used least often. Postings to ComputerLink's public bulletin board included both information-seeking and supportive messages. These findings are congruent with reports of other community-based interventions for caregivers and consistent with evaluations of computerized decision-support systems.

The Alzheimer's Disease Support Center (ADSC) is a telecomputing-based project designed to provide information and support to caregivers of persons with dementia. Inherent features of telecomputing make computer-mediated information and support systems like the ADSC a viable complement to existing efforts to meet caregivers' needs. This article outlines the rationale for the ADSC and describes its context, structure, content, and operation.

How personality changes in Alzheimer's disease is not well understood. Accentuations of premorbid personality, systematic shifts in personality traits, and specific personality changes affecting subtypes of patients have been postulated. To investigate which of these alternatives occurs in Alzheimer's disease, caregivers were given a comprehensive personality inventory standardized for use by informants. Caregivers observed more neurotic, less extroverted, and less conscientious behavior. To a smaller extent, patients with Alzheimer's disease were reported as becoming less agreeable and less open. The changes in reports of neuroticism, extroversion, agreeableness, and openness suggested consistent systematic shifts across all patients. Patients with depressive features were reported to have been more neurotic; those with paranoid delusions were reported as having been more hostile. Premorbid personality traits may predispose to subsequent psychiatric symptoms in Alzheimer's disease.

Assessment of activities of daily living (ADL) in Alzheimer disease (AD) is critical in establishing the diagnosis, monitoring disease progression, evaluating the efficacy of treatment interventions, and determining the need for health and social services. The proper method to measure ADL depends on the purposes to which the scale is to be put. Existing ADL scales differ as to the type of behaviors assessed, the nature of the observations made, and the manner in which the observations are quantified. These scales were not specifically designed to evaluate changes in the nature and extent of the broad spectrum of functional difficulties seen in individuals with AD. We describe the Cleveland Scale for Activities of Daily Living (CSADL), an informant-based instrument designed to expand upon the capacity of existing physical and instrumental ADL scales by assessing both premorbid and current component acts (e.g., initiation versus implementation) of daily living functions.

Computers have become ubiquitous in contemporary society, as has the demand for home care for the elderly. Caregiving is recognized as a normal experience across the life span, and nurses must develop innovative responses to support caregivers. Computer networks offer caregivers access to a wide range of services such as communication, information, and decision support. Presented here is an interim report of a randomized field experiment demonstrating the feasibility of computer networks as a mechanism for delivering nursing services to caregivers of persons with Alzheimer's disease. Caregivers can and do use the computer network in home care.

A retrospective chart review was undertaken to assess the prevalence of specifically defined psychiatric symptoms in 217 outpatients with clinically probable Alzheimer's disease. A weak but significant correlation was found between Alzheimer's disease and suspiciousness and paranoia (reported by 35.5% of patients), delusions (30%), and formed visual hallucinations (18.4%). Mild depressive symptoms, such as sad affect, hopelessness, and helplessness were reported by 40.6% of patients, anxiety and fearfulness by 30.9%, and aggressive acts by 24.9%. Psychotropic medications used to manage these symptoms included antipsychotics, in 11.5% of patients, anxiolytics, in 9.2%, and antidepressants, in 7.4%.