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Objective: To characterize the differences of caregiver burden in patients with Alzheimers disease (AD)
and vascular dementia (VaD) in order to improve the care counselling and management plan.
Methods: We included 506 patients consecutively attending the Alzheimers Evaluation Unit of a
Geriatric Unit, evaluated with Mini Mental State Examination (MMSE), Clinical Dementia Rating
(CDR), Hamilton Rating Scale for Depression, and Neuropsychiatric Inventory. To all caregivers were
administered the Caregiver Burden Inventory (CBI), a 24-item multidimensional questionnaire in which
5 subscales explore 5 dimensions of caregiver burden: (1) CBI-Objective; (2) CBI-Developmental; (3)
CBI-Physical; (4) CBI-Social; and (5) CBI-Emotional.
Results: The present study included, respectively, 253 AD patients and 253 VaD patients. AD patients at
baseline showed a signicantly higher instruction level (p < .0001), higher grade of cognitive impairment (MMSE, p < .0001), and increased severity stage of dementia (CDR, p < .0001) than VaD patients.
AD caregivers, mainly females (p = 0.010), devoted signicantly more length of time care (in months,
p = 0.010) and time of daily care (in hours, p = 0.011) and showed a signicantly higher burden level
in CBI-Objective (p = 0.047), CBI-Physical (p < .0001), CBI-Social (p = 0.003), CBI-Emotional
(p < .0001), and CBI-total score (p < .0001), than VaD caregivers. In both caregiver groups, a higher
presence of spouses and sons (p < .0001) compared to other relatives was observed. AD caregiver
burden showed a signicant association with sex of caregivers and length of time care in months.
Conclusions: AD caregivers showed a higher burden level than VaD caregivers, and this appeared to be
associated with sex and length of time care. Copyright # 2014 John Wiley & Sons, Ltd.
Key words: caregiver burden; Alzheimers disease; vascular dementia
History: Received 14 March 2014; Revised 27 September 2014; Accepted 15 October 2014; Published online in Wiley Online
Library (wileyonlinelibrary.com)
DOI: 10.1002/gps.4232
Introduction
Dementia is a term that describes disorders causing
cognitive impairment severe enough to affect functional status and with devastating consequences for
the entire familiar network. The most common forms
of dementia are Alzheimers disease (AD) and vascular
dementia (VaD). The global prevalence of dementia is
rising and AD, which accounts for about 60% of all
Copyright # 2014 John Wiley & Sons, Ltd.
G. DOnofrio et al.
For dichotomous variables, hypotheses regarding differences between the groups were tested using Fishers
exact test. This analysis was made using the 2-Way
Contingency Table Analysis available at the Interactive
Statistical Calculation Pages (The R Project for Statistical Computing; available at URL http://www.r-project.
org/). For continuous variables, normal distribution
was veried by the ShapiroWilk normality test and
the one-sample KolgomorovSmirnov test. For normally distributed variables, hypotheses regarding differences among the groups were compared by means of
the Welch two sample t-test or by means of the analysis
of variance (ANOVA) under general linear model. For
non-normally distributed variables, hypotheses regarding differences among the groups were compared by
means of the Wilcoxon rank sum test with continuity
correction or by means of the KruskalWallis rank
sum test. Finally, AD diagnosis as independent predictor of caregiver burden was assessed using univariate
multinomial logistic regression analysis (ANCOVA)
including into the model gender, length of time care
(in months), and time of day care (in hours). Risks will
be reported as odds ratios (OR) along with their 95%
condence interval (CI). All the statistical analyses were
made with the R Ver. 2.8.1 statistical software package
(The R Project for Statistical Computing; available at
URL http://www.r-project.org/). Tests in which the
p value was smaller than the Type I error rate
= 0.05 were declared signicant.
Results
Clinical and functional characteristics of patients
G. DOnofrio et al.
than 65 years, 31 patients had an incomplete examination, and 21 patients had severe comorbidity associated with cognitive impairment. Thus, the nal
population included 506 patients, 183 men (36.2%),
and 323 women (63.8%) with a mean age of
78.04 years 5.70 and a range from 65 to 95 years.
253 patients had a diagnosis of AD and 253 of VaD. Demo-
Table 1 Demographic and clinical characteristics of Alzheimers disease (AD) and vascular dementia (VaD) patients
AD
VaD
(n = 253)
(n = 253)
78.44 5.15
6590
99/154
60.9%
6.62 5.11
018
18.48 3.83
1123
1.32 0.51
12
18.08 4.93
024
18.76 16.35
067
2.40 1.68
06
77.60 6.23
6595
84/169
66.8%
5.13 4.04
018
20.46 3.20
1023
1.15 0.50
12
18.00 4.86
022
40.52 18.48
0108
2.08 1.41
07
Age (years)*
Range
Sex (M/F)
Female
Instruction level (years)*
Range
MMSE (score)*
Range
CDR*
Range
HDRS (score)*
Range
NPI (score)*
Range
N of medications*
Range
0.108
0.165
<0.0001
<0.0001
<0.0001
0.856
<0.0001
0.157
MMSE, Mini-Mental State Examination; CDR, Clinical Dementia Rating scale; HDRS, Hamilton Rating Scale for Depression;
NPI, Neuropsychiatric Inventory.
*Values are presented as mean standard deviation.
Sex (M/F)
Female
Length of time care
(months)*
Range
Time of day care (h)*
Range
Relationship with patient
Spouses N (%)
Sons N (%)
Other relatives N (%)
Private carers N (%)
AD
(n = 253)
VaD
(n = 253)
114/139
54.9%
16.28 8.18
143/110
43.5%
14.35 8.89
0.010
640
8.15 0.72
712
636
5.72 2.20
412
126 (49.8)
91 (36.0)
30 (11.9)
6 (2.4)
172 (68.0)
54 (21.3)
6 (2.4)
21 (8.3)
0.011
0.000
<0.0001
Table 3 Caregiver burden level in Alzheimers disease (AD) and vascular dementia (VaD) caregivers explored with the Caregiver Burden Inventory
(CBI) subscales
AD
(n = 253)
VaD
(n = 253)
64.71 11.45
3386
12.04 3.10
419
12.63 2.60
417
14.64 2.16
919
12.90 2.64
416
12.50 2.04
816
60.83 12.86
1986
11.48 3.14
420
12.46 2.60
418
13.44 2.78
519
12.21 2.48
516
11.24 2.55
418
<0.0001>
0.047
0.468
<0.0001
0.003
<0.0001
severity stage of dementia than VaD patients. Conversely, AD patients showed a signicant lower impairment in NPS than VaD patients. Germain et al.
(2009) reported the results of a Principal Component
Analysis on a sample of 1091 AD patient/caregiver
dyads suggesting that, although the strongest determinants of the caregiver burden were NPS, instrumental
activities of daily living (IADL) difculties, and time
spent caregiving, the impact of the degree of cognitive
impairment on burden is also signicant. The increased level of cognitive impairment and dementia
stage in our AD patients may partly explain the
increased caregiver burden of this group of patients
compared to those with VaD. Therefore, intervention
with drugs targeting cognitive symptoms may alleviate
also caregiver burden for AD and VaD patients. In
fact, neurotransmitter-focused drugs (cholinesterase
inhibitors and memantine) have demonstrated to
reduce the severity of cognitive symptoms and NPS
Int J Geriatr Psychiatry 2014
5.310)
2.006)
1.558)
0.534)
0.703)
0.271)
9.464
3.023
2.492
1.411
1.675
1.101
3.890
0.593
0.139
1.227
0.668
1.262
<.0001
0.034
0.551
<.0001
0.004
<.0001
CBI Total
CBI-Objective
CBI-Developmental
CBI-Physical
CBI-Social
CBI-Emotional
OR
p Value
(1.7456.034)
(0.0461.141)
( 0.3130.597)
(0.7891.666)
(0.2171.118)
(0.8551.669)
0.012
0.933
0.159
<.0001
0.074
<.0001
1.824
0.014
0.2238
0.840
0.315
0.920
(0.3973.250)
( 0.3410.313)
( 0.5700.093)
(0.5091.172)
( 0.0300.661)
(0.6141.227)
<.0001
<.0001
<.0001
<.0001
<.0001
0.0001
7.387
2.514
2.025
0.973
1.189
0.686
(
(
(
(
(
(
(95% CI)
OR
(95% CI)
p Value
OR
(95% CI)
p Value
Table 4 Univariate logistic regression analysis (ANCOVA) of Caregiver Burden Inventory (CBI) subscales, sex, length of time care (in months), or time of day care (in hours) for Alzheimers
disease (AD) vs. vascular dementia*(VaD) caregivers
G. DOnofrio et al.
psychotherapeutic interventions showing the most consistent short-term effects on all outcome measures
(Srensen et al., 2002). Furthermore, studies with
neurotransmitter-focused drugs (Feldman et al., 2003)
and caregiver trainings (Hyer and Ragan, 2003) have
been tested for effectiveness on caregiver burden, with
only modest benecial impact. Similarly, some randomized clinical trials (RCTs) designed to address NPS in dementia, like Clinical Antipsychotic Trials in Intervention
Effectiveness (CATIE) (Schneider et al., 2003) and Cholinesterase Inhibitor and Atypical Neuroleptic in the
Management of Agitation in Alzheimer Disease
(CALM-AD) study (Howard et al., 2007), also have
resulted in poor outcomes or effect sizes. These unsatisfactory ndings suggest the need for research covering
non-pharmacologic treatments or other outcome
markers. Notwithstanding the lack of a clearly dened
and effective caregiver intervention, there is an emerging
consensus that optimal care in dementia may require an
integrated approach. Multimodal interventions with
cognitive stimulation and behavioural management
focusing on patient behaviour and caregiver skills,
together with the judicious use of pharmacotherapy,
psychoeducational intervention regarding management
of NPS, caregiver coping skills training, and environmental management may be especially helpful (Gauthier
et al., 2010). Ideally, such programs should be tailored
according to patient and caregiver factors to prevent
patient/caregiver crises. Results from the present study
supported the idea of intervention customization, as we
demonstrated that global cognitive impairment and
diagnosis category and aetiology may cause different
caregiver responses and levels of burden. In this sense,
caregivers of AD patients should be counselled regarding
the particular heavy burden associated with the nal
phase of the disease. Given the relatively higher physical
and objective burden found in the present study, especially for relatives engaged in their caregiving activities
for a longer and intensive period of time, interventions
should focus on the dementia-specic burden factors,
like aggressiveness and personality changes on the part
of the patients, especially for AD, and loss of control
and increased workload on the part of the caregivers
(Selwood et al., 2007). Our results also showed a greater
impact of emotional burden for AD caregivers than for
VaD caregivers. Successful intervention programs should
be designed to help caregivers in developing an effective
coping style when dealing with the manifestations of AD.
Such programs should provide adequate training for both
managing the day-to-day demands of the cognitively impaired relative (by relying, particularly, on problemfocused strategies) and monitoring the emotional distress
experienced by the caregiver (using emotion-focused
Copyright # 2014 John Wiley & Sons, Ltd.
strategies). Instrumental strategies seem to promote positive effect, with acceptance techniques consistently corresponding to lower levels of pathology. Wishfulness and
intrapsychic strategies, on the other hand, are related to
mental health problems (Pruchno and Resch, 1989).
Helping caregiving spouses to acknowledge and understand the changes in their cognitively impaired partner
and also to take action in appropriate ways are suggested
as the best ways to promote positive mental health and
alleviate stress (Graham et al., 1997).
Caregiver education programs should include components addressing the acknowledgement of the disease, the cognitive shift into a caregiving role, and the
development of emotional tolerance, with the aim of
establishing realistic goals, gauging the patients capacities, and designing opportunities for satisfying work
and leisure (Hepburn et al., 2003). In fact, the best
results have been obtained with multi-modal and intensive interventions and those targeting caregiver stress individually (Roth et al., 2005; Schulz and Martire, 2004).
These recommendations were based on previous studies
with enhanced counselling and support intervention for
dementia caregivers (Mittelman, 2003; Mittelman et al.,
2004), the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) multicenter trial
(Ball et al., 2002), and the more recent RCTs Resources
for Enhancing Alzheimers Caregiver Health (REACH)
I (Schulz et al., 2003; Gitlin et al., 2003) and II (Lykens
et al., 2014) with multicomponent interventions,
among others (Srensen et al., 2002).
Limitations of the present study were the absence of
data about the caregiver age and instruction level and
the study population comprising only Caucasian patients recruited in a single centre, so it is possible that
our ndings may not be applicable in other populations. Larger prospective multicenter studies are therefore needed to conrm our ndings.
Conclusion
In conclusion, we found that CBI may be a useful tool
in the prediction of caregiver burden and correlated
well with months of care and hours of daily care. In
fact, AD caregivers showed a higher burden level than
VaD caregivers, and this appeared to be associated
with sex and length of time care. Interventions that
seek to reduce caregiver burden should address intrinsic specic differences of every patients, also linked to
dementia diagnosis, and developing tailored action
plans to improve the disease management and the
resource consumption.
Int J Geriatr Psychiatry 2014
G. DOnofrio et al.
Conict of interest
None declared.
Key Points
Alzheimers disease (AD) and vascular
dementia (VaD) are common in older
people, determining relevant social and
human consequences for the patients and
their caregivers.
Informal caregivers reported higher levels of
depression and anxiety, use of psychotropic
medication more frequently, engagement
in fewer protective health behaviours,
and increased risk of medical illness and
mortality. High caregiver burden is also a
predictor of early institutionalization of
the patients.
The present study attempted to investigate
the factors associated with an independent
etiology of caregiver burden in AD and
VaD caregivers using the Caregiver Burden
Inventory.
AD caregivers showed a higher burden level
than VaD caregivers, and this appeared to
be associated with sex and length of time
care. Implications for clinical practices
were discussed.
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