Caregiver Preparedness: A therapeutic mechanism and moderating factor on outcomes for the Savvy Caregiver Program

Abstract

Objectives:

Evidence-based interventions for dementia caregivers, such as the Savvy Caregiver Program (SC), seek to address skills and knowledge deficits, caregiver burden, depressive symptoms, and grief. Little research has examined mechanisms by which these interventions accomplish their goals. Caregiver preparedness may be a possible mechanism by which caregiver interventions may confer benefits.

Methods:

The sample included 76 dementia caregivers who completed the 6-session SC. Participants completed the Anticipatory Grief Scale, Center for Epidemiological Studies-Depression Scale, the Preparedness for Caregiving Scale, and the Zarit Burden Interview-Short Form.

Results:

A repeated measures ANOVA was utilized to determine the interaction between baseline scores and pre-post change in caregiver preparedness. Analysis significantly predicted caregiver burden, (F₍₁₎=6.68, p=.012, partial η²=.10), depressive symptom endorsement, (F₍₁₎=6.41, p=.014, partial η²=.09, and anticipatory grief, (F₍₁₎=6.22, p=.02, partial η²=.1), post-treatment.

Conclusions:

Pre-post change in caregiver preparedness significantly predicted pre-post change across measures of caregiver burden, depressive symptom endorsement, and anticipatory grief. Findings suggest that caregiver preparedness may be one mechanism by which the SC confers positive outcomes. These findings provide an empirical and theoretical basis for tailoring future dementia caregiver interventions.

Introduction

The majority of caregiving for individuals with Alzheimer’s disease and other dementias occurs in community-based settings across the United States and is carried out primarily by 41.8 million informal caregivers, significantly higher than in 2015 (AARP & National Alliance for Caregiving [NAC], 2020; NAC & AARP Public Policy Institute, 2015; National Institute on Aging, 2016; Trivedi et al., 2014). The Alzheimer’s Association reported 18.6 billion hours of unpaid caregiving labor in 2019 for Alzheimer’s and dementias (Alzheimer’s Association, 2020). A majority of these caregivers report experiencing high amounts of stress and negative effects on employment. While many caregivers acknowledge no need for clinical intervention (Marino et al., 2017), many seek professional or informal support to improve their own well-being, increase dementia knowledge, develop new skills, and network with other caregivers. Gitlin et al. (2015) and others have noted that few of the 200-plus empirically supported interventions for caregivers have been widely translated and evidence-based care may still be inaccessible to 15 million family dementia caregivers. Past work (Cheng et al., 2019; Gitlin et al., 2015) has identified the need for research examining mechanisms by which these interventions confer benefits. Meanwhile, others have suggested caregiver preparedness as both a prospective therapeutic target and a possible therapeutic mechanism for caregiver-focused interventions (Archbold et al., 1990; Hancock et al., 2022). The goal of this study is to propose a theoretical framework for characterizing individual differences between caregivers and to examine a hypothesized therapeutic mechanism by which the Savvy Caregiver Program (SC) improves outcomes among informal dementia caregivers.

Gitlin et al. (2015) and others have argued for the advancement of dementia caregiving interventions through a cyclical self-correcting process of disseminating best-supported interventions based on the ever-growing clinical literature. A recent systematic review by the Agency for Healthcare Research and Quality (AHRQ) employed standards developed for systematic assessment of standardized biomedical treatments to the assessment of psychosocial interventions for individuals with dementia (Butler et al., 2020). This comparative effectiveness review included 627 unique studies with 267 companion studies with widely-ranging patient populations, research approaches, and levels of program development (pilot study, dissemination study, etc.) to conclude that insufficient evidence exists to support dissemination of existing interventions. Others have responded (Gaugler et al., 2021) that more focused pilot studies, translational studies, pragmatic clinical trials, randomized clinical trials, and meta-analyses clearly support the efficacy and utility of a range of evidence-based interventions for dementia caregivers. In particular, the mechanisms by which caregiver interventions confer benefit to caregivers are not well-established; identifying such mechanisms may inform both the refinement of already-disseminated interventions and the development of interventions (Gitlin et al., 2015).

Savvy Caregiver Program

The Savvy Caregiver Program is an evidence-based 6-week group intervention for dementia caregivers aimed at strengthening caregivers’ dementia knowledge, care management skill development, and overall outlook for caregiving (Hepburn et al., 2003). One of the original goals for SC was to offer a “turn-key” intervention for interested agencies with little or no training required from the original investigators. Based in Lazarus & Folkman’s stress mediation theory, SC was tested through randomized-controlled trials and field-effectiveness testing, with NINR support (Lazarus & Folkamn, 1984). Participation in Savvy Caregiver is associated with reduced caregiver distress and burden and increasing caregiver mastery (Hepburn et al., 2003; Hepburn et al., 2007; Hepburn et al., 2021) . The program has been tested extensively in various settings including Colorado (Hepburn et al., 2007) California (Kally et al., 2014), Alaska, Mississippi, Minnesota (Hepburn et al., 2003) and Maine (Samia et al., 2014). A combined study of field trials held in Alaska, Colorado, and Minnesota found significant improvement in caregiver distress related to care recipient mood, behavior, burden, and beliefs about caregiving (Hepburn et al., 2003). Others have reported that the SC program is still beneficial for Hispanic, Black/African American, and Asian/Pacific Islander family caregivers at 6- and 12-month follow-up periods (Hu et al., 2021; Kally et al., 2014). Studies of the SC program have established efficacy in both urban and rural populations, and in ethnically diverse English-speaking populations (Hepburn et al., 2003; Hepburn et al., 2007; Kally et al., 2014; Smith & Bell, 2005). Findings from these and other trials indicate that the SC intervention can be delivered effectively by trainers from a range of professional backgrounds with adequate fidelity (Hepburn et al., 2003; Samia et al., 2014) and that the program functions best when offered in the context of organizational support for dementia caregivers and the ability to refer to other resources in the community (Hepburn et al., 2003). While the SC program does not necessarily provide concrete answers to every challenge confronted by someone in the caregiving role, it provides foundational knowledge of how to appropriate resources to best navigate emergent challenges. Contents of SC modules are listed in Table 1.

Table 1.

Savvy Caregiver Program Module directly from the Savvy Caregiver Trainer’s Manual

Week	Content
1	Introduction to the program and program material • Introduction of participants • Exploring dementia – facts about dementing disorders • The impact of Alzheimer’s and other progressive dementias on thinking and the implications of these losses for Savvy Caregiving • Introduction to the resource materials for the program
2	Review of last week’s materials, readings, and homework • Caregiver self-care: Recognizing and dealing with Feelings • Confusion: the central problem in dementing diseases • The implication of Confusion for Savvy Caregiving • A simple Model of Behavior • Communicating with Confusion: Dealing in Emotional Truth Taking Control
3	Review of last week’s materials, readings, and homework • Contented Involvement: A reasonable goal for caregiving • The concept of Fit: Matching tasks and activities to abilities • Performance – the Important Elements • Introducing a Staging System
4	Review of last week’s materials, readings, and homework • Anchors of Contented Involvement – Structure and Support • Linking Disease Stages to Structure and Support • Basic Communication Techniques • Developing strategies for common behavioral problems
5	Review of last week’s materials, readings, and homework • Applying Savvy Caregiver principles to day-to-day life: using the Anchors to design daily tasks • Introducing a Model for Decision-Making
6	Review of last week’s materials, readings, and homework • Types of Caregiving Families • Strengthening Families as Resources of Care • Review of Savvy Caregiver Program

Interventional Targets

Dementia caregiving is associated with burden, depression, and a range of comorbidities associated with inadequate stress management and poor caregiver self-care (Brodaty & Donkin, 2009; Burns & Iliffe, 2009; Collins & Kishita, 2020; Etters et al., 2008; Schulz & Sherwood, 2008). Caregiver burden is conceptualized as the subjective physical, psychological, social and financial problems associated with the caregiving role (Chou, 2000; Hoffman & Mitchell, 1998). Caregiver burden is associated with depression among caregivers (Clyburn et al., 2000; D’Aoust et al., 2015; Epstein-Lubow et al., 2008), which affects 30 to 40 percent of caregivers (Alzheimer’s Association, 2018). Caregiver depression is associated with both dementia severity indicated by neuropsychiatric symptoms (sleep disturbances, aggressive behavior, mood symptoms, irritability) (Cheng, 2017; Covinsky et al., 2003; Danhauer et al., 2004; Hughes et al., 2014; Ornstein & Gaugler, 2012) and patient suffering (Schulz et al., 2008), and caregiver income and caregiver ethnicity (Covinsky et al., 2003). Because caregivers with depression (Mittelman et al., 2006) and caregiver burden (Eska et al., 2013) are more likely to seek institutional long-term care for their loved ones, mood symptoms are a priority of caregiver interventions. Depressive symptoms (Brodaty et al., 2003; Lee et al., 2020; Pinquart & Sorensen, 2006) and caregiver burden are somewhat mitigated through caregiver interventions; though, caregiver burden outcomes vary consistently between studies (Acton & Kang, 2001; Brodaty et al., 2003; Cheng et al., 2020; Chien et al., 2011; Chu et al., 2011; Parker et al., 2008; Pinquart & Sorensen, 2006; Schulz et al., 2002; Walter & Pinquart, 2019).

Another critical facet of dementia caregiving is the grief of repeated losses throughout the care recipient’s dementia progression while they are still living, a concept defined as anticipatory grief (Holley & Mast, 2009). While anticipatory grief is not unique to dementia caregivers, the losses experienced by the caregiver are compounded by the shared experience of loss related to physical and cognitive function, as well as intimacy and long-term relationship with their care recipient. Anticipatory grief may encompass personal losses such as loss of control of personal life, social activities, well-being, and occupation (Garand et al., 2012; Large & Slinger, 2015; Loos & Bowd, 1997). Anticipatory Grief is associated with higher levels of burden and depression (Garand et al., 2012; Gilsenan et al., 2022; Holley & Mast, 2009). Though associated with higher levels of burden and depression, anticipatory grief has not usually been a target focus of existing interventions.

Caregiver Preparedness

The caregiver preparedness measure used in this study was proposed by Archbold et al. (1990). Caregiver preparedness was hypothesized to ameliorate role strain associated with dementia caregiving. Caregiver preparedness was conceptualized as a domain-general perception of one’s role fitness, in contrast to self-efficacy which is task-specific (Archbold et al., 1990). This construct is conceptually based on concepts of self-efficacy and caregiving mastery, defined as a positive view of one’s ability and ongoing behavior during the caregiving process. For instance, a caregiver may feel capable of assisting patient transfers, but still feel ill-prepared to provide for a loved one’s physical needs given that this broader domain reflects the breadth of tasks required of someone in the caregiving role over the course of the intertwined disease and caregiving trajectories, thus making self-efficacy and caregiver preparedness, two distinct constructs Prior studies have investigated self-efficacy as a mechanism for intervention effects. One such study investigated ameliorating depression and anger in women caregivers (Coon et al., 2003), and utilized the Revised Scale for Caregiving Self-Efficacy (Steffen et al., 2002) which rates the respondents confidence in performing very specific tasks such as “...Can ask a friend/family member to stay with ____ for a day when you need to see the doctor yourself?” and “When ____ forgets your daily routine and asks when lunch is right after you’ve eaten, . . .can answer him/her without raising your voice?” By contrast, the role-focused construct of caregiver preparedness, operationalized in this study using the Preparedness for Caregiving Scale (Archbold et al., 1990), asses respondents’ readiness for negotiation of non-specific challenges common to the caregiver role, such as “How well prepared do you think you are to take care of his or her emotional needs?”

Few studies have investigated mechanisms of change in caregiver interventions. Self-efficacy was mentioned as one investigated mechanism, and found to mediate some negative outcomes (i.e., managing distressing thoughts), it did not relate to changes in negatively valanced thinking, depressive symptoms, and role-overload (Cheng et al., 2019). Cheng et al. (2019) summarized research on other examined mechanisms including skills utilization (Gallagher-Thompson et al., 2008); emotion-focused coping (Li et al., 2014); reduction in maladaptive thinking, leisure activity engagement (Losada et al., 2011); and self-efficacy for controlling negatively valanced thinking (Cheng et al., 2016; Cheng et al., 2017). However, these agents of change were specific for the type of intervention used which ranged from psychoeducation with cognitive behavior strategies and positive psychology strategies, respectively. Thus, due the limited number of studies investigating these mechanisms, the review suggested that more research is needed to determine if these same mechanisms are active in other types of caregiver interventions with different content from those previously mentioned.

Caregiver preparedness relates to anxiety, role strain (Henriksson & Arestedt, 2013), and was hypothesized to be an effective mechanism by which interventions may seek to mitigate role strain among dementia caregivers (Archbold et al., 1990; Scherbring, 2002). Caregiver preparedness, which has been broadly related to caregiver distress, may thus be conceptualized as an interventional target (Henriksson & Arestedt, 2013; Schumacher et al., 2008; Shyu et al., 2010). Thus, engaging in preparatory contemplation for the caregiving role may promote skills acquisition and anticipation of others’ need, thereby mitigating emergent caregiving related stress (Scherbring, 2002; Hancock et al., 2022).

Goals of this study

While prior research has identified mechanisms, this study specifically examines caregiver preparedness as a prospective mechanism in the SCP. It is quite likely that measurable mechanisms will vary across caregiver interventions. Because SCP focuses on psychoeducation, disease trajectory, and practical skills that may be deployed as needed over the care recipients’ clinical trajectory, it is conceivable that caregiver preparedness might emerge as a predictor of clinical change over the course of the study. To our knowledge, past research has not systematically examined the hypothesis that caregiver preparedness plays a more complex role in dementia caregiver interventions. Ill-prepared caregivers may be more vulnerable to becoming overwhelmed by role demands, and thus experience undue burden and distress. It is hypothesized that, among dementia caregivers completing the SCP, rate of change in caregiver preparedness will positively relate to change in caregiving-related distress, indicated in this study by caregiver burden, depression, and anticipatory grief. The first goal of this study is to replicate past findings demonstrating the effectiveness of the Savvy Caregiver Program with informal dementia caregivers as delivered through a non-profit community organization in a large Southeastern American city. The second goal of this study is to examine caregiver preparedness as one mechanism by which the Savvy Caregiver Program confers benefits to caregivers. Thus, examined hypotheses are as follows:

H1: Participants who complete the Savvy Caregiver Program will report a significant improvement in (H1A) caregiver burden, (H1B) depressive symptoms, and (H1C) anticipatory grief.

H2: The change in caregiver preparedness from pre-intervention to post-intervention will significantly moderate pre-post changes in (H2A) caregiver burden, (H2B) depressive symptoms, and (H2C) anticipatory grief.

Methods

Participants

The Orlando Later-Life Developmental Research Lab (OLDeR) at the University of Central Florida collected data on 10 Savvy Caregiver Program workshops series that were facilitated by a local, non-profit Alzheimer’s and Dementia Resource Center (ADRC) staff between March 2017 and August 2019. Of the 140 who initially enrolled in the Savvy Caregiver Program, 124 consented to participate in the study. Of those, 15 did not complete baseline questionnaires and 33 did not complete follow-up data. The final sample included 76 caregivers that provided pre- and post-intervention data (See consort diagram in Figure 1).

Figure 1.

Consort Diagram

*Number of participants varies across analyses as a result of missing item-level and measure-level data.

Measures

Demographic and background variables were collected using questionnaire items assessing gender, age, educational level, income (less than $20,000; $21,000-$40,000; $41,000-$55,000; $56,000-$150,000; more than $150,000), ethnic identity (Caucasian, non-Hispanic; African American, non-Hispanic; Hispanic; Native American/Pacific Islander), relationship to caregivers (Spouse/Partner, Parent, Sibling, Aunt/uncle, Friend/Extended/Family, Other), time spent caregiving (in months), and status of cohabitation. The age of care recipients and time that the recipient has needed care (in months) was also gathered. Functional independence of the individuals for whom the participants provided care for was assessed on the basis of activities of daily living (ADL’s; walking across a room, getting in and out of bed, dressing, bathing and eating) and instrumental activities of daily living (IADL’s; using the telephone, taking medication and handling money; (Stephanie & Herzog, 2004).

Caregiver burden.

The Zarit Burden Interview (ZBI), short form (Bedard et al., 2001) was used to measure participants perceived burden associated with their caregiving role. The short form is a 12-item version and correlates highly (r = .92 to .97) with the original 22-item ZBI (Zarit et al., 1985). Respondents are asked to rate how the frequency (“never, 0” “rarely, 1”; “sometimes, 2”; “quite frequently, 3”; or “nearly always, 4”) of occurrence for question items (e.g., “Do you feel strained when you around your Care Recipient?”; “Do you feel that you should be doing more for your Care Recipient?”). Total scores are compiled by summing all the items.

Depressive symptoms were measured using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10)(Andresen et al., 1994). Participants endorsed depression symptoms during the past week by rating the frequency of their subjective occurrence (rarely or none of the time [less than 1 day]; some or a little of the time [1–2 day]); occasionally or a moderate amount of time [3–4 days]; and all of the time [5–7 days]). Eight of the ten items are worded negatively (e.g., “I felt depressed”) and two of the items are worded positively (e.g., “I was happy”), and reverse scored. Clinically significant levels of depression are indicated by the summed scores of all items greater than 10 (Andresen et al., 1994). The CESD-10 is commonly used in caregiver research (Gallagher et al., 2011; Mausbach et al., 2012) and the internal consistency is high (Cronbach’s alpha = 0.86–0.88; Andresen et al., 2013).

Anticipatory grief was measured using the Anticipatory Grief Scale (AGS) (Theut et al., 1991). The AGS is a 27-item self-report questionnaire using a 5-point Likert scale (ranging from Strongly Agree to Strongly Disagree) that assesses grief in dementia caregivers. Some of the items include “I daydream about how life with my relative was before the diagnosis of dementia was made” and “I am able to move ahead with my life.” Additionally, AGS demonstrated internal reliability (α = 0.84) and construct validity, being positively and significantly correlated with depression (p < .001) and anxiety (p < .001). Total scores are summed up from the 27 items, with 7 questions being reversed coded.

Caregiver preparedness (CGP).

The Preparedness for Caregiving Scale (PCS) (Archbold et al., 1990) was operationalized using 8-items that assess the degree of preparedness experienced by participants in various aspects of caregiving. Participants answered the questions on a 5-point Likert scale (0 = “not at all prepared”; 5 = “very well prepared”). Items included “How well prepared do you think you are to take care of his or her physical needs?” and “How well prepared do you think you are for the stress of caregiving?”. Scores are derived by determining the mean of the summed-up items. Higher mean scores denote a stronger sense of preparedness for the caregiving role. The measure has very adequate internal consistency (Cronbach’s alpha = 0.88–0.93; Schumacher et al., 2007).

Procedures

The research protocol was approved by the University of Central Florida Institutional Review Board (SBE-17–12946). The researchers did not provide the intervention and therefore written consent was not required. The first page of the survey included the consent information and completion of the survey indicated consent of the participant. The proposed study was a within subjects repeated measures design. Participants were recruited from group members who registered for the Savvy Caregiver Workshop facilitated by the ADRC and self-identified as caregivers to dementia patients. Of note, the researchers were requested to supplement the SCP with information addressing anticipatory grief and advanced care planning. These materials were developed in consultation with SCP designers and added as in small sections over the 6-week protocol. This modest protocol addendum is beyond the scope of the current study, although analyses found no major differences in effectiveness with respect to any outcome variables.

Participants who agreed to take part in the study were supplied with information by ADRC staff to access the survey through the Qualtrics program or provided with paper and pencil surveys immediately prior to the first group of the 6-week series. After six 2-hour sessions of the Savvy Caregiver, an ADRC staff provided instructions to the participants to access the post-survey through the Qualtrics program or paper and pencil surveys. Participants were not offered reimbursement. Participation in this study was not a requirement for participation in Savvy Caregiver.

A comparison of included and attrited participants was conducted using a series of chi-square tests of independence and independent samples t-tests. Addressing efficacy of the SCP, assessment of pre-post change in caregiver burden (using the ZBI), depressive symptoms (using the CESD-10), and anticipatory grief (using the AGS) was completed using a series of one sample t-tests. Lastly, a repeated measures ANOVA, with pre-post change in CGP as a continuous covariate, was used to examine the moderating effect of CGP on change from pre to post intervention on measures of caregiver burden, anticipatory grief, and depressive symptoms.

Results

The majority of Savvy Caregiver participants were 40 to 64 years of age (51.3%) and female (81.6%; see Table 2). Most participants were college graduates (52.6%) and identified as White/Caucasian (72.4%). Caregivers (participants) identified that they were caring for their parents (52.6%), spouse (28.9%), and other relations (including sibling or parent-in law) (18.3%). The caregivers reported an average caregiving length of 41.58 months. The average age of care recipients was reported to be 81.26 years old (± 8.69) and 64.5% live with their caregivers. By comparison to those who completed the study, those who enrolled but attritted were similar with respect to age, Χ²(3, 107) = 3.86, p = .28, education, Χ² (3, 107) = 2.52, p = .47, caregiver gender, Χ² (, 107) = .08, p = .78, caregiver race, Χ² (4, 107) = 4.32, p = .37, care recipient relationship type (parent, spouse, or other) Χ² (4, 107) = 7.87, p = .10, length of caregiving relationship, t₍₉₅₎ = 0.26, p = .94, duration of care need t₍₉₅₎ = 1.07, p = .22, care recipient age t₍₁₀₄₎ = 0.97, p = .22, or cohabitation status (Χ² (1, 105) = 0.26, p = .61. On average, attritted caregivers reported slightly better caregiver preparedness, less caregiver burden, fewer depressive symptoms, and less anticipatory grief; though these differences were not statistically significant (p>.05; see Table 2).

Table 2.

Comparison of demographic characteristics between participants who completed and attrited, respectively

	Mean (SD) or n (%)		Comparison
	Completers	Attrited	(t) or x2
Age			3.86
40–64	51.3%	36.4%
65+	47.4%	51.5%
Education			2.52
No High School Diploma	2.6%	3.0%
High School Diploma or Equivalent	10.5%	15.2%
Trade School or some college	34.2%	18.2%
College Graduate	52.6%	57.6%
Caregiver Gender			0.08
Female	81.6%	78.80%
Caregiver Race			4.32
White/Caucasian	n = 55 (72.4%)	n = 17 (51.5%)
African-American	n = 11 (14.5%)	n = 7 (21.2%)
Hispanic/Latino	n = 6 (7.9%)	n = 3 (9.1%)
Asian	n = 2 (2.6%)	n = 3 (9.1%)
Other (indicated: West Indian, Middle Eastern)	n = 2 (2.6%)	n = 1 (3%)
Care Recipient			7.87
Parent	n = 40 (52.6%)	n = 10 (30.3%)
Spouse	n = 22 (28.9%)	n = 16 (48.5%)
Other (Sibling, Parent-in-law, Friend)	n = 14 (18.3%)	n = 5 (15.2%)
Length of Caregiving (in months)	41.58 (48.59)	38.88 (43.25)	(0.26)
How long has care recipient needed care (in months)	38.53 (26.75)	33.11 (20.29)	1.07
Care Recipient Age (years)	81.26 (8.69)	79.17 (10.54)	(0.97)
% Cohabitate	n = 49 (64.5%)	n = 18 (54.5%)	0.26
Caregiver Preparedness	2.03 (.811)	2.36 (.96)	(1.65)
Zarit Burden Scale	25.64 (8.99)	24.00 (8.21)	(.75)
CES-D	11.03 (6.44)	10.13 (4.73)	(.62)
Anticipatory Grief	78.01 (13.12)	73.85 (13.46)	(1.23)

^*p<.05

^**p<.01

^***p<.001

Univariate analyses reflected statistically significant improvements in caregiver burden (t₍₆₂₎ = 4.08, p = < .001), anticipatory grief (t₍₆₁₎ = 3.73, p < .001), and in depressive symptom endorsement (t₍₇₀₎ = 2.66, p = .01). A repeated-measures ANOVA (Table 3) was used to assess how change in caregiver preparedness influenced the association of pre- and post-intervention caregiver burden (see Figure 2A). Neither the main within-subject’s effect of time, F₍₁₎= 1.34, p=.25, partial η²=.02, nor the between-subjects effect for caregiver preparedness change, F₍₁₎=.11, p=.75, partial η²=.002 were statistically significant, though the interaction of caregiver preparedness change and passage of time did significantly associate with change in caregiver burden over the course of the study, F₍₁₎=6.68, p=.012, partial η²=.10. Higher CGP change scores predicted large attenuation in ZBI scores from pre- to post-intervention (Figure 2A).

Table 3.

Results of repeated-measures ANOVA analyses

	Mean (SD)
	Pre	Post	F	p	Partial η 2
CGP	2.00 (0.78)	2.74 (0.61)
ZBI	25.65 (9.08)	22.17 (8.74)
Time			1.34	0.25	0.02
Time*Preparedness Change			6.68	0.01	0.10
CESD-10	11.23 (6.43)	9.46 (4.57)
Time			0.004	0.95	<.01
Time*Preparedness Change			6.41	0.01	0.09
AGS	78.05 (13.29)	72.51 (12.51)
Time			1.27	0.26	0.02
Time*Preparedness Change			6.22	0.02	0.10

ZBI= Zarit Burden Inventory; CESD = Center for Epidemiological Studies-Depression 10-item; AGS= Anticipatory Grief Scale.

Figure 2A.

Depiction of interaction between change in caregiver preparedness and time predicting change in Zarit Burden Inventory Score assessed before and after completion of the Savvy Caregiver Program

Note. CGP= Caregiver Preparedness as measured by PCS; ZBI= Zarit Burden Inventory.

The second repeated-measures ANOVA examined change in depressive symptom endorsement. Similar to the pattern reported above, neither the main within-subject’s effect of time, F₍₁₎=.004, p=.95, partial η²=.00, nor the between-subjects effect for caregiver preparedness change, F₍₁₎= 3.62, p=.06, partial η²=.05, were statistically significant, though the interaction of caregiver preparedness change and passage of time did significantly associate with change in depressive symptom endorsement over the course of the study, F₍₁₎=6.41, p=.014, partial η²=.09. Higher CGP change scores predicted large attenuation in CESD-10 scores from pre- to post-intervention (Figure 2B).

Figure 2B.

Depiction of interaction between change in caregiver preparedness and time predicting change in CES-D Score assessed before and after completion of the Savvy Caregiver Program

Note. CGP= Caregiver Preparedness as measured by PCS; CESD-10 = Center for Epidemiological Studies-Depression 10-item.

The third repeated-measures ANOVA examined change in subjective anticipatory grief. This same pattern was again observed for this outcome variable. Neither the main within-subject’s effect of time, F₍₁₎=1.27, p=.26, partial η²=.02, nor the between-subjects effect for caregiver preparedness change, F₍₁₎=2.32, p=.13, partial η²=.04, were statistically significant, though the interaction of caregiver preparedness change and passage of time did significantly associate with change in anticipatory grief over the course of the study, F₍₁₎=6.22, p=.02, partial η²=.1). Higher CGP change scores predicted large attenuation in AGS scores from pre- to post- intervention (Figure 2C).

Figure 2C.

Depiction of interaction between change in caregiver preparedness and time predicting change in Anticipatory Grief Score assessed before and after completion of the Savvy Caregiver Program

Note. CGP= Caregiver Preparedness as measured by PCS; AGS= Anticipatory Grief Scale.

Discussion

The first finding of this study is that, when administered by representatives of a well-established nonprofit organization in the community setting, dementia caregivers who completed the Savvy Caregiver Program reported improvements in caregiver preparedness, caregiver burden, depressive symptom endorsement, and anticipatory grief relative to their own baseline. The second, and more novel, finding of this study is that changes in caregiver preparedness moderated change in caregiver burden, depressive symptom endorsement, and anticipatory grief. These results extend the existing caregiving literature by suggesting that caregiver preparedness is one mechanism by which the Savvy Caregiver Program confers benefits to caregivers. These findings suggest that caregiver preparedness is highly modifiable via this well-structured, manualized caregiver intervention, and that improvements in caregiver preparedness may facilitate alleviation of caregiving burden, depressive symptoms, and grief.

The outcomes of this research suggest that benefits (with respect to burden, depression, and anticipatory grief offered by Savvy Caregiver, and likely other manualized caregiver interventions) may be partially attributable to improvements in caregiver preparedness. While caregiver preparedness has often been cited as a correlate of caregiver distress and caregiving outcomes (Archbold et al., 1990; Schumacher et al., 2007; Schumacher et al., 2008), no studies to our knowledge have examined caregiver preparedness as a therapeutic mechanism. One implication of this finding is that caregiver interventions may be refined by better focusing on both the caregiver’s actual readiness to address their care recipients’ needs and by promoting role orientation through dementia education, structured problem solving, and skills-focused training. The study results also suggest that caregivers with a poor sense of subjective preparedness may particularly benefit from SCP.

Informal support groups typically provide validation, empathy, mentorship, and useful tasks for emergent needs, and are known to offer some benefit to caregivers (Brodaty et al., 2003; Parker et al., 2008). By contrast, manualized, meta-analytic findings indicate larger benefits to caregivers for psychoeducational groups such as SCP (Chien et al., 2011; Mittelman, 2013). It is likely that benefits offered by Savvy Caregiver are augmented through a heavy focus on psychoeducation and application of practical skills across the care recipient’s clinical trajectory and the corresponding caregiving trajectory, thus promoting readiness for the role (Hepburn et al., 2003). Caregiver preparedness reflects both pragmatic readiness for necessary tasks and mastery in the caregiving role. It is, perhaps, important to distinguish perceived caregiver preparedness, which relates with subjective outcome variables, from both caregiving skills and actual preparedness, characterized by implementation of acquired skills, readiness from a financial or occupational perspective, and preparedness of the home with whatever accommodations are indicated by the care recipient’s level of need, among other considerations. While acquisition and implementation of skills is necessary to execution of the caregiving role, the conceptual framework employed here posits that caregiver preparedness is a psychological mechanism of action. Future research should further investigate how acquisition and implementation of skills relates to both pragmatic and psychosocial outcomes for dementia caregiving dyads.

The sex distribution was roughly consistent with that found in other studies (Belle et al., 2006; Hepburn et al., 2007). A recent meta-analysis by Cheng et al. (2020) found that 75.6% of informal dementia care was provided by women, and a separate report by the Alzheimer’s Disease International (Wimo et al., 2018) found that 71% of informal care is provided by women. While it is likely that male caregivers are systematically underrepresented in caregiving research historically and nationwide (arguably internationally), the important issue sex differences in help-seeking or resource utilization are beyond the scope of this manuscript. The present sample skewed somewhat younger, suggesting greater involvement of “sandwich generation” caregivers including adult children and a non-negligible minority of “other” caregivers including siblings, in-laws, and friends. These differences may reflect the choice of venue for data collection (community outreach) by contrast to prior studies, which typically representing an earlier phase of research development with interventions being conducted through medical or academic institutions (Gitlin et al., 2015). No demographic predictors of attrition were identified, and it is thus believed that the sample in this study reasonably represents help-seeking dementia caregivers in the Orlando area at this time.

Given that the primary goals were to examine predictors of change in caregiver burden, depressive symptoms, and anticipatory grief, the study was conceptualized as a within-subjects design. Future research may revisit these hypotheses using an experimental design with an inactive control group or an examination contrasting mechanisms across various caregiver interventions. Lack of a control group is the primary limitation of this finding. Another limitation of this study is the absence of a systemic check on fidelity of therapeutic fidelity. The community partner who administered the intervention is very experienced in working with these populations, and values evidence-based interventions for their replicability. Additionally, a fidelity checklist was therefore implemented to improve compliance with SCP manual. Nonetheless, known departures from the conventional Savvy Caregiver protocol were incurred, as is common when transferring manualized interventions from highly controlled laboratory settings to less controlled community settings. A third limitation of this study is the sample size. As the intervention itself was being delivered by the community partner, recruitment was limited to participants who were already signed up for the intervention workshops. In-person workshops are limited in the number of participants per workshop series (Hepburn et al., 2021), and the period of data collection was about 2 years. Future studies may implement a multi-site study approach, recruiting participants from various SC providers in different communities to help alleviate the length of time and maximize the available participants. The last limitation to address is the absence of a long-term follow-up data collection. While it would be preferable to examine longer-term outcomes, resources were not available to facilitate collection of this data. Future research may further explore the hypothesis that caregiver preparedness is one mechanism by which caregiver interventions confer benefits over longer periods of time.

In conclusion, these findings support use of the Savvy Caregiver Program in the community setting and suggest that caregiver preparedness is one mechanism by which this intervention confers therapeutic benefits for informal caregivers. These findings suggest one route for modification of existing intervention programs that may augment the benefits of these clinical efforts.

Clinical Implications.

• Findings support the use of Savvy Caregiver Program for dementia caregivers in community settings.

• Caregiver preparedness is a correlate of conceptually downstream manifestations of caregiver distress. It may also capture clinically relevant information to determine therapeutic success of caregiver interventions.

• Emerging clinical interventions and modification of existing interventions may to seek to emphasize promotion of caregiver preparedness through skills development, dementia knowledge, and structured problem solving.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author, DP, upon reasonable request.