Linking Family Dynamics and the Mental Health of Colombian Dementia Caregivers

Abstract

This cross-sectional, quantitative, self-report study examined the relationship between family dynamics (cohesion, flexibility, pathology/ functioning, communication, family satisfaction, and empathy) and mental health (depression, burden, stress, and satisfaction with life [SWL]) in 90 dementia caregivers from Colombia. Hierarchical multiple regressions controlling for caregiver demographics found that family dynamics were significantly associated with caregiver depression, stress, and SWL and marginally associated with burden. Within these regressions, empathy was uniquely associated with stress; flexibility with depression and marginally with SWL; and family communication marginally with burden and stress. Nearly all family dynamic variables were bivariately associated with caregiver mental health variables, such that caregivers had stronger mental health when their family dynamics were healthy. Family-systems interventions in global regions with high levels of familism like that in the current study may improve family empathy, flexibility, and communication, thereby producing better caregiver mental health and better informal care for people with dementia.

Worldwide, 35.6 million people were living with dementia in 2010, which is expected to double every 20 years with projections to approximately 115.4 million in 2050. The prevalence of dementia in Latin America (8.5%) is higher than other global regions, such as the United States (6.5%), Western Europe (6.9%), and Eastern Asia (4.2%). ¹ This is especially important because of the increasing number of older adults in Latin America and the Caribbean, from 50 228 individuals aged 60 and older in 2005 to a projected 186 721 in 2050. ² This is in part due to the rising life expectancy in Latin America, which has increased over the past 60 years from 51.8 to 73.4 years. ² However, life expectancy has increased rapidly in more developed Latin American countries, such as Costa Rica, Brazil, and Colombia (78.8, 72.4, and 72.8 years, respectively), as compared with less developed countries, such as Haiti (60.6 years) and Bolivia (65.5 years). ²

Dementia is characterized by a significant decline in cognitive ability such as memory loss, communication deficits, changes in mood and personality, and poor judgment as well as in functional skills (eg, bathing, eating, and dressing). More severe symptoms arise as the condition progresses, including the complete loss of functional daily activities, impaired ability to communicate, and failure to recognize loved ones, leaving individuals with dementia bedridden, prone to infections (eg, pneumonia), and requiring a constant caregiver. ³ Due to the pervasive nature of these symptoms, a large number of dementia caregiving responsibilities fall onto unpaid family caregivers. ⁴ As a result, caregivers often experience restrictions in activities outside of caregiving, which has been related to increased caregiver stress. ⁵ Caregivers report markedly high burden, ⁶ increased depressive and anxiety symptoms, ^7,8 lowered subjective well-being, and poor physical health. ⁶ Among caregivers of older adults with various types of medical conditions, those caring for a person with dementia have been shown to experience some of the most adverse mental and physical health outcomes. ⁶ Specifically among caregivers of people with dementia, strain is associated with more caregiver depressive and anxiety symptoms. ⁹ The mental health of dementia caregivers is especially important to study, because research has shown that higher caregiver mental health is associated with less time spent caregiving, ¹⁰ less behavioral problems in the individual with dementia, and increased perceived quality of care. ¹¹

A number of studies have examined possible moderators and mediators of dementia caregiver mental health issues. Restriction of dementia caregivers’ life activities and perceived global control have been shown to mediate the relationship between stress and depressive symptoms. ⁵ Caregiver cognitive factors associated with their mental health include the use of engagement coping, ¹² problem-oriented coping, ¹³ functional coping strategies, ¹⁴ improved self-efficacy in dementia symptom management, ^15,16 and greater perceived control over one’s life. ⁵ Patient factors associated with caregiver mental health include patient cognitive status, ^10,17 overall functioning, ^10,15 and neuropsychiatric symptoms. ¹⁵ It has been similarly well documented that dementia caregivers’ own physical health negatively impacts their mental health ^10,16,18,19 and demographic variables, such as older age, being female, and Latino ethnicity are associated with increased risk of caregiver depression ^10,20,21 and anxiety. ⁸

One especially important connection with the mental health of dementia caregivers uncovered in the research literature is family dynamics. High family cohesion has been associated with less caregiver burden and depression, ²² and family conflict has been associated with increased caregiver depression and anger. ²³ A similar relationship has emerged between negative emotional interactions directed toward dementia caregivers by members of the extended family and caregiver depressive symptoms, ²⁴ and poor relationship quality between caregivers and care recipients has been associated with increased caregiver anxiety. ⁸ Social support from family members contributes over 2 times more to caregiver resilience than does support from friends, ²⁵ highlighting the extreme importance of family dynamics. Additionally, skills learned in dementia caregiver communication training are associated with decreased behavior disturbances and increased functioning in the individual with dementia, ²⁶ and effective communication strategies among dementia caregivers have been shown to be related to lower caregiver burden. ¹⁷ Thus, the quality of the relationship between caregivers and their family, including effective communication with the individual with dementia, is very powerfully related to caregiver mental health.

Research has identified unique characteristics in Latino families that may influence the type of care they provide. For example, strong family values in Latino families contribute to the sense of obligation that family members have to care for their elders, a characteristic that has been associated with an aversion to nursing home placement and to an increasing burden of care on family caregivers. ²⁷ Additionally, caregiving in Latino families has been seen as a way to pass on cultural values, such as respeto (respect) for elder relatives. ²⁸ Most of the current literature on dementia caregiving involves samples comprised heavily of spousal caregivers, ^5,10,15 whereas caregivers in Latino families are less likely to be spouses ²¹ and often involves middle-aged adults caring for elder relatives. ²⁹ Relatedly, several studies have addressed the mental health of dementia caregivers from Latino communities in the United States. Latino caregivers are particularly vulnerable to the effects of caregiving compared to their white and black counterparts and are more likely to experience strain ³⁰ and depressive symptoms, ^18,20,21 which may be due in part to the fact that Latino caregivers are more likely to be female and have lower income. ³¹ Latino caregivers in the United States tend to provide informal care for longer periods of time than caregivers of other racial/ethnic groups and have worse physical health than white caregivers, ²¹ which has been shown to be exacerbated in those who are less acculturated. ³² Latinos in the United States also report stronger familial commitment beliefs, ²¹ and Latino dementia caregivers utilize more religiously based coping strategies (eg, prayer), report behavioral problems of the care recipient as less stressful, and generally view caregiving as a more positive experience than their white counterparts. ³² Furthermore, Latino dementia caregivers have reported higher self-efficacy compared to white caregivers. ³³ Given their strong commitment to cultural values, Latino families may cope with and appraise caregiving tasks differently than caregivers from more individualistic cultures.

The Current Study

Although research has documented that family dynamics play a strong role in the mental health of dementia caregivers, no studies have been conducted in Latin America examining this set of relationships, despite the fact that research has shown Latino cultures to endorse unique values such as familism. A framework for understanding the importance of this research focus can be derived from the Stress Process Model of Caregiving, ³⁴ by which the context of care for individuals with dementia is directly associated with caregiver outcomes. This model suggests that psychosocial resources, such as coping, social support, and family dynamics, can buffer the relationship between caregiving stressors and negative outcomes of caregiving. ³⁴ Due to culturally specific family values, studying the relationships between family dynamics and dementia caregiver mental health in Latin America is critical, especially from the context of this model. The current study directly addresses these limitations in the research literature by examining this pattern of connections in a sample of dementia caregivers from Colombia, South America.

Method

Procedure

For this cross-sectional, quantitative, self-report study, participants took part in a 1.5- to 2-hour interview with a psychologist involving the collection of demographic information and administration of questionnaires assessing family functioning and caregiver mental health. The psychologist read all items from the measures aloud to participants and answered any questions that participants had about the items. The psychologist circled participants’ responses to items using a paper-and-pencil administration of the study’s measures. The study was reviewed and approved by the institutional review board of the Alzheimer Foundation of Cali. All participants received an explanation of the study and signed an informed consent form, and all 90 participants who consented to participate completed the measures.

Participants

Caregivers were eligible to participate in this study if they (1) were related to the person with dementia, (2) were the primary caregiver of that person, (3) had been providing care for at least 3 months, (4) were knowledgeable about the patient’s family and medical history, and (5) had no history of neurological and psychiatric disorders or learning disabilities. Participants were recruited as part of a convenience sample between February 2011 and June 2012 from the Alzheimer Foundation (Cali, Colombia), which is a nonprofit facility providing medical, psychological, occupational, speech therapy, and rehabilitation services to individuals with dementia and their caregivers (eg, music, dance, and art therapies). First, caregivers participating in existing Alzheimer Foundation weekend psychoeducational workshops were screened for eligibility. Second, a medical record review identified a total of 100 individuals with dementia seen at the foundation and their caregivers who met inclusion criteria. The primary caregivers of these individuals with dementia were contacted and invited to participate. Ten did not consent because they did not believe that the study was necessary for them. The final sample consisted of 90 caregivers—82 caregivers of individuals with Alzheimer’s disease, 4 with vascular dementia, 2 with Parkinson’s disease, and 2 with mixed dementia.

The sample of caregivers was 64.4% female, with an average age of 54.12 (standard deviation [SD] = 11.50) and an average education level of 15.18 years (SD = 4.69), with the majority of caregivers having completed some college or graduated college or completed postgraduate education. Most (60.0%) of the caregivers were siblings of the person with dementia, 22.2% were children, 15.6% were spouses, and 2.2% were a live-in romantic partner. An equal number of caregivers were married (30.0%) and single (30.0%). Additionally, 18.9% were divorced, 12.2% were widowed, 4.4% were in a common law marriage, and 4.4% were separated. Almost half of the caregivers in the sample earned more than 5 times minimum wage (45.6%), followed by those making between 4 and 5 times minimum wage (23.3%), 2 and 3 times minimum wage (20.0%), 1 and 2 times minimum wage (7.8%), and less than minimum wage (3.3%). Caregivers reported having been a caregiver for 43.91 months (SD = 38.24) and spending 63.84 hours per week (SD = 27.76) providing care. For a summary of caregiver demographics, see Table 1.

Table 1.

Caregiver Characteristics.

Variables	N = 90
Age, years, M (SD)	54.12 (11.50)
Sex, %
Male	35.6
Female	64.4
Martial status, %
Married	30.0
Single	30.0
Divorced	18.9
Separated	4.4
Widowed	12.2
Cohabitating	4.4
Relation to patient, %
Spouse	15.6
Domestic partner	2.2
Sibling	60.0
Child	22.2
Education, %
Graduated primary school	4.4
Some high school	5.6
Graduated high school	16.7
Some trade or technological school	6.7
Graduated trade or technological school	12.2
Some college/university	4.4
Graduated college/university	18.9
Postgraduate education	31.1
Income, %
<1× minimum wage	3.3
1-2× minimum wage	7.8
2-3× minimum wage	20.0
4-5× minimum wage	23.3
>5× minimum wage	45.6
Weekly time caregiving in hours, M (SD)	63.84 (27.76)
Total time caregiving in months, M (SD)	43.91 (38.24)

Abbreviation: SD , standard deviation.

Measures

Caregivers completed a series of questionnaires assessing family dynamics and their own mental health. Spanish versions of Family Adaptability and Cohesion Evaluation Scale-Fourth Edition (FACES-IV), ³⁵ The Family Communication Scale (FCS), ³⁵ Family Satisfaction Scale (FSS), ³⁵ Zarit Burden Interview (ZBI), ³⁶ Patient Health Questionnaire 9 (PHQ-9), ³⁷ and Satisfaction with Life Scale (SWLS) ³⁸ were readily available. The Family Assessment Device-General Functioning (FAD-GF), ³⁹ Relationship-Focused Coping Scale (RFCS), ⁴⁰ and Perceived Stress Scale (PSS) ⁴¹ did not have Spanish versions available and were translated by a bilingual and bicultural researcher and back-translated into English by another bilingual and bicultural researcher. If inconsistencies emerged between the back-translated version and original English version, they were addressed mutually.

Family Adaptability and Cohesion Evaluation Scale-Fourth Edition

The Spanish version of the FACES-IV ⁴² was used to evaluate family cohesion and flexibility. Six subscales measure balanced and unbalanced domains of flexibility (eg, “It is important to follow the rules in our family.”) and cohesion (eg, “Family members seem to avoid contact with each other when at home.”). The unbalanced subscales measure the upper and lower limits of cohesion, such as disengagement and enmeshment, and flexibility, such as rigid and chaotic, whereas the balanced subscales measure the intermediate range of cohesion and flexibility. To determine the amount of balance versus unbalance in a family system, cohesion, flexibility, and total ratio totals are calculated, and then final cohesion and flexibility ratios signify the level of functional versus dysfunctional behavior observed in the family structure. For research purposes, only the cohesion and flexibility ratios should be used, however. ³⁵ Ratio scores range from 0 to 10, where 1 indicates a comparable amount of balance versus unbalance in the system. ³⁵ Healthier or balanced systems are associated with a greater ratio score. ³⁵ The Spanish version of the FACES-IV has been shown to have adequate convergent, concurrent, and content validity as well as good internal consistency (α = .87). ⁴²

The Family Communication Scale

A Spanish version of the FCS was used to determine the quality of each family’s communication patterns. ³⁵ The scale consists of 10 items (eg, “Family members are very good listeners.”) that participants rate using a scale from 1 (strongly disagree) to 5 (strongly agree), with a range of 10 to 50 for the total score. Higher scores signify better communication. ³⁵ Although no psychometric data are available for the Spanish version of the FCS, the English version has good internal consistency (α = .97), ⁴³ test–retest reliability, ³⁵ and construct validity. ⁴³

The Family Satisfaction Scale

A Spanish version of the FSS was used to determine the extent to which family members feel happy, content with each other, and satisfied with their overall family functioning. ³⁵ Respondents rate their level of satisfaction with 10 items (eg, “Your family’s ability to cope with stress.”) on a scale of 1 (very dissatisfied) to 5 (extremely satisfied). Scores range from 10 to 50, where higher scores signify more satisfaction. This scale has shown excellent internal consistency (α = .93) and good discriminant validity. ³⁵

Relationship-Focused Coping Scale

This 10-item scale was used to measure empathic responding aimed at preserving, managing, and/or maintaining relationships with family members during stressful periods. ⁴⁰ Sample questions include “Tried to see things from the other person's point of view” and “Tried to understand how the other person felt.” Item responses range from 0 (not at all) to 3 (a lot), with higher total scores for the scale representing higher levels of empathic responding. The RFCS has been validated and has demonstrated high internal consistency (α = .93). ⁴⁰

Family Assessment Device-General Functioning

The FAD-GF contains 12 items and measures overall health and pathology in the family system. ³⁹ Participants rate items (eg, “Planning family activities is difficult because we misunderstand each other.”) on a 4-point scale from 1 (strongly agree) to 4 (strongly disagree). Higher total scores indicate more pathology within the family’s dynamics. Because a Spanish version did not exist, the FAD-GF was translated for the purposes of this study. The English version of the FAD-GF has demonstrated good discriminant validity ³⁵ and good internal consistency (α = .83). ⁴⁴

Zarit Burden Interview

A Spanish version of the ZBI, a 22-item self-report questionnaire, was used to measure caregiver burden. ³⁶ Item responses range from 0 (never) to 4 (nearly always) to questions such as “Do you feel that because of the time you spend with your relative that you don’t have enough time for yourself?” and “Overall, how burdened do you feel in caring for your relative?” which assess the caregiver’s level of stress, emotional and physical health, financial strain, embarrassment, and overall burden regarding the caregiver–care recipient relationship. Total scores range from 0 to 88, and higher scores indicate higher levels of burden. ³⁶ The Spanish version of the ZBI has shown good construct validity and internal reliability (α = .92). ⁴⁵

Patient Health Questionnaire 9

A Spanish version of the PHQ-9, a 9-item self-report measure, was used to measure depression. ³⁷ Participants indicate how often each item has bothered them in the past 2 weeks (eg, “Little interest or pleasure in doing things.”) on a scale of 0 (not at all) to 3 (nearly every day). Total scores range from 0 to 27, where higher scores indicate more depressive symptoms. The Spanish version of this scale ⁴⁶ has demonstrated good criterion, construct validity, ⁴⁷ and convergent validity as well as high reliability (α = .92) in Spanish speakers. ⁴⁸

Satisfaction With Life Scale

A Spanish version of the SWLS was used to measure global satisfaction with life (SWL). ³⁸ This is a 5-item self-report scale with items such as “I am satisfied with life,” and item response options ranging from 1 (strongly disagree) to 7 (strongly agree). Total score ranges from 5 to 35, where higher scores indicate higher life satisfaction. The SWLS has demonstrated good construct validity. ³⁸ A previous study using the Spanish version of this scale demonstrates good internal consistency (α = .82). ⁴⁹

Perceived Stress Scale

The PSS was used to measure caregiver stress. ⁴¹ Self-report responses for the scale’s 10 items (eg, “In the last month, how often have you felt that you were unable to control the important things in your life?”) range from 0 (never) to 4 (very often), with higher scores indicating more stress. ⁴¹ A Spanish version of this scale was created for the purposes of this study. The PSS has demonstrated good concurrent and predictive validity, as well as good reliability, with α’s ranging from .84 to .86. ⁴¹

Data Analysis

A correlation matrix was created examining the bivariate relationships among all variables in the study. Four hierarchical multiple regressions then investigated the extent to which family dynamic variables (flexibility, cohesion, family satisfaction, family communication, family functioning/pathology, and empathy) were associated with caregiver mental health variables (depression, burden, stress, and SWL) after controlling for participant demographics and caregiving characteristics. In each regression, caregiver gender, income, romantic relationship status (partnered vs not partnered), months spent caregiving, and hours per week spent caregiving were entered as independent variables in the first step, the 6 family dynamic variables were entered as independent variables in the second step, and each of the 4 mental health variables was entered as the criterion variable in each regression.

Results

Correlation Matrix

A correlation matrix was generated to examine the bivariate relationships among all variables in the current study (Table 2). Depression and burden were very positively and significantly correlated (r = .55), and both correlated negatively with SWL (r = −.39 and −.61, respectively). Stress was also significantly positively related to depression (r = .59) and burden (r = .65) and was significantly negatively related to SWL (r = −.54).

Table 2.

Correlation Matrix.

	1	2	3	4	5	6	7	8	9
1. Depression	–
2. Burden	.55a	–
3. Sat w/life	−.39a	−.61a	–
4. Stress	.59a	.65a	−.54a	–
5. Cohesion	−.20	−.17	.23b	−.30a	–
6. Flexibility	−.32a	−.22b	.27b	−.27b	.50a	–
7. Communication	−.41a	−.33a	.31a	−.51a	.64a	.55a	–
8. Family sat	−.35a	−.24b	.36a	−.46a	.40a	.30a	.67a	–
9. Functioning	.36a	.22b	−.31a	.46a	−.63a	−.46a	−.73a	−.65a	–
10. Empathy	−.29a	−.08	.33a	−.46a	.09	.07	.23b	.35a	−.40a

Abbreviations: sat, satisfaction; sat w/life, satisfaction with life.

^a p < .01.

^b p < .05.

Most family dynamic variables were significantly related to each other; however, empathy did not relate to either cohesion or flexibility. Caregiver SWL was positively correlated with cohesion, flexibility, communication, family satisfaction, and empathy and was negatively related to family functioning/pathology. Caregiver depression and burden were significantly negatively associated with flexibility, communication, and family satisfaction and positively associated with family functioning/pathology; however, neither were significantly associated with cohesion. Depression was significantly negatively related to empathy, while burden was not. All family dynamic variables, except family functioning/pathology, were significantly negatively related to caregiver stress. Family functioning/pathology was positively related to stress.

As the family dynamic variables were generally significantly associated, there is the possibility of multicollinearity. According to Tabachnick and Fidell, ⁵⁰ the diagnostic criterion for multicollinearity is when the tolerance statistic (1 minus the squared multiple correlation of each independent variable) is less than .10. For the family dynamic variables, the tolerance ranged from .294 to .969, which is greater than the .10 cutoff. Another criterion for multicollinearity is a variance inflation factor (VIF) above 10; however, for these variables, the VIF ranged from 1.032 to 3.401, indicating no multicollinearity problems. ⁵⁰

Depression

In the first hierarchical multiple regression with depression as the criterion variable (Table 3), caregiver demographic characteristics (gender, income, romantic relationship status, months spent caregiving, and hours per week spent caregiving) were entered into the first step.

Table 3.

Final Models of Hierarchical Multiple Regression Analyses.

Independent Variable	Depression		Burden		Stress		SWL
	ΔR2	β	ΔR2	β	ΔR2	β	ΔR2	β
Step 1
Control  variablesa	.10		.14b		.21c		.13b
Step 2
Flexibility	.24c	−.30b	.11	−.16	.30d	−.16	.15b	.23e
Cohesion		.13		.11		.07		.00
Satisfaction		−.02		.06		−.05		.18
Communication		−.18		−.32e		.07		.00
Functioning		.14		.01		−.29e		.03
Empathy		−.11		.06		−.23b		.20
Total R2	.34		.25		.50		.28

Abbreviation: SWL, satisfaction with Life.

^a Control variables included caregiver gender, income, relationship status, months spent caregiving, and hours per week spent caregiving.

^b p < .05.

^c p < .01.

^d p < .001.

^e p < .10.

The first model was not statistically significant, F _5,82 = 1.89, p = .105, and R² = .10. The second model including the 6 family dynamic variables in the second step, however, was significant, F _11,76 = 3.53, p < .001, and R² = .34, and the amount of variance explained in caregiver depression increased by a significant ΔR²= .24, ΔF _6,76 = 4.50, and p = .001. In the second model, caregiver relationship status was uniquely associated with depression, β = .29, t ₈₇ = 2.80, and p = .006. Additionally, family flexibility was significantly associated with depression, β = −.30, t ₈₇ = −2.42, and p = .018, although cohesion, communication, satisfaction, functioning, and empathy were not (all ps ≥ .291).

Burden

The second hierarchical multiple regression was run in the same manner but substituting caregiver burden as the criterion variable (Table 3). The first model with only demographics was statistically significant, F _5,82 = 2.65, p = .029, and R² = .14. When the 6 family dynamic variables were entered into the second step, the model was statistically significant, F _11,76 = 2.31, p = .017, and R²= .25; however, the amount of variance explained in caregiver burden did not increase significantly, ΔR² = .11, ΔF _6,76 = 1.89, and p = .094. Caregiver relationship status was uniquely associated with burden, β = .38, t ₈₇ = 3.23, and p = .002, and family communication was marginally associated with burden, β = −.32, t ₈₇ = −1.75, and p = .084. None of the other family dynamic variables was statistically significant (all ps ≥ .220).

Stress

A third hierarchical multiple regression was run in the same manner but with caregiver stress as the criterion variable (Table 3). The first step including caregiver demographics was statistically significant, F _5,83 = 4.33, p = .001, and R² = .21. The second model including the 6 family dynamic variables was also significant, F _11,77 = 7.05, p < .001, and R² = 50, and the amount of variance explained in caregiver stress increased by a significant ΔR² = .30, ΔF _6,77 = 7.60, and p < .001. Family income and relationship status were uniquely associated with caregiver stress, β = −.22, t ₈₈ = −2.54, and p = .013 and β =.28, t ₈₈ = 3.05, and p = .003, respectively. Empathy [β = −.23, t ₈₈ = −2.37, and p = .020] was uniquely associated with caregiver stress, while family communication was marginally associated [β = −.29, t ₈₈ = −1.99, and p = .051]. Cohesion, flexibility, family satisfaction, and family functioning were not (all ps ≥ .136).

Satisfaction With Life

A fourth hierarchical regression examined the relationship between the 6 family dynamic variables and caregiver SWL after controlling for caregiver demographics (Table 3). The first model with demographics was statistically significant, accounting for 13% of variability in caregiver SWL, F _5,82 = 2.38, p = .046, and R² = .13. The second model was also significant, F _11,76 = 2.67, p = .006, and R² = .28, and the amount of variance explained in caregiver SWL increased by a significant ΔR² = .15, ΔF _6,76 = 2.67, and p = .021. Income and family flexibility were marginally associated with caregiver SWL, β = .21, t ₈₇ = 2.00, and p = .050 and β = .23, t ₈₇ = 1.75, and p = .085, respectively, although the other family dynamics were not (all ps ≥ .102).

Discussion

To our knowledge, this study is the first to examine the links between family dynamics (cohesion, flexibility, pathology/overall functioning, communication, family satisfaction, and empathy) and mental health (depression, burden, stress, and SWL) in dementia family caregivers from Latin America. In a series of hierarchical multiple regressions, family dynamics were significantly associated with caregiver depression, stress, and SWL and marginally associated with caregiver burden after controlling for caregiver demographics. Within these regressions, empathy was uniquely associated with caregiver stress; flexibility was uniquely associated with caregiver depression and marginally associated with caregiver SWL; and family communication was marginally associated with caregiver burden and stress. When examining bivariate relationships, nearly all family dynamic variables were significantly associated with all caregiver mental health variables, such that caregivers had stronger mental health when their family dynamics were healthy.

Consistent with previous studies, better psychological well-being, including lower depression and stress, and higher SWL emerged in family caregivers who experienced more family flexibility, healthier interactions between caregivers and care recipients, and stronger family communication. ^17,22,51 With healthier family dynamics such as good communication skills, less pathological interaction patterns, family togetherness and connection, and an appropriate amount of flexibility in family roles and leadership, caregivers may feel more supported and reinforced and be more capable of carrying out caregiving tasks for their family members with dementia. These associations between family dynamics and dementia caregiver mental health may be especially robust in Latin America, where strong family values and a sense of obligation to sick family members may crystallize the role of family in the caregiving process. ²⁷

Interestingly, the overall regression model of family dynamics on caregiver burden was not statistically significant, and in the SWL model, although the overall model was significant, no individual family dynamic variable was uniquely associated with caregiver life satisfaction; however, flexibility was marginally related to SWL. This set of findings may reflect the equal but moderate effect of each family dynamic variable on caregiver SWL, the small effect of these variables on burden, and the moderate and large intercorrelations among many of the family dynamic variables shown in the correlation matrix. Alternatively, given the complex and long-term nature of care demands as dementia progresses, those family dynamic variables may fluctuate over the course of caregiving, so an effect on the development of reduced SWL and burden may go uncaptured by the cross-sectional design of this study.

In the 2 regressions including the 6 family dynamics as independent variables and caregiver stress and depression as criterion variables, after controlling for caregiver characteristics, empathy and (marginally) family communication were uniquely associated with caregiver stress, and flexibility was uniquely associated with caregiver depression. The finding that caregivers whose families engaged in more positive communication styles experienced lower stress is consistent with previous dementia family caregiver research. ¹⁷ Also, previous research outside of the caregiving literature has found that empathy aimed at relieving others’ stress is extremely helpful in managing, preserving, and maintaining relationships with others during stressful periods. ⁵² Empathy has long been considered an important coping mechanism in marital, family, and other close interpersonal contexts, ^40,52 and as such, previous research on couples coping with stress has found that empathy is associated with reduced marital tension. ⁵³ This previous research bears directly on the current findings, such that caregivers whose families engaged in more empathy tended to report lower stress. When faced with a stressful situation, such as the everyday challenges of dementia caregiving, caregivers whose families demonstrate empathy for them and their care recipient may be more able to access and perceive social support, lessening their stress. Interestingly, previous research has not found an association between more flexible family styles and burden or depression. ²² This may indicate that flexibility is a unique resource for families in this region, such that balanced levels of organization and leadership roles may help families organize efficiently during times of stress and chaos. Additionally, families with better communication styles, empathy, and flexibility may be more willing to constructively manage conflict emanating from caregiving roles and duties, which in turn reduces caregiver stress and depression.

Marshaling the findings from the current study, as well as from previous research, implications emerge for clinical practice among individuals with dementia and their caregivers in Latin America. Because of the research documenting the importance of family in Latino populations, and the findings in this study documenting the relationships between caregiver mental health and flexibility and empathy, it would be appropriate to infer that family-systems interventions for families caring for an individual with dementia in this global region could have effects on caregiver mental health. These interventions may specifically include strategies to improve the ways in which family members communicate with each other and organize and adapt as well as the empathy they display during times of acute caregiving stress. For example, Silvestri et al ²⁶ administered communication training to dementia caregivers in Italy addressing skills to interact with the patient across multiple phases of dementia and the use of verbal and nonverbal language. The authors found outcomes such as decreased behavior disturbances and increased functioning in the individual with dementia. This type of training could very readily be adapted not only for dementia caregivers in Latin America but also for all family members in families caring for a person with dementia. Improvements in flexibility, empathy, and communication may lead to better caregiver mental health and to better overall quality of care.

Limitations and Future Directions

Despite these implications for clinical practice, the current study has several limitations, and as a result, directions for future research. The cross-sectional nature of this study limits conclusions about causality in the relationship between these 2 sets of variables. Healthy family dynamics may provide support to caregivers during times of acute caregiving stress, resulting in good caregiver mental health. But caregivers and other family members with poor mental health may also engage in unhealthy family dynamics, or perhaps rate their family dynamics as unhealthy when they are not so. As a result, future studies should collect longitudinal data on these constructs incorporating more objective measures, such as by trained clinicians or researchers, in order to use cross-lagged panel designs to infer causality more accurately between family dynamics and caregiver mental health.

Additionally, the current study does not address the mechanisms through which family dynamics affect caregiver mental health. Future research should address the potential moderation and/or mediation pathways in which family dynamics and caregiver mental health are connected. Future studies may also more fully embrace the cultural uniqueness of samples like that in the current study, such as by gathering multiple ratings of family dynamics, as well as of other constructs like level of collectivism and family values, in order to explore how collectivist Latino family values differ from those in more Western cultures in accounting for variance in dementia caregiver mental health.

Recruitment for this study occurred at 1 medical facility in Cali, Colombia, which provides dementia caregiving support, which is a scarce resource in this region. Recruitment from this facility may help explain the relatively high income of the current sample, and it is unlikely that the income of this sample reflects that of the region more broadly. Accordingly, future studies should recruit participants from a variety of communities and multiple facilities in Latin America to examine the associations found in the current study in caregiving samples with less access to health care resources. Additionally, the majority of previous dementia caregiver research has included samples comprised heavily of spousal caregivers, ^5,10,15 whereas the current sample was comprised heavily of sibling caregivers. This represents a particular strength to the current study given the lack of focus on sibling caregivers in previous research, but it may also limit the findings’ generalizability to other spousal caregiving groups. Although the current sample was too small to perform comparisons of the primary outcome variables based on caregivers’ relationship to their patient, this would be a ripe area for future research.

Although all participants were Spanish speaking and lived in Colombia, racial/ethnic background of participants was not assessed. Future studies in Latin America should avoid lumping together all caregivers from this region under the term “Latino” and would benefit from collecting information on racial/ethnic identification of participants, which could be closely tied to historical experiences and unique cultural practices affecting mental and physical health. Finally, this study did not collect data on impairments in individuals with dementia, and therefore, level of disease severity and progression could not be examined as a potential influence on caregiver mental health in the context of family dynamics. Future studies should incorporate this important variable and determine whether family dynamics, for example, moderate the relationship between dementia impairments and caregiver mental health.

Conclusion

The findings from the current study indicate that family dynamics and dementia caregiver mental health are robustly related in Colombia, and that flexibility, empathy, and communication within families may be particularly connected to caregiver mental health. In cultures that strongly value familial commitment and the interdependence of the extended family, especially in the context of caring for a loved one with dementia, the utilization of relationship-focused coping strategies may play an important role in caregivers’ mental health outcomes. Family-systems interventions in global regions with high levels of familism like that in the current study may improve family communication and empathy, thereby producing better caregiver mental health and better informal care for people with dementia.