Qualitative content analysis of mental-behavioral health problems and resilience of the elderly and home caregivers

Abstract

BACKGROUND:

The rapid growth of the elderly population in Iran has made studying the mental and behavioral health challenges of the elderly and their home caregivers a necessity for health policymaking; in this regard, the study was conducted with the aim of identifying the behavioral and mental health problems and resilience of home caregivers and the elderly.

MATERIALS AND METHODS:

The research was conducted with a qualitative content analysis approach and with a purposeful sampling of 15 elderly people in need of care and 18 home caregivers. Data were collected through semistructured interviews and analyzed using the inductive content analysis method. Compliance with the principles of validation of qualitative research, including confirmability, transferability, reliability, and validity, was considered at all stages of the study.

RESULTS:

The present study provided a perspective on the multidimensional challenges of the elderly and their caregivers. Findings from the perspective of the elderly showed that a combination of chronic physical problems, mental disorders such as depression and anxiety, social isolation, financial insecurity, and challenges in the living environment affects their health and quality of life. On the other hand, home caregivers face severe psychological stress, family conflicts, lack of caregiving skills, and economic hardships.

CONCLUSION:

The findings of this study, addressed to health policymakers, emphasize the need to develop comprehensive support programs that simultaneously cover the needs of the elderly and their caregivers, and reveal the need to provide specialized counseling services for the elderly and their caregivers. It also provides a basis for designing caregiving skills training programs, developing telephone and online counseling services, and establishing financial support mechanisms, and provides a conceptual framework for future research in the field of designing and evaluating effective interventions in this area.

Introduction

Old age is one of the most important and decisive stages in the human life cycle, accompanied by physical, psychological, and social changes, and is known as one of the most challenging periods for individuals, families, and society. This issue affects various dimensions, including economic, social, and health care, especially in developing countries that are facing rapid and complex demographic changes. Global statistics show a growing trend in population aging around the world.[1] This trend is also clearly observed in Iran, and according to estimates by the Population and Family Health Office, the elderly population will increase significantly from 2041 onwards.[2] This demographic change increases the need to pay attention to issues and challenges related to aging.

One of the most important challenges of aging is physical and mental disabilities, which are known as one of the main factors in reducing the quality of life of the elderly. According to the results of various studies, the inability to perform daily activities of life and various physical disabilities and mental disorders are among the main problems of this age group.[3,4,5] In this context, a study emphasized the need to prioritize mental health issues of the elderly.[6] This issue has become more important, especially in cases where the elderly require special care and comprehensive support. In the meantime, families are known as the main care institution for the elderly and bear the greatest burden of care for this age group.[2] However, social changes and structural transformations of families in recent decades, including the nuclearization of families, the shrinking of households, the increase in the number of working women, the increase in divorce rates, and urbanization, have presented the caregiving role of families with serious challenges.[2,3] These social changes have not only reduced the caregiving capacity of families but also increased the health and behavioral problems of home caregivers and the elderly. Home caregivers, as those who have the most direct contact with the elderly, are exposed to psychological stress, depression, physical, psychological, economic, and social problems. The results of various studies show that home caregivers of the elderly face increased rates of chronic diseases,[7,8,9] low resilience,[10] and even premature death due to chronic and severe conditions.[11,12,13,14] In this regard, the results of a systematic review showed that the stress caused by caring for the elderly affects all aspects of physical, psychological, social, spiritual, quality of life, and mental health of caregivers.[15] These problems, as well as their role in the health of caregivers, also affect the quality of care for the elderly. In contrast, the elderly are also exposed to more health and mental problems due to their greater dependence on caregivers and reduced physical and mental abilities. Therefore, paying attention to the mental and behavioral health of both groups, namely home caregivers and the elderly, is of particular importance.[9,10] In this regard, the study aimed to identify behavioral mental health problems and resilience of home caregivers of the elderly and the elderly.

Materials and Methods

Study design and setting

The study was conducted as a scoping and qualitative review with a content analysis approach, with the aim of extracting and identifying data related to behavioral mental health problems of home caregivers of the elderly and the elderly.

Data collection tool and technique

In the review stage, information was collected from reputable scientific sites and journals, theses, research projects, and books. To conduct the review, a specific information search strategy and keywords related to the topic were first developed in Persian and English, including Elderly, Old, Mental health, Behavioral health, Resilience, Home caregivers of the elderly, aging.

Databases for search: Considering the characteristics, subject coverage, and capabilities of foreign databases, databases such as Web of Science, Scopus, PubMed, Cochrane, Embase, and ProQuest were searched, and among Persian databases; the Iranian Journals Database, the Scientific Database of the Academic Jihad, Irandoc, and the Islamic World Citation Database were searched without any time limit.

Retrieved sources were reviewed. After removing duplicates, the researcher and the person in charge of the project reviewed the titles and abstracts of the articles for relevance to the research topic. Then, the full text of the documents that were determined to be relevant was extracted and completely relevant documents were identified and stored. After that, the text of the articles was studied. Based on the purpose of the research, important keywords were identified from the texts and labeled next to each text as a note.

The study was conducted in a qualitative phase of content analysis and derived from the naturalistic paradigm, which was conducted on home caregivers of the elderly, elderly people from health departments, and psychological counseling and rehabilitation centers.

The elderly in this study, according to the definition of the World Health Organization, were people who crossed the age of 60 or 65[16] and were unable to take care of themselves alone and needed the support of others. Participants in this phase were selected from various stakeholders, including home caregivers of the elderly and the elderly themselves, who were invited to the study by attracting cooperation from universities of medical sciences, health departments, health centers, and psychological counseling centers. Caregivers who had at least one year of experience caring for the elderly and the elderly they provided care services to were included.

Purposive sampling was used. To obtain different backgrounds, experiences, and perspectives on the topic, heterogeneous samples with the greatest diversity in terms of age, gender, and caregivers were selected to provide diverse perspectives on the phenomenon under study; given that generalizability is not the goal in qualitative studies, sample adequacy was determined through data saturation and during the implementation process. Data saturation was declared when the information did not lead to further description of the new concept and did not lead to the creation of a new category.

The interview form was developed in a semistructured manner. To determine the sequence, adequacy, and appropriate flow of the questions, two preliminary interviews were conducted. The interviewees were invited to cooperate via telephone. During the telephone conversation, the interviewees were introduced to the researcher’s request and the purpose of the study. To facilitate the interviewees’ participation and increase their cooperation, the interview sessions were held online or in person in a manner that they were willing and ready to participate. Consent and permission to record the interview were obtained. Trust and consent were gained regarding the confidentiality of the information and adherence to ethical principles. The interviewees were informed that they had the right to withdraw from the interview process at any time if they did not wish to continue. The interviews lasted between 25 and 71 minutes.

Ethical consideration

All ethical considerations were observed in this study, and the study was approved by the code of ethics IR.ARI.MUI.REC.1403.186.

Statistical analysis method

After responding, each interview was transcribed. The data obtained from the interviews were analyzed using a qualitative content analysis method known as the inductive method. To increase the validity of the research findings, in-depth interviews were conducted on samples with the greatest diversity, and data review by the professor in charge of the project to match and ensure that the categories were consistent with the participants’ statements. To establish trustworthiness, an attempt was made to clearly and in detail describe the work process, data analysis, coding, and related results, and provide examples of how coding was done, arriving at the categories, and excerpts of narratives for each category. For verifiability, the researcher helped ensure the verifiability of the research by maintaining documentation at all stages of the study. For transferability, the researcher provided others with a clear, precise, and purposeful description of the research process and the steps of implementing the study, enabling them to follow the research and evaluation path and the applicability of the study data.

Results

Fifteen elderly people (9 women and 6 men), with a mean age of 75.4 years, of whom 10 were single and only one was childless, and 18 caregivers with a mean care of 47.5 years, participated in the study, who were caring for their father, mother, simultaneous parents, grandparents, older sister, uncle, and mother-in-law. In identifying behavioral mental health problems in the elderly, 252 codes, 13 subcategories, and 5 main categories were identified.

Findings from Table 1 revealed that the mental and behavioral health problems of the elderly are categorized into five main categories and thirteen subcategories.

Table 1.

Identifying behavioral mental health problems in the elderly under home care

Main category		Subcategory		Extracted codes
Physical and mental health problems		Physical diseases and bodily issues		Metabolic disorders,[17] muscular issues,[18] bone fractures (hip, back, etc.), diabetes,[19] hypertension,[19] asthma,[17] stroke,[20] chronic diseases,[17] heart problems,[20] respiratory issues,[19] stroke, arthritis,[20] urinary and fecal incontinence,[18,19,21] absorption and excretion problems,[22] disability,[17,20] infectious diseases,[17] kidney problems,[17] digestive issues,[17,20] hearing and vision loss,[18,19] limited mobility, joint pain and stiffness,[20] headaches,[23] oral and dental problems,[19] bedsores,[19] osteoporosis,[21] sexual dysfunction,[20] history of surgery.
		Psychological disorders and symptoms		Depression,[19,21,24] loneliness,[25] social isolation,[23] regret over the past,[23] helplessness,[26] fear of dying alone,[25] fear of death, suicide,[25] negative emotions,[25] emotional instability,[25] boredom,[25] nighttime fear,[23] anxiety,[19,24] confusion, restlessness, perfectionism,[27] aggression, memory impairment,[19] Alzheimer’s,[21] psychotic symptoms,[18] neuropsychiatric disorders.[28]
Elderly behavioral challenges		Stubbornness and resistance		Resistance to support and help (e.g., bathing, taking medication), arguments with spouse, refusal to accept a caregiver.
		Risky behaviors		Tobacco and drug use,[19,21,29] hookah,[19] alcohol,[18,21] medication misuse,[21] polypharmacy,[18] deliberate self-harm,[18] smoking.[9]
Life risks and insecurity challenges		Vulnerability and life risks		Sexual abuse of the elderly,[29] theft attempts targeting the elderly,[29] lack of safety,[22] accidents,[17] falls,[18,19] injuries,[21] bullying, financial exploitation,[19] physical threats, inability to defend oneself.
		Elderly dissatisfaction with neglect and abuse		Poor and inadequate nutrition,[19] neglect of illnesses, poor personal hygiene (17, 20), emotional neglect,[28] caregiving neglect,[28,30] rejection,[28] financial abuse,[28] physical abuse,[30,31] shouting, cursing.
		Housing and living environment issues		Moving from a lively house to a small apartment,[32] unsafe living environment,[23,29] physical safety concerns,[25] social insecurity,[21] residential problems.[18]
Social, communication, and functional challenges		Functional and dependency issues		Loss of appetite, sleep disorders,[19] unfulfilled sexual desires,[25] walking speed,[21] energy levels,[21] medication problems,[18] ineffective medications, difficulty preparing meals,[18,20] weight fluctuations,[19] daily shopping challenges,[20] performing daily activities,[21] household chores,[20] banking and administrative tasks,[20] dependency on others for minor tasks, childlessness,[26] marital problems.[24]
		Role and social status changes		Inability to fulfill social roles,[24] social role changes, loss of independence,[25] lifestyle changes due to living with married children.[21]
		Social deprivation and limitations		Lack of participation in social networks,[25] social support,[25] citizenship rights,[25] leisure and recreation,[23,25] inability to enjoy life,[22] limited access to outdoor spaces,[25] reduced social visits.[23]
		Interaction challenges with children and caregivers		Lack of companionship, children not being present during times of need, feeling like a burden, caregiving pressure on children, burden falling on one child.
		Information and technology challenges		Low digital literacy,[31] unfamiliarity with mobile phone use,[20,32] lack of access to information,[25] unfamiliarity with internet use,[25] unfamiliarity with social media.
Contextual and economic factors		Financial issues		Elderly insurance,[22,25] social insurance,[25] supplemental insurance,[25] healthcare costs,[25] out-of-pocket health payments,[25] poverty,[25] retirement income,[25] living expenses,[25] financial decline due to inflation,[23] salaries and benefits,[18,22] hospitalization costs,[33] caregiving costs,[33] treatment expenses.[27]
		Individual and social characteristics		Older age,[21,33] gender,[21] education level, literacy, and schooling,[21,34] income,[21,34] marital status,[34] occupation.[34]

Note: In the table, codes 1−18 refer to caregivers, and codes 19−34 refer to the elderly (superscripted)

Interviewee 20 highlighted some of the physical illnesses and bodily issues faced by the elderly:

“Living with joint pain is so hard. My whole body feels weak. I can’t even get out of bed without help. At night, my body stiffens up I need someone to move me around several times until morning.”

Depression, anxiety, and loneliness were among the most common psychological issues. Interviewee 25 shared their struggles:

“I feel so lonely, like the whole world has turned its back on me. My chest feels heavy nothing makes me feel better. I’m scared of dying alone.”

Second Category: “Elderly Behavioral Challenges”

This includes “Stubbornness and Resistance” and “Risky Behaviors.” Many elderly individuals resist accepting help, making caregiving difficult. Interviewee 7 described this:

“My mom won’t listen to anything we say. We tell her it’s for her own good, but she just resists and argues. She gets herself and us all worked up. She insists on taking her pills and water herself, but every time, she spills it and then complains.”

Tobacco uses and unnecessary medication were noted as risky behaviors. Interviewee 9 explained:

“My dad still smokes despite his heart problems… Every time I warn him, he just says, ‘Mind your own business.’”

Third Category: “Life Risks and Insecurity Challenges”

This covers “Vulnerability and Life Risks,” “Elderly Dissatisfaction with Neglect and Abuse,” and “Housing and Living Environment Issues.” Some elderly people face financial or emotional abuse. Interviewee 19 shared:

“I have a pension, but my eldest son takes the money and says, ‘I’ll spend it for you.’ I tell him, ‘Just give me part of it I have my dignity.’ I want to give my grandkids some money when they visit, or lend a little when needed. I’ve always been independent I hate having to depend on others.”

Poor living conditions also affect mental health. Interviewee 32 lamented:

“I used to live in an old house with a garden it was so lively. Neighbors would visit every day. They sold my home, and now I’m stuck in a tiny apartment. Dust everywhere… I feel so lonely now.”

Fourth Category: “Social, Communication, and Functional Challenges”

This includes “Functional and Dependency Issues,” “Changes in Social Roles,” “Social Deprivation,” “Interaction Problems with Children and Caregivers,” and “Information and Technology Struggles.” Many elderly people experience losses of independence and social roles. Interviewee 21 said:

“I sold my house to live with my kids they said it’d be easier. But now it’s so hard. My son-in-law barely says ‘hi’ before turning on the TV. My daughter says, ‘He’s tired.’ They argue, and I feel like a burden. I don’t know if it’s me or their own issues… It was better when they just visited.”

Reduced social connections lead to isolation. Interviewee 23 shared:

“I used to go to the park every day. But after I fell and broke my arm, only my 70-year-old neighbor visits. I’m not the same anymore. I can’t go out. I’ve never felt so alone.”

Fifth Category: “Contextual and Economic Factors”

This includes “Financial Issues” and “Individual and Social Characteristics.” Financial constraints limit access to care. Interviewee 27 explained:

“My pension isn’t enough for meds and treatment. Sometimes I skip prescriptions. Everything’s so expensive now meat, chicken, even fruit is unaffordable.”

Findings from Table 2 show that the behavioral mental health problems of home caregivers for the elderly were categorized into four main categories. In this regard, the narratives of interviewees 1, 15, 8, 2, and 23 are presented in order:

Table 2.

Identifying behavioral mental health problems in home caregivers of the elderly

Main category		Sub category		Extracted codes
Psychological and emotional challenges of caregivers		Psychological problems of caregivers		Chronic stress,[9,13] anxiety, depression,[9,13] guilt over inadequate care,[1] irritability, resentment toward others for lack of cooperation,[15] low patience, mood swings, low resilience,[7,10] mental health issues.[7,15]
		Caregiver’s worry and compassion for the elderly		Compassion for the elderly, feeling the elderly are defenseless and vulnerable,[8] fear of caregiving responsibilities, worry about leaving the elderly alone, fear of the elderly’s death.
		Burden and harm related to elderly care		Physical exhaustion, chronic pain, chronic illnesses,[7,8,9] neglecting self-care,[2] self-neglect,[35] neglecting work, feeling isolated, social problems,[15] pressure from the elderly’s difficult behavior, lack of time, insufficient sleep, poor sleep quality, caregiving stress,[7] early mortality.[7,10]
		Behavioral and relational problems of caregivers		Being unaffectionate or rude, feeling trapped, anger and irritability,[35] complaining, disrespect, impatience,[23] indifference, excessive sleeping, giving silent treatment, sarcasm, grumbling, blaming, crying, retaliation.
Interpersonal and relational challenges of caregivers		Problems with other caregivers and family		Neglect by other siblings,[4] family conflicts over elderly care, arguments with spouse, rejection of duty shifts by other siblings,[9] disrupted and limited relationships.[35]
		Daily caregiving and communication challenges		Stubbornness, continuous physiotherapy appointments, constant doctor visits and imaging, lack of cooperation in personal tasks, disobedience, difficulty moving the elderly,[10] challenges with toileting and bathing, caregiving pressure.[35]
		Unrealistic expectations of the elderly		Pressure from the elderly’s demands,[17] crying over trivial matters, expecting abilities from their youth, expecting excessive time, listening to repetitive stories.
Knowledge and skill limitations of caregivers		Lack of awareness and educational challenges		Unawareness of caregiving methods,[11] unfamiliarity with elderly needs, ignorance about disease symptoms and risks, unfamiliarity with resources for help during crises.
		Lack of caregiving skills		Feeling ineffective, inability to handle challenges, inexperience with drug interactions, unprepared for emergencies (e.g., low blood pressure, seizures, falls).
Economic and financial pressures		Direct caregiving costs		Expensive medications and services, transportation costs for family and others,[12] doctor visits, insufficient insurance coverage, medical equipment expenses.
		Economic and occupational consequences		Government neglect and lack of support, reduced income due to part-time work, lost job opportunities, declining income.

Note: In the table, codes 1−18 refer to caregivers, and codes 19−34 refer to the elderly (superscripted)

“I wish I could spend more time with them. But I have my own life and struggles... I’m constantly worried they’ll be alone and something might happen to them. I always carry this guilt with me.”

“The whole burden has fallen on my shoulders. Others just know how to say “good job.“ Nobody actually helps. My brother says ‘just ask if you need anything’ but he’s never once come forward to say ‘I’ll stay with our loved one today so you can take care of your own things.“

“Mom has become like a child who can’t do anything. She used to have such dignity and didn’t like needing help. Sometimes I wonder - what would happen if I weren’t here? Who would take care of her?”

“There are times when I think to myself - I wish I could get sick too so I could rest a little. I can’t remember the last time I had a proper night’s sleep... I’m sleep deprived at night and exhausted during the day... I used to go for morning walks and visit relatives... Now even taking a shower fills me with stress and anxiety.”

“They come, do the bare minimum and leave. They don’t even talk to me. I just want someone to sit with me for a while and chat... But they’re all wrapped up in their own worlds.”

The “Interpersonal and Relational Challenges of Caregivers” emerged from three subcategories, including “Problems with other caregivers and family,” “Daily caregiving and communication challenges,” and “Unrealistic expectations of the elderly.” Narratives from interviewees 4, 9, 10 and 17 illustrate these issues:

“Sometimes I just want to burst into tears. From loneliness, from having no one, from my siblings’ unfairness. It’s like we’re not even a family anymore. Everyone does their own thing and I’m the only one who has to answer for everything. I’m alone, sick and tired, and have no one to call my own.”

“We had agreed to take shifts. Everything seemed fine at first, everyone had agreed. But within two weeks, my sister called saying she was too busy to come. My brother had already backed out from the beginning. In the end, everything fell on poor me.”

“My father, their body has become so heavy and they just go limp. Moving them is backbreaking work. Taking them to the bathroom or shower is a huge ordeal. I have to lift them, put them in the wheelchair. Their hands and feet are stiff - dressing them is so difficult. Just one trip to the bathroom and back to bed takes two hours.”

“I work 24/7 without any days off... Breakfast, lunch, dinner, medications, bathing, dressing, toilet. everything is on me. I’ve become a personal servant. When they make unreasonable demands, it really gets to me. Sometimes I just lose my temper.”

The narrative of interviewee 11 relates to the category of “Caregiving knowledge and skill limitations”:

“When it was decided I would be the caregiver some days, I only knew the basics about food and medicine. The first time I tried to get them out of bed, we really struggled. Bathing them and moving them in bed is so difficult with their osteoporosis and pain - their bones could break so easily. You have to learn as you go, but sometimes mistakes happen and then a whole new problem starts.”

The narrative of interviewee 12 relates to the category of “Economic and financial pressures”:

“...I can’t tell relatives to stop visiting mom because they’d take offense and mom would be upset. But even a simple visit ends up costing so much money. Then there are all the other expenses - doctors, medicine, diapers, transportation...”

Discussion

The findings in Table 1 show that mental and behavioral health problems of the elderly are categorized into five main categories and thirteen subcategories. In the following, each of the findings was discussed and interpreted.

Physical and mental health problems

This main category includes two subcategories: “physical diseases and physical problems” and “psychological disorders and symptoms.” The findings showed that the elderly face a wide range of chronic diseases (such as diabetes, blood pressure, heart problems) and physical disabilities (such as joint pain and mobility limitations).[17,19,20] Also, mental disorders such as depression, anxiety, and loneliness are common in this age group.[19,21,24] Similar studies have emphasized that chronic diseases and physical disabilities are the main factors that reduce the quality of life of the elderly.[3,4,5] In this context, the findings of one study showed that chronic pain and mobility limitations are associated with decreased health in the elderly.[23] Other studies have also highlighted the high prevalence of depression and anxiety in the elderly due to isolation and dependence on others.[19,23] There are several reasons for the prevalence of physical and mental problems in the elderly. On the one hand, the natural aging process leads to a decrease in the functioning of body systems and an increase in vulnerability to diseases. On the other hand, a decrease in mobility and individual independence can exacerbate feelings of helplessness and depression. In addition, social changes such as a decrease in family support and the nuclearization of families may also lead to an increase in social isolation and an exacerbation of mental problems.[2,3] These findings indicate the need to pay attention to comprehensive care programs that simultaneously cover the physical and mental needs of the elderly.

Elderly behavioral challenges

This category includes two subcategories: “elderly stubbornness” and “high-risk behaviors.” Findings: Studies indicate that some elderly people are resistant to accepting help and engaging in risky behaviors such as smoking or taking unnecessary medications.[18,19,21,29] In this regard, caregivers have pointed out that elderly people are resistant to change and accepting care. In this regard, it can be stated that tobacco and alcohol use in some elderly people can be considered as a strategy to cope with stress or feelings of loneliness, or resistance and stubbornness can have different explanations. These behaviors may be a sign of defense mechanisms against feelings of dependence, fear of losing independence, loss of control, or lack of trust in caregivers, or from a social perspective, the change in the role of elderly people from active individuals to dependent individuals, which can lead to feelings of inadequacy and resistance to care. In this context, any awareness raising for caregivers to better understand the reason and origin of these behaviors will lead to acceptance and selection of a more appropriate response to the elderly.

Risky and insecure challenges of elderly life

This category includes three subcategories: “vulnerability and risks of elderly life”, “elderly dissatisfaction with caregiver neglect and abuse”, and “housing and living environment problems”. Findings from studies showed that elderly people are exposed to financial, emotional abuse and neglect from caregivers.[17,19,20,28,30] These studies pointed to elder abuse and neglect as serious challenges. Also, studies emphasized the negative impact of an inappropriate living environment on the loneliness and depression of the elderly.[18,23,29] In this context, elderly people indicated that inappropriate living environments, such as small and dimly lit apartments, negatively affect their mental health. Several factors play a role in creating insecurity, risks and dissatisfaction among the elderly. On the one hand, physical and cognitive weakness makes them vulnerable to abuse. On the other hand, structural changes in families and reduced social support may lead to neglect of the elderly.[2,3] Also, inappropriate design of the living environment can exacerbate feelings of isolation and disability. These findings indicate the need to develop supportive and monitoring policies to reduce abuse and improve the living conditions of the elderly.

Social, communication, and functional challenges

This category includes five subcategories: “functional and dependency problems,” “social role and status changes,” “social deprivations,” “interaction problems with children and caregivers,” and “information and technology problems.” Findings suggest a decline in social connections, loss of independence, and functional limitations in older adults;[19,21,25,26] in this regard, studies have emphasized the negative impact of reduced social connections on older adults’ health and that the loss of social roles, such as retirement, can lead to feelings of purposelessness and depression.[24,25] Social and cultural changes in recent decades, including a decline in family connections and increased individualism, may have contributed to the isolation of older adults. In addition, the inability to use new technologies, which have become much more common than in the past, can prevent them from participating in social activities.[31,32] Therefore, low digital literacy in the elderly and their lower social participation can exacerbate their social, communication, and functional challenges.

Contextual and economic factors

This category includes two subcategories: “elderly financial issues” and “elderly personal and social characteristics.” Findings from studies have shown that financial constraints such as inadequate income and medical expenses negatively affect the quality of life of the elderly, and have shown the negative role of poverty and lack of appropriate insurance on the health of the elderly, and that high medical costs can lead to reduced access to health services and exacerbation of diseases.[22,23,25,33] Economic factors, such as inflation and inadequate retirement pensions, can expose the elderly to poverty and deprivation. These conditions affect both their physical and mental health.[25] In the absence of supportive economic policies such as increased pensions and comprehensive insurance coverage, improving the quality of life of the elderly is facing further challenges.

The findings in Table 2 show that the mental health and behavioral problems of home caregivers of the elderly were categorized into four main categories and eleven subcategories. In the following, each of the findings was discussed and interpreted.

Psychoemotional challenges of caregivers

This main category includes four subcategories: “psychological problems of caregivers”, “caregiver concern and compassion for the elderly”, “complexities and injuries related to caring for the elderly”, and “behavioral and communication problems of caregivers”. The findings showed that caregivers face chronic stress, anxiety, guilt, and psychological burnout. Also, constant worry about the elderly’s condition and neglect of their own needs are other reported challenges.[7,9,10,13,15] In this context, studies have pointed out the heavy psychological burden of caring for the elderly.[7,15,35] Studies have emphasized the role of caregiving stress in reducing the quality of life of caregivers and the role of resilience as a moderating factor for these pressures.[7,10] Home caregivers in this study reported experiencing chronic stress, anxiety, and feelings of psychological burnout, and in a way confirmed the role of pressures resulting from long-term care that can contribute to the development of psychological disorders. This means that constant exposure to the elderly’s declining abilities and their increasing needs can lead to emotional burnout for caregivers. Also, according to caregivers, the lack of equitable distribution of caregiving responsibilities in families and the lack of formal support exacerbate these pressures. In addition, chronic stress[7,9,13,35] can cause disruption in the functioning of the caregivers’ immune system. Accordingly, without psychosocial interventions such as forming support groups and stress management, ensuring the mental health of caregivers cannot be achieved.

Communication and interpersonal challenges of caregivers

This category includes three subcategories: “problems with other caregivers and family”, “communication and everyday caregiving challenges”, and “unreasonable expectations of the elderly”. The caregivers’ narratives indicated family conflicts, lack of division of responsibilities, and unrealistic expectations of the elderly from caregivers. In this regard, study findings showed that the responsibility of caring for the elderly leads to disruption of relationships and communication limitations, and subsequently to tension and pressure of care.[7,15,35] According to the caregivers’ narratives, disagreement between family members about caregiving methods is one of the most important sources of tension. Family conflicts around caregiving responsibilities are one of the main sources of stress for primary caregivers. Today’s family structures, which are often nuclear,[2] have less ability to divide caregiving responsibilities. Many caregivers have reported that despite the presence of several children in the family, the main burden of care falls on one person. This situation not only causes physical and mental fatigue for the primary caregiver, but can also lead to damage to family relationships. On the other hand, cognitive and personality changes in the elderly, especially in cases of dementia or Alzheimer’s, create additional communication challenges that require special skills in interactions and providing appropriate care.

Knowledge and skill limitations of caregivers

This category includes two subcategories: “ignorance and educational challenges” and “lack of care skills.” The findings reported that caregivers are struggling with the lack of knowledge and skills necessary for care or need specialized training to at least understand common diseases of the elderly and how to care. One of the worrying findings of this study is the lack of knowledge and care skills among home caregivers. In this context, some caregivers have reported that they have taken on the responsibility of caring for the elderly without any prior training and based solely on personal experiences. This is especially true for specialized care such as medication management, safe transportation of the elderly, and or special care is becoming increasingly important. Especially since the lack of formal education systems to prepare family caregivers, the increasing complexity of the care needs of older adults with multiple chronic conditions, and rapid changes in care and medical technologies are making caregiving challenges more serious.

Economic constraints and financial strain

This category includes two subcategories: “direct costs of care” and “economic and occupational consequences of caregiving.” Caregivers of older adults reported financial strains due to medical costs, reduced employment opportunities, and decreased income for caregivers.[12,14,33] From an economic perspective, findings suggest that caring for older adult’s places significant financial strain on families. This strain includes both direct costs, such as purchasing medications, medical equipment, and hiring a nurse, as well as indirect costs, such as reduced income due to caregivers’ occupational limitations. This is while existing support systems are often inadequate and many families have to bear these costs alone. Insurance coverage for long-term care services is not sufficient and government financial support for family caregivers is not defined.

Conclusion

The findings of this study show that the elderly and home caregivers face multidimensional challenges in the physical, psychological, social and economic domains. These challenges affect their quality of life and increase the caregiving burden of families and their tensions and dissatisfaction. In this regard, according to the findings of this study, the need to develop multilayered support systems and design comprehensive intervention programs that pay attention to all these dimensions is necessary for the elderly and home caregivers. These programs should include psychological support and improvement of environmental conditions, education of caregivers, communication strategies and strengthening economic support policies. Also, it seems that the development of care technologies and digital care education platforms can be effective in reducing some of these challenges.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This letter is the result of postdoctoral research No. 4026656 and was conducted with the support of Iran National Science Foundation: INSF. Tehran. Iran.