Table 1.

U.S. studies incorporating caregiver psychological health and hospitalization characteristics of older care recipients

First Author (Year)	Study Objective	Sample (with age)		Care Reason	Study Design	Caregiver Psychosocial Measure	Findings
Miller (2012)	To explore the moderating effect of caregiver burden on the relationship between patients’ health status and institutional costs in Alzheimer’s disease.	421 community-dwelling AD patients in clinical antipsychotic trials in U.S. Patients diagnosed with AD, living at home, and having severe symptoms (delusions, hallucinations, etc). Patients were on average 77.9 years of age, 56% female, 59% married, and 79% white.	Caregiver was one who lived with or visited the participant for at least 3 days per week for an accumulative 8 hours. Caregivers were on average 63 years of age, 71% female, predominantly spouse (52%) or adult child (34%)	Dementia	Longitudinal	CDS BDI ZBI CAS	This study, using different analyses (logistic regression), reported similar overall findings of Miller 2010 (below). Caregiver burden weakens the inverse relationship between health utilities and institutional service use.
Miller (2010)		Same sample as above		Dementia	Longitudinal	CDS BDI ZBI CAS	Monthly, patients were admitted to hospital care at a rate of 4.5%. Of those hospitalized, the average days hospitalized was 6.7. Institutional service use was defined as use of any of the following services: inpatient hospital care, nursing home care, or residential care. Higher burden through the Caregiver Distress Scale, BDI, and Caregiver Activity Survey were shown to lead to an increased use of institutional services than expected based on solely on health utilities or health functioning. Assessment of burden using the Zarit Burden Interview showed a weaker, non-significant moderating effect.
Thorpe (2010)	To identify veteran, caregiver, and community factors that may explain urban-rural differences in ambulatory care sensitive hospitalizations.	1,186 US male veterans with dementia and primary caregivers in U.S. Patients had either Alzheimer’s disease or vascular dementia. The sample of dyads was limited to only African American or white dyads, dyads with female caregivers, dyads whose caregiver was a spouse, daughter or sister, and dyads of caregivers who resided with recipient.	Primary caregivers were defined as the person who provided the most time with the older veteran and provided the most care, assistance and support.	Dementia	Longitudinal	CES-D-10 DSSI	Over one-year, 30% of the dementia patients had at least one non-ambulatory hospitalization and 13% had at least one ambulatory hospitalization. The caregivers had a mean depression score of 5.7 (SD: 4.7, range 0–20). Caregiver depression was not associated with ambulatory or non-ambulatory patient hospitalizations over one year in unadjusted and adjusted analyses. Instrumental and emotional social support (as well as perceived financial adequacy) were associated with non-ACSC hospitalizations in unadjusted analyses but not adjusted analyses.
Wolff & Kasper (2004)	To examine caregiver attributes with respect to recipients’ hospitalization experiences.	420 female Medicare beneficiaries aged 65 or older receiving informal care and primary caregivers from Maryland, U.S. Of 420, 384 remained in year 2 and 319 remained in year 3. Main reason for attrition was death. Patients were on average 80 years of age, 31% African American.	Caregiver was defined as someone who was providing unpaid care. Caregivers had a median age of 57 years and were predominantly offspring (54%) or spouses (17.4%); 31% were African American.	Moderately to severely (cognitively well) disabled due to chronic illness	Secondary Medicare data, prospective longitudinal (3 years)	GDS Study created survey of burdens (overload, role captivity, competence) based on work of Pearlin.	Approximately 52% of care recipients were hospitalized over the 3 years. Reasons for hospitalizations varied, including issues related to circulatory, respiratory, skin, digestive, and nervous system. Primary caregivers characterized with role captivity (which is related to perceived burden) were more than twice as likely to be delayed from hospital in univariate but not in adjusted analysis.
Saunders (2008)	To explore caregiver characteristics for associations with hospitalizations of heart failure patients	41 heart failure patients and primary caregivers in U.S. (Detroit). Patients had to have had a primary diagnosis of heart failure for at least 12 months. Patients had a mean age of 77.6 years (SD: 9.8, range 53–93), 51% female, 85% white.	Primary caregiver as designated by the patient and ability to speak and understand English. Caregivers had a mean age of 59 years (SD: 15, range 18–82 years), 85% female, and most often provided care as an adult child (46%) or spouse (46%).	Cardiovascular disease	Retrospective (12-months prior to caregiver interview)	CES-D-10 CRA (caregiver appraisal)	21% of caregivers had a score of 16 or higher on the CES-D, suggesting depression. Caregivers perceived mild to moderate levels of negative caregiver appraisal. Caregiver depression was not significantly correlated with hospitalizations or number of days hospitalized. Lack of family support (as well as caregiver-perceived patient severity, caregiver hours per week) were significantly correlated with hospitalizations, while lack of family support was the only variable significantly associated with the number of days hospitalized. A lack of family support was significantly correlated with depression (p<.01).
Schwarz (2003)	To determine predictors of hospital readmission for older adults with heart failure.	156 patient-caregiver dyads in northeastern Ohio consented with 128 dyads completing the study (only difference was mental function between those who completed study and those who did not). Drop out from the study was due to patient death. Patients were 65 or older and had been hospitalized with a primary diagnosis of heart failure. Patients were excluded if receiving hospice or regular treatments in a hospital. Patient demographics: Age: M: 77.3 (±6.1), range 65 to 92 years; 50% male; 89% white.	Caregiver description: M: 64.8 (±14.6), range 16 to 86; 74% female; 89% white; 62% were spouses. Caregivers were family members who lived in the same city as the patient and provided the majority of assistance.	Heart Failure	Longitudinal	PSS CES-D PGCCAS (caregiving appraisal) MISSB (Informal Social Support)	Caregivers perceived stress had a mean of 16.5 (±8.8). Depressive symptoms had a mean of 11.4 (±8.8), range 3 to 46. 21% scored >16 on CES-D indicating depressive symptomology. Caregivers also had high positive appraisal of caregiving (M:21.5) and high informal social support (M: 25.7). 44% of patients were readmitted to the hospital within 3 months. Increased caregiver informal social support significantly reduced risk for readmission (HR: .933, P<.01, CI: .991–1.037) as did the presence of depressive symptoms (HR: .882, P<.05, CI: .778–.999). Further analyses indicated that an interaction between stress and depression increased the risk for patient readmission (HR: 1.005, P<.05, CI: 1.001–1.008).
Schwarz (2000)	To determine whether low informal social support, low satisfaction with social support, high depressive symptomology of caregiver, and minimal use of home health care predicted hospital readmission of older adults.	Convenience sample from 2 hospitals of family members providing care to patients age 65 years of age or older who had been hospitalized. 60 of 85 family caregivers completed the 3-month follow-up (completers and non-completers did not differ with regard to primary measures). Hospice patients were excluded. Patient demographics: Age: M: 78.9 (±6.4), range 66 to 93 years; 48% male; 97% white.	Caregivers resided with the older adult and were able to speak and understand English. Characteristics: Age: M: 64.4 (±14.29), range 27–92, 73% female, 92% white, 60% spouses.	Chronic illness and were functionally impaired in two activities of daily living (ADL). Most care recipients had heart disease (25%), stroke (26%), cancer (15%), or skeletal problems (15%).	Longitudinal (over 3-months)	MISSB: (informal social support) ISSS (satisfaction with informal support) CES-D	Caregivers had a mean score of 9.68 (SD: 10.20) on CES-D at baseline and a mean score of 10.26 (SD: 12.49) at 3-month follow up. 33% of patients were readmitted at 3-months. The number of hospital readmissions ranged from 0 to 8 (M: .57, SD = 1.18). At 3-month interview, a greater number of hospital readmissions was significantly related to greater depressive symptoms (r = .24), lower tangible support (r = −.24) and lower emotional support (r = −.24). In adjusted analyses, depressive symptoms were not a significant predictor of readmission (tangible and integration subscales of social support were significant predictors).