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. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: Issues Ment Health Nurs. 2020 Apr 7;41(6):486–493. doi: 10.1080/01612840.2019.1693670

Resourcefulness as a Mediator of the Effects of Dementia Symptoms and Caregiver Reactions on Caregiver Mental Health

Jaclene A Zauszniewski 1, Christopher J Burant 2
PMCID: PMC7314645  NIHMSID: NIHMS1546388  PMID: 32255406

Abstract

In this secondary analysis of 138 community-dwelling women caregivers of persons with dementia, we examined whether caregiver resourcefulness mediated the effects of both the frequency of and reactions to their care recipients’ memory-related, depressive, and disruptive symptoms of dementia on caregiver depressive symptoms. Caregiver resourcefulness mediated the effects of care recipient depressive symptoms on caregiver depressive symptoms, and the effects of caregiver actions to depressive and disruptive symptoms on caregiver depressive symptoms. The findings suggest the potential benefit of teaching resourcefulness skills to reduce depressive symptoms of caregivers whose care recipients frequently exhibited depressive or disruptive symptoms associated with dementia.

Keywords: dementia caregivers, caregiver reactions, dementia symptoms, caregiver depression

An estimated 15.7 million family caregivers in the United States provide care for older adults who have Alzheimer’s disease or other dementia (Alzheimer’s Association, 2018). These family caregivers are often called “informal caregivers” because they receive no pay for assisting their family member with their basic activities of daily living (e.g. bathing, dressing, and eating) and for performing some medical tasks (e.g. managing their medications) (Family Caregiver Alliance, 2016). The most recent statistics indicate that about 75% of caregivers are women and that they may spend as much as 50% more time providing care than male caregivers (Family Caregiver Alliance, 2016). Studies also indicate that 36% of female caregivers perform the most difficult caregiving tasks associated with their care recipients’ activities of daily living (e.g. bathing, toileting, and dressing) while male caregivers are more likely to assist their care recipients with less burdensome instrumental activities of daily living (e.g. financial matters, grocery shopping, and arranging for care needs to be met) (Family Caregiver Alliance, 2016). Family caregivers of persons with Alzheimer’s disease and other dementias provide almost 22 hours of care per week (Alzheimer’s Association, 2016). In addition, the duration of caregiving for persons with Alzheimer’s disease and other dementias may be for five years or longer (Alzheimer’s Association, 2016).

Dementia Caregiving.

Providing care for an older adult with dementia goes beyond meeting their needs in relation to their basic and instrumental activities of daily living. It also includes managing the symptoms and behaviors associated with dementia that may be particularly challenging and produce added strain and psychological distress in family caregivers (Robinson, Crawford, Buckwalter, & Casey, 2018; de Vugt, Nicolson, Aalten, Lousberg, Jolle, & Verhey, 2005). Behaviors and symptoms associated with dementia may be exhibited as memory-related symptoms (e.g. forgetfulness), depressive symptoms (e.g. sadness), and disruptive symptoms (e.g. agitation) (Alzheimer’s Association, 2016; Robinson et al, 2016).

Effects of Dementia Caregiving on Caregivers.

Research has shown that the psychological and behavioral symptoms of dementia produce great stress in caregivers (Robinson et al., 2016). When such symptoms and behaviors are exhibited by persons with dementia, the reaction of family caregivers is influenced by their feelings of burden and psychological well-being (Alvira et al., 2015; Robinson et al., 2016). Although memory related symptoms occur most frequently, caregivers react most strongly when care recipients exhibit depressive symptoms (e.g. feelings of hopelessness, threats of self-injury) or disruptive behaviors (e.g. aggression, hostility) (Robinson et al., 2016). When family caregivers can no longer manage their care recipients’ symptoms or behaviors associated with dementia, they may decide to institutionalize that family member, which may bring about feelings of guilt, dissatisfaction with care of their family member, and financial burden (Gaugler et al., 2011; Nikzad-Terhune, Anderson, Newcomer, & Gaugler, 2010). The physical and emotional exhaustion that family caregivers of persons with dementia experience is well-documented whether they provide care at home or have decided on placement in a dementia care facility (Sorenson and Conwell, 2011). Considering the time commitment involved, the types and number of tasks performed, and the behaviors and symptoms of dementia, family caregivers experience tremendous burden, and their own health is compromised, particularly their mental health (Ma, Dorstyn, Ward, & Prentice, 2018).

Caregiver Depression.

A conservative estimate reports that 20% of family caregivers suffer from depression, which is twice the rate of the general population (Family Caregiver Alliance, 2016). While the effects of the symptoms and behaviors of dementia exhibited by the care recipient on the caregiver’s mental health have not been examined, a recently published analysis of caregiver reactions to symptoms and behaviors of dementia showed that the depressive and disruptive symptoms exhibited by the care recipient were significantly correlated with depressive symptom in the family caregivers (Zauszniewski, Lekhak, & Musil, 2018). Moreover, it is not known whether the effects of the care recipient’s dementia symptoms or the caregiver’s reactions to those symptoms on the family caregiver’s mental health (i.e. absence of depressive symptoms) might be mediated by a positive psychological resource.

Positive Caregiver Resources.

In a recently published study of dementia family caregivers in China, researchers reported a significant correlation between the care recipient’s level of depressive symptoms and caregiver burden (Yang, Ran, & Luo, 2019). However, the researchers also found that this correlation was weaker for those family caregivers who viewed their caregiving situation in a more positive way that focused on positive gains, self-affirmation, and improved family relations (Yang, et al, 2019). Other recent studies showed significant relationships in the expected directions among neuropsychiatric symptoms of dementia and caregiver depressive symptoms and resilience (de Rosa, Simoes-Neto, Santos, Torres, Baptista, Kimura, & Dourado, 2018; Mavounza, Ouellet, & Hudon, 2018). In addition, family caregiver reactions to dementia symptoms, specifically the depressive and disruptive symptoms exhibited by their care recipient, have been positively correlated with caregiver depressive symptoms and negatively associated with caregiver resourcefulness (Zauszniewski, et al, 2018).

Resourcefulness in Caregivers.

Resourcefulness is defined as a collection of cognitive and behavioral strategies, including strategies performed independently (i.e. self-help) and strategies for seeking help from others. These strategies are used for managing adverse situations and promoting mental health (Zauszniewski, 2016). Resourcefulness has been studied in various caregiver populations, including dementia caregivers (Bekhet & Avery, 2018; Gonzalez, Polansky, Lippa, Gitlin, & Zauszniewski, 2014; Zauszniewski, Lekhak, Burant, Variath, & Morris, 2016). Consistently, greater resourcefulness has been associated with positive health outcomes, such as adaptive functioning, life satisfaction, self-assessed health, psychological well-being, and physical functioning (Zauszniewski, 2016). Moreover, resourcefulness has also been linked with lower stress and fewer depressive symptoms (Zauszniewski, Lekhak, Yolpant, & Morris, 2015). However, missing from the scientific literature are studies that examine whether resourcefulness mediates the relationship between dementia symptoms/behaviors and caregiver depressive symptoms and whether it mediates the relationship between the caregiver’s reactions to dementia symptoms/behavior and their depressive symptoms. If resourcefulness is found to mediate either or both of those relationships, implementation of a resourcefulness training program may be indicated.

Theoretical Framework.

Zauszniewski’s middle range theory of resourcefulness (Zauszniewski, 2016) provided the framework for identifying the study variables and formulating the research questions examined in this secondary analysis of existing data from women caregivers of older adults with dementia. Within this framework (Figure 1), each of the study variables (i.e. frequency of dementia symptoms, caregiver reactions to dementia symptoms, resourcefulness, and absence of depressive symptoms) operationalize one of the four major constructs of the theory (i.e. antecedent / contextual factors, process regulators, resourcefulness, and quality of life). Dementia symptoms and behaviors correspond to the antecedent / contextual factors because they exist outside the family caregiver. These symptoms are memory-related, depressive and disruptive symptoms of dementia. All other study variables exist within the family caregiver. The caregiver’s reactions to the dementia symptoms (i.e. memory-related, depressive, and disruptive) reflect process regulators in the theoretical framework. Resourcefulness is the central construct that will be tested as a mediator. Caregiver depressive symptoms will be examined as a reverse indicator of quality of life, meaning that the absence of such symptoms would reflect a better quality of life. Figure 1 shows the hypothesized relationships among the variables that were examined in this study.

Figure 1.

Figure 1.

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Proposed relationships among dementia symptoms, caregiver reactions, resourcefulness, and depressive symptoms within Resourcefulness Theory.

Purpose and Research Questions

This study examined the mediating effects of resourcefulness in the relationships between the frequency of memory-related, depressive, and disruptive symptoms of dementia exhibited by the care recipient and the caregiver’s reaction to those symptoms and her own depressive symptoms. The following research questions were addressed:

  1. Are the effects of the frequency of the care recipient’s dementia symptoms (i.e. memory-related, depressive, and disruptive) on caregiver depressive symptoms mediated by the caregiver’s resourcefulness?

  2. Are the effects of the caregiver’s reactions to the care recipient’s dementia symptoms (i.e. memory-related, depressive, and disruptive) on caregiver depressive symptoms mediated by the caregiver’s resourcefulness?

Methods

Design

This secondary analysis was conducted from existing data from a three-wave clinical trial that tested interventions for managing stress and promoting mental health in a community-based sample of women caregivers of older adults with dementia. Specifically, the baseline data (obtained prior to intervention) from these women caregivers were used to address the research questions.

Sample

The sample included 138 community-dwelling women caregivers in a large Midwestern city in United States. They were recruited with flyers describing the parent study that were posted in venues that included health centers, churches, and places of business (e.g., grocery stores, department stores, restaurants, coffee houses, bookstores, and libraries) or were distributed to support groups for caregivers of older adults with dementia. Criteria for participating in the study were female gender, age 21 years or older, and currently serving as a caregiver (e.g. monitoring or providing direct care) for an older adult with dementia for a minimum of 4 hours per day and for at least 6 months. This convenience sample of 138 women caregivers was considered sufficient for performing regression analyses to test the mediating effects of resourcefulness between three types of dementia symptoms in terms of frequency or caregiver reaction and caregiver depressive symptoms. Given this sample size, a small to medium effect size of f2 = .06 could be detected at a significance level of α=.05, and power of B = .80 (Cohen, 1992).

Sample demographics are published elsewhere in detail (Zauszniewski et al., 2016). However, a brief summary of relevant characteristics are reported here. The women caregivers had an average age of 56 years (range = 25 to 89 years). They reported providing care to older adults who were mostly women (72%) whose ages averaged 82 years (range 65 to 100 years). The average length of time for proving care was 4.5 years, ranging from a minimum of 6 months to 23 years. The average number of caregiving hours per day was 8.2 hours, ranging from 4 to 14 hours per day. The sample was diverse, with more than half (54%) reporting they were Caucasian, 38% identifying as African American, and 8% claiming to be of another or mixed races/ethnicities. More than half (55%) were unmarried / unpartnered (single, divorced, separated, or widowed) while 45% said they were married or partnered. Although 60% reported achieving an Associate degree or higher, more than half (56%) claimed an annual household income of less than $30,000. Nearly 60% of the women caregivers reported their health to be good, while another 16% believed their health was excellent.

Procedures

The data used for this secondary analysis were collected during face-to-face interviews with the women caregivers using the structured instruments described below in the following paragraphs. Approval was obtained prior to the study from the university’s institutional review board.

Frequency of dementia symptoms was measured by the 24-item Revised Memory and Behavior Problems Checklist on which caregivers report the occurrence of dementia symptoms, including memory-related, depressive, and disruptive symptoms, over the past week on a 5-point scale ranging from “never occurred” to “occurring every day” (Teri, Truax, Logsdon, Uomoto, Zarit, & Vitaliano, 1992). Internal consistency for caregiver report of frequency of dementia symptoms was established by Cronbach’s alphas ranging from .82 to .84 (Robinson et al., 2016; Teri et al., 1992). Cronbach’s alphas for the three subscales were .71 to .79 (memory-related symptoms), .80 to .83 (depressive symptoms), and .67 to .75 (disruptive symptoms) (Robinson et al., 2016; Teri et al., 1992). Alphas for the analysis reported here were .84, .75, .82, and .75, for the total scale, and frequency of memory-related, depressive, and disruptive symptoms, respectively. Construct validity has been established through correlations with measures of care recipient depression and mental status with the memory-related symptoms correlated significantly with mental status (r =.48; p < .01), and the depressive and disruptive symptoms correlated significantly with care recipient depression (r = .44; p < .01) (Teri et al., 1992). In addition, factor analysis confirmed three first-order factors, consistent with three subscales (Teri et al., 1992).

Caregiver reaction to dementia symptoms was captured by the same 24-item Revised Memory and Behavior Problems Checklist previously described, which also provides scores for the caregiver’s reaction to symptoms consistent with dementia, including depressive, disruptive, and memory-related symptoms (Teri, et al., 1992). Items reflecting caregiver reactions are rated on a 5-point scale ranging from “not at all” (0) to “extremely” (4) bothersome. Similar to the frequency scale described above, internal consistency for caregiver reaction to dementia symptoms was established by Cronbach’s alphas ranging from .87 to .90 (Robinson et al., 2016; Teri et al., 1992). For the three subscales, the Cronbach’s alphas range from .77 to .86 (depressive symptoms), .70 to .76 (disruptive symptoms) and .76 to .79 (memory-related symptoms), (Robinson et al., 2016, Teri et al., 1992). For the analysis reported here, the alphas were .88, .78, .86, and .79, for the total scale, and caregiver reactions to memory-related, depressive, and disruptive symptoms, respectively. Construct validity has been reported with correlations with measures of caregiver depression and burden. All three subscales were significantly correlated with caregiver depression or burden (r’s =.29, .31, and .26; p <.01) (Teri et al., 1992). As with the frequency of dementia scale previously described, factor analysis for the three subscales reflecting caregiver reactions to dementia symptoms confirmed the presence of three first-order factors, consistent with three subscales (Teri et al., 1992).

Resourcefulness was operationalized by the 28-item Resourcefulness Scale (RS; Zauszniewski, Lai, & Tithiphontumrong, 2006). It is comprised of two subscales: 16 items measuring personal resourcefulness, and 12 items measuring social resourcefulness. Item responses were rated on a 6-point Likert scale, from “not at all like me” to “very much like me.” Scores may range from 0 to 140, with higher scores indicating greater resourcefulness (Zauszniewski, et al., 2006). The RS has published estimates of internal consistency (Cronbach’s alpha = .83) and construct validity has been shown by confirmatory factor analysis that demonstrated the presence of subscales reflecting personal and social resourcefulness. Higher-order factor analysis revealed the two subscales were moderately correlated (r = .41, p < .001) (Zauszniewski, et al., 2006). Cronbach’s alpha for the RS in the study sample was .81.

Depressive symptoms were measured by the 20-item Center for Epidemiological Studies-Depression (CES-D) scale (Radloff, 1977). Items on the CES-D are scaled on a 5-point continuum from “rarely” to “always.” Scores may range from 0 to 80 with higher scores, after reversing the scores on four items that are positively worded, reflecting greater frequency of depressive symptoms (Radloff, 1977). In published studies of healthy older adults, Cronbach’s alphas for the CES-D have ranged from .80 to .88 (Lewinsohn, Seely, Roberts, & Allen, 1997; Zhang, Sun, Kong, & Wang, 2012). The CES-D has widely reported construct validity and it has been standardized for diverse age groups and races/ethnicities (Radloff, 1977). In the caregivers sampled in the study reported here, the Cronbach’s alpha was .87.

Data Analysis

Preliminary data analyses were conducted to ensure that the statistical assumptions underlying correlational and multiple regression analyses (e.g., normality, linearity, homoscedasticity, and absence of multicollinearity) were not violated. To address the research questions, the data analysis included Pearson’s correlation and multiple linear regression. Following the examination of correlations among all the study variables, (i.e., dementia symptoms, caregiver reaction to dementia symptoms, resourcefulness, and caregiver depressive symptoms), two hierarchical regression analyses were conducted to address the research questions. Using the classical method for testing for mediating effects (Baron & Kenny, 1986), the three requirements for testing mediation by resourcefulness in this study were fulfilled. These included: 1) the independent variable (dementia symptoms or caregiver reaction to dementia symptoms) predicted the dependent variable (depressive symptoms); 2) the independent variable (dementia symptoms or caregiver reaction to dementia symptoms) predicted the mediator variable (resourcefulness); and 3) prediction of depressive symptoms by the care recipient’s dementia symptoms or the caregiver reaction to dementia symptoms was diminished when resourcefulness was added to the equation (Baron & Kenny, 1986).

Results

Correlations between care recipient symptoms and caregiver reactions

Prior to conducting analyses to address the major research questions, we examined associations between the three clusters of dementia symptoms (memory-related, depressive, and disruptive) and the caregiver reactions to each of those three symptom clusters. The frequency of dementia symptoms exhibited by care recipients within all three clusters correlated significantly with the caregiver reactions to those symptoms. However, the correlation between the frequency of memory-related symptoms and the caregiver’s reaction to those symptoms (r =.16, p <.05) was not as strong as the correlations between the depressive (r =.41, p <.001) and disruptive symptoms (r =.58, p <.001) and respective caregiver reactions. Although these correlations emerged, because caregiver reaction to a specific cluster of dementia symptoms depends on whether or not those symptoms are present, empirical literature (e.g. Johnson, Wackerbarth, & Schmitt, 2001; Teri et al, 1992) supported our examination of relationships with other outcomes, namely, resourcefulness and depressive symptoms, in the analysis reported here.

Correlations among dementia symptoms and caregiver reactions, resourcefulness, and depressive symptoms

Each of the two research questions involved three independent variables. Three clusters of dementia symptoms (memory-related, depressive, and disruptive) were tested in the first hierarchical analysis and three sets of caregiver reaction to dementia symptoms (memory-related, depressive, and disruptive) were examined in the second hierarchical analysis. For both analyses, resourcefulness was tested as the mediator and caregiver depressive symptoms was the dependent variable of interest. To establish the relevance for testing the mediating effects by resourcefulness, we examined Pearson’s correlation coefficients among these eight study variables (Table 1).

Table 1.

Correlations between dementia symptoms and caregiver reactions with caregiver resourcefulness and depressive symptoms (N=138)

Symptoms and reactions Dementia symptom
cluster		 Correlation with
caregiver
resourcefulness		 Correlation with
caregiver
depressive
symptoms
Care recipient symptoms Memory symptoms r = −.22 * r = .03
Depressive symptoms r = −.41 ** r = .32 **
Disruptive symptoms r = −.34 ** r = .32 **
Caregiver reactions Memory symptoms r = −.28 ** r = .16 +
Depressive symptoms r = −.50 ** r =.45 **
Disruptive symptoms r = −.54 ** r = .46 **
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+

p < .05

*

p < .01

**

p < .001

Effect of dementia symptoms on caregiver resourcefulness and depressive symptoms

Before conducting the hierarchical analysis for mediation, we needed to establish that all three dementia symptom clusters were significant predictors of resourcefulness. We found that only the depressive symptoms of dementia exhibited by the care recipients significantly predicted resourcefulness (Standardized Beta = −.32, p < .001), while the disruptive and memory-related symptoms did not (Standardized Beta’s = −.15 and −.13, respectively). Thus, resourcefulness could not mediate the effects of these two clusters of dementia symptoms on caregiver depressive symptoms.

Next, the two-step hierarchical multiple regression analysis was performed. On the first step, the three sets of frequency of dementia symptoms, including frequencies of memory-related, depressive, and disruptive symptoms, were entered into the model; the dependent variable was caregiver depressive symptoms. On this first step, all three clusters of dementia symptoms were entered together; this accounted for only 14% of the variance of caregiver depressive symptoms. The frequency of depressive and disruptive symptoms of dementia in the care recipient were significant predictors of depressive symptoms in the caregiver (Standardized Beta’s = −.22 and −.23, p’s < .02, respectively); the frequency of memory-related symptoms was not significant.

When resourcefulness was added to the model on the second step, 31% of the variance of caregiver depressive symptoms was explained. The standardized beta coefficients for both depressive and disruptive symptoms dropped substantially, rendering them both insignificant in predicting caregiver depressive symptoms and indicating that resourcefulness mediated their effects on caregiver depressive symptoms. Results appear in Table 2.

Table 2.

Hierarchical Regression Analyses of Frequency of Dementia Symptoms Predicting Resourcefulness and Depressive Symptoms (N = 138).

Resourcefulness
 Depressive Symptoms
Model 1 Model 2
Predictors B SE B Beta t p B SE B Beta t p B SE B Beta t p
Memory symptoms −.37 .22 −.13 −1.64 .10 −.12 .14 −.07 −0.87 .39 −.22 .12 −.13 −1.77 .08
Depressive symptoms −.75 .21 −.32 −3.60 .00 .30 .13 .22 2.40 .02 .10 .12 .07 0.84 .40
Disruptive symptoms −.39 .24 −.15 −1.62 .11 .35 .15 .23 2.41 .02 .24 .13 .16 1.86 .07
Resourcefulness −.27 .05 −.47 −5.77 .00
   R .459 .375 .559
   R Square .210 .140 .313
Change in R-Square; ----- ----- .172
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B = unstandardized beta

SE B = standard error for the unstandardized beta

Beta = standardized beta

t = t test statistic

p = significance.

Effect of caregiver reactions to dementia symptoms on caregiver resourcefulness and depressive symptoms

Again, before conducting the hierarchical analysis for mediation, we needed to establish that caregiver reactions to all three dementia symptom clusters were significant predictors of resourcefulness. We found that caregiver reaction to the depressive and disruptive symptoms of dementia significantly predicted resourcefulness (Standardized Beta’s = −.24 and −.35, p’s < .02 and .001, respectively) memory-related symptoms did not (Standardized Beta = −.12). Thus, resourcefulness could not mediate the effects of the caregiver reaction to memory-related symptoms of dementia on caregiver depressive symptoms.

Next, the two-step hierarchical multiple regression analysis was performed. On the first step, the caregiver reactions to the three sets of dementia symptoms were entered into the model; the dependent variable was caregiver depressive symptoms. On this first step, caregiver reactions to all three clusters of dementia symptoms were entered together: this accounted for 23% of the variance of caregiver depressive symptoms. Caregiver reactions to their care recipient’s depressive and disruptive symptoms of dementia were significant predictors of depressive symptoms in the caregiver, but caregiver reaction to memory-related symptoms was not significant.

When resourcefulness was added to the model on the second step, 31% of the variance of caregiver depressive symptoms was explained. The standardized beta coefficients for caregiver reactions to both depressive and disruptive symptoms dropped substantially, rendering them both insignificant in predicting caregiver depressive symptoms and indicating that resourcefulness partially mediated their effects on caregiver depressive symptoms. Results appear in Table 3.

Table 3.

Hierarchical Regression Analyses of Caregiver Reactions to Dementia Symptoms Predicting Resourcefulness and Depressive Symptoms (N = 138).

Resourcefulness
 Depressive Symptoms
Model 1 Model 2
Predictors B SE B Beta t p B SE B Beta t p B SE B Beta t p
Memory symptoms −.44 .26 −.12 −1.68 .10 .03 .16 .02 0.19 .85 −.06 .16 −.03 −0.38 .70
Depressive symptoms −.57 .23 −.24 −2.48 .01 .36 .14 .26 2.54 .01 .24 .14 .17 1.77 .08
Disruptive symptoms −1.04 .29 −.35 −3.58 .00 .49 .18 .28 2.73 .01 .28 .18 .16 1.54 .13
Resourcefulness −.21 .05 −.36 −4.10 .00
   R .582 .497 .576
   R Square .339 .247 .332
Change in R-Square; ----- ----- .084
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B = unstandardized beta

SE B = standard error for the unstandardized beta

Beta = standardized beta

t = t test statistic

p = significance.

Discussion

Although a recent caregiver study of persons with dementia (Baharudin, Din, Subramaniam, & Razali, 2019) examined the mediating role of coping strategies between behavioral and psychological symptoms of dementia and caregiver burden, this was the first study to examine whether caregiver resourcefulness mediated the effects of dementia symptoms exhibited by the care recipient on caregiver depressive symptoms as well as to examine whether caregiver resourcefulness mediated the effects of the caregiver’s reactions to the care recipient’s memory-related, depressive, and disruptive symptoms of dementia on their own depressive symptoms. Baharudin and colleagues (2019) found that self-distraction, active coping, planning, and acceptance, which may constitute resourcefulness skills, were the coping strategies that mediated the effects of dementia symptoms (predominantly irritability, apathy, and agitation), on caregiver burden.

Our preliminary correlational analysis indicated significant correlations between the type of dementia symptoms exhibited by care recipients and their caregiver’s reactions to those same symptoms in terms of how bothersome those symptoms were to them. Thus, the more frequently the older adults with dementia exhibited memory-related, depressive, or disruptive symptoms, the more bothersome it was for their caregiver. This finding is consistent with other studies that have reported significant positive associations between dementia symptom frequency and caregiver reactions (e.g. Jackson, Fauth, & Geiser, 2014). In addition, this finding is also plausible because caregiver reaction to a specific cluster of dementia symptoms was contingent on whether or not those symptoms were exhibited by the care recipient (Johnson et al., 2001; Teri et al., 1992).

However, we also found a weaker correlation between the frequency of memory-related symptoms exhibited by care recipients and caregiver reaction to these symptoms than we found for frequency of and caregiver reaction to depressive and disruptive symptoms. A possible explanation for this finding is provided in a study by Nogales-Gonzalez, Romero-Moreno, Losado, Marquez-Gonzalez and Zarit (2005), which found a moderating effect of self-efficacy between the frequency of depressive and disruptive, but not memory-related symptoms of dementia and caregiver reactions to those symptoms.

The analysis to address the first research question showed that increased frequencies of dementia symptoms of all three clusters (memory-related, depressive, and disruptive) by the care recipient were significantly correlated with lower caregiver resourcefulness. Higher frequencies of depressive and disruptive symptoms of dementia were associated with greater depressive symptoms in the caregiver while memory-related symptoms were unrelated. An explanation for this finding may lie in the more limited variation on the scores for frequency of memory related symptoms in comparison with depressive and disruptive symptoms although caregivers reported memory-related symptoms more frequently than depressive or disruptive symptoms.

Memory-related symptoms are typically the first symptoms to appear in the earliest stages of dementia. At that stage, they may be very subtle; they may go undetected and may even be dismissed by family caregivers. This may account for a lower reaction by caregivers and fewer depressive symptoms due to these symptoms. On the other hand, as the course of dementia progresses to the mid and later stages, disruptive and depressive symptoms begin to emerge in the person with dementia. Because the caregivers who participated in this study reported an average of 4.5 years of caregiving, their care recipients may have been in a mid-stage of dementia during which symptoms of disruption and depression were more prominent and therefore more bothersome and distressing to them.

Caregiver resourcefulness was found to mediate the effects of the frequency of the care recipient’s depressive symptoms on the caregiver’s depressive symptoms. This finding is consistent with research by Sorensen and Conwell (2011), who suggested that certain problem behaviors associated with dementia, such as depressive symptoms, may be better tolerated by caregivers if they are able to keep their overall burden under control. Resourcefulness skills are strategies that may be used for maintaining control and managing adverse aspects of the caregiving situation (Zauszniewski, 2016).

In the analysis addressing the second research question, the caregiver’s greater reaction to their care recipient’s memory-related, depressive, and disruptive symptoms of dementia correlated significantly with lower resourcefulness and greater depressive symptoms in the caregiver. However, only the effects of their reaction to the care recipient’s depressive and disruptive symptoms on their own depressive symptoms was mediated by resourcefulness. Our findings in relation to caregiver reactions to the depressive and disruptive symptoms of dementia and their potentially deleterious effect on the caregiver’s mental health, are consistent with those reported by other researchers (Fauth, Zarit, Fernia, Hofer, & Stephens, 2006; Hansen, Hodgson, & Budhathoki, 2018; Ornstein, Gaugler, Devanand, Scarmeas, Zhu, & Stern, 2013; Zauszniewski et al., 2018).

However, our finding that resourcefulness mediated the effects of the depressive and disruptive symptoms of dementia on caregiver depression were somewhat inconsistent with those reported by Tang, Jang, Lingler, Tamres, and Erlen (2015), who simultaneously examined social support, problem-solving, and self-efficacy as mediators between caregiver hassles associated with similar dementia symptoms and caregiver depressive symptoms and found that only self-efficacy was significant. This is somewhat surprising because resourcefulness skills comprise a social dimension in which individuals seek and obtain social support and a personal dimension that includes problem-solving strategies (Zauszniewski, 2016). However, in their discussion, Tang and colleagues (2015), who recognized this finding to be inconsistent with other empirical studies, explained its occurrence in relation to the sample characteristics. That is to say, the caregivers in their study reported lower frequency of dementia symptoms in their care recipients and lower distress in association with those symptoms than in other studies (Tang et al., 2015). In comparison with the study reported here, on average, the scores on frequency of dementia symptoms and caregiver reactions (using the same measure) were lower by 7 and 18 points, respectively.

Though limited by convenience sampling, restricted to women, and constrained geographic representation, the findings suggest that caregiver resourcefulness is particularly important when providing care for an older adult with dementia who was frequently exhibiting depressive or disruptive symptoms and when the presence of these symptoms was distressing to them. Taken together, the results from both mediation analyses suggest the potential benefit of teaching resourcefulness skills to caregivers, to reduce depressive symptoms in these individuals whose care recipients frequently exhibit depressive or disruptive symptoms associated with dementia and who become distressed by the presence of these symptoms. Research to date indicates that, overall, interventions for dementia caregivers tend to be relatively small unless they involve active participation of the caregivers and teaching of specific skills (Sorensen & Conwell, 2011). Indeed, the behavioral symptoms of dementia and the caregiver reactions to those symptoms are considered amenable to both caregiver and caregiver-care recipient dyad directed interventions that target stress reduction (Campbell, 2009).

Resourcefulness training interventions involve teaching specific personal (self-help) and social (help-seeking) skills and active participation of caregivers in maintaining a daily log to record their application of those skills in their caregiving situation (Zauszniewski, 2016). In addition, resourcefulness training interventions can be tailored to help caregivers manage the disruptive and depressive symptoms of their care recipients, resulting in the promotion of the caregiver’s own mental health by reducing their risk of depressive symptoms. Future research is needed to develop, tailor, and test interventions to help dementia caregivers to manage the depressive and disruptive symptoms associated with dementia in their family members. Limitations related to sampling and design can be overcome through larger, randomized controlled trials, which include male caregivers and target a diverse sample with wider geographic representation.

Acknowledgments

Funding for the study was provided by a grant from the National Institutes of Health, National Institute of Nursing Research (R21-NR-010368) awarded to Dr. Jaclene A. Zauszniewski.

Contributor Information

Jaclene A. Zauszniewski, Kate Hanna Harvey Professor of Community Health Nursing, Case Western Reserve University.

Christopher J. Burant, Associate Professor of Nursing, Case Western Reserve University.

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