Depressive symptoms in child caregivers of very old Mexican Americans

Abstract

Objective:

To study the effects of disability, cognitive impairment, and neuropsychiatric disturbance among older Mexican Americans on depressive symptoms in their children caregivers.

Methods:

This study utilizes data from Wave 7 (2010-2011) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE). The final sample included 200 adult children caregivers that provided direct personal care with activities of daily living (ADL) (e.g. bathing, toileting, dressing, etc.) to their older parents (average age = 87). We analyzed the influence of ADL disability, cognition (MMSE), and neuropsychiatric symptoms (NPI) of the care recipient on depressive symptoms of the adult child caregiver. A cross-sectional multivariable linear regression analysis was conducted to examine the effect of neuropsychiatric disturbance on caregiver depressive symptoms.

Results:

Presence of care recipient NPI symptoms was associated with higher depressive symptoms for caregivers. Additional characteristics associated with caregiver depressive symptoms were not being married, and higher perceived social stress. ADL disability of the care recipient, cognitive functioning of the care recipient, or caregiver health status alone did not have a significant effect on depressive symptoms of the caregiver.

Conclusions:

In a Mexican American familistic culture, disability and cognitive impairment might be better tolerated by families but neuropsychiatric behavioral symptoms related to dementia may take an increased toll on family member caregivers. The need to provide respite services, mental health resources and community services for caregivers of care recipients with neuropsychiatric symptoms is of paramount importance to alleviate depressive symptoms and burden among caregivers.

Introduction

According to the U.S. Census Bureau, the older U.S. adult population 65+ is projected to increase by 56% from 40.3 million in 2010 to 72.1 million by 2030 (Institute of Medicine, 2012, 2013). More specifically, those 85 and older is expected to triple from 5.4 million to 19 million by 2050 (Kalapatapu & Sullivan, 2010; U.S. Census Bureau, 2010). The older U.S. population is also becoming increasingly diverse and at the forefront of changes are older Hispanics who are projected to be the largest cohort of older minority people in the U.S. with Hispanics of Mexican origin leading the way (Anthony, John Geldhof, & Mendez-Luck, 2016; Federal Interagency Forum on Aging-Related Statistics, 2012; Salazar, Royall, & Palmer, 2015).

These trends raise serious questions about a lack of geriatric specific facilities, services, and professionals, which leaves an increasingly disproportionate amount of older individuals reliant on friends, family and informal support systems for care (National Alliance on Caregiving, 2015). Most older individuals, particularly older Hispanics, ’age in place’ due to cultural or structural factors (i.e. limited financial resources) thus, placing responsibility of caregiving on loved ones (Aranda, Castaneda, Lee, & Sobel, 2001; Rote, Angel, & Markides, 2014). Furthermore, Mexican American families are less likely than non-Hispanic white families to utilize long-term care facilities and hospice even though they may acknowledge the need for such formal care (Apesoa-Varano, Gomez, & Hinton, 2016). Thus, caregivers feel an increased sense of obligation due to cultural expectations, traditions, and gender role expectations. These cultural expectations represent the values, norms, and traditions that affect how Mexican-origin individuals think and behave about caregiving role (Mendez-Luck & Anthony, 2016; Villatoro, Morales, & Mays, 2014).

Although there have been several studies on Hispanic caregivers, less research has focused on Mexican American caregivers providing care for elderly family members. Further, despite the abundance of research on caregiver depression, little is known about the inherent risks and benefits stemming from taking on the role of caregiver family members of older Mexican Americans who are increasingly surviving beyond age eighty (Adelman, Tmanova, Delgado, Dion, & Lachs, 2014; Aranda et al., 2001; Aranda & Knight, 1997). Understanding these mechanisms becomes crucial as rising disability rates increase the need for caregiving (Apesoa-Varano et al., 2016; Evans, Belyea, Coon, & Ume, 2012; Garcia & Reyes, 2018; Schneider & Shardell, 2008).

In this study, we employ a unique data set of older Mexican Americans (H-EPESE) to examine how care recipient disability (Activities of Daily Living, ADL), cognitive functioning of the care recipient (Mini Mental State Examination, MMSE), and care recipient neuropsychiatric disturbance (Neuropsychiatric Inventory, NPI) influence caregiver depressive symptoms. Both caregiver and care recipient mental health status, physical health and care recipient behavior are expected to be associated with caregiver depressive symptoms.

The traditional cultural value of familismo (emphasis on obligation to the family) among Mexican Americans and other Hispanics is a steadfast obligation and prioritization of the family that attenuates focus on the individual (Smith, Sudore, & Perez-Stable, 2009). Caregiving of older relatives in the home, as opposed to institutionalization, is seen as an expected cultural obligation as opposed to institutionalization (Angel, Angel, McClellan, & Markides, 1996; Aranda & Knight, 1997; Mendez-Luck & Anthony, 2016).

Neuropsychiatric symptoms (NPS) are commonly associated with dementia and mild cognitive impairment (MCI) and elderly Hispanics are 1.5 times more likely to present with dementia and MCI compared to non-Hispanic whites (Turner et al., 2015). Symptoms may include apathy, aggression, irritability, agitation, depression, accusatory behavior, delusions, hallucinations, sleep disturbance, loss of appetite, paranoia, and social withdrawal (Jost & Grossberg, 1996). Roughly one-third of community dwelling elders with dementia have been found to experience NPS (Lyketsos et al., 2000; Salazar et al., 2015). It has been suggested that dementia associated symptoms often go unrecognized in older Mexican Americans due to lower levels of education, perception of ‘normal aging behaviors,’ traditional values, and family caregiving expectations (Espino et al., 2002; Hinton, Haan, Geller, & Mungas, 2003; O’Bryant, Humphreys, Schiffer, & Sutker, 2007).

One recent study by Salazar and colleagues found a cross-ethnic positive association between Hispanic ethnicity and greater NPS symptoms in Alzheimer’s patients versus controls (Salazar, Dwivedi, & Royall, 2016). In another study they found that Hispanics presented with higher proportions of neuropsychiatric symptoms compared to non- Hispanic whites (Salazar et al., 2016). Another study by Rote and colleagues found significant correlations between neuropsychiatric disturbance and depression among caregivers of Mexican American older adults (Rote et al., 2014). Neuropsychiatric symptoms are commonly associated with dementia and MCI in community dwelling elders and Hispanic elderly are 1.5 times more likely to present with dementia and MCI compared to non-Hispanic whites (Turner et al., 2015). Studies suggest that MCI, NPS, and cognitive dysfunction often go unrecognized in older Mexican Americans due to lower levels of education, perception of ‘normal aging behaviors,’ traditional values, and family caregiving expectations (Espino et al., 2002; Hinton et al., 2003; O’Bryant et al., 2007). Unfortunately, literature on the NPS of Hispanics, and more specifically Mexican Americans, remains limited.

For this study, we hypothesize that caregiver health status, cognition of the care recipient (MMSE), degree of care recipient neuropsychiatric symptoms (NPI) and care recipient disability (ADL) will predict caregiver depressive symptoms. Findings will be key to informing caregiving dyads thus, increasing quality of life and allowing aging individuals to remain independent in their communities. Figure 1 represents our conceptual framework which is adapted from Rote et al. (2014). Our model explores care recipient characteristics including nativity, cognition (MMSE), degree of disability (number of ADLs), caregiver reported neuropsychiatric symptoms (NPI), along with caregiver characteristics including nativity, age, gender, education, marital status, health variables (diabetes, hypertension, and arthritis), and self-perceived stress influence on caregiver depressive symptoms. An important feature of our analysis is that we limit our sample to child caregivers who provide ‘personal ADL-type’ care to their older parents.

Figure 1.

Conceptual framework of care recipient health predicting caregiver depression.

Methods

Data sample

We employ data from Wave 7 (2010-2011) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE). The HEPESE is an ongoing longitudinal study of Mexican American adults aged 65 and older living in Texas, California, Colorado, Arizona and New Mexico (Black, Markides, & Miller, 1998; Markides et al., 1999). The HEPESE was initiated in 1993-1994 (n = 3050) and a total of eight waves of observation have been completed as of 2013. A total of 1,078 subjects aged 82 and over were interviewed during Wave 7 in 2010-2011 along with 925 people identified by the subjects as those who know them the best and who help them the most ‘with tasks they are no longer able to do for themselves. These "informants" were asked questions regarding the health, financial wellbeing, and functioning of the interviewed subject as well as questions about their own health status and other characteristics.

Recently there has been conjecture in the literature as to whether the type of ‘personal care’ provided (ADLs versus IADLs) is more burdensome to the caregiver along with, to some degree what constitutes actual ‘caregiving.’ Of the literature that does exist, ADLs have been shown to be more ‘burdensome’ and are more highly correlated with depressive symptoms in caregivers compared to IADLs (Angel, Angel, Aranda, & Miles, 2004; Caskie, Sutton, & Margrett, 2010; Evans et al., 2012). Loss of ADL capacity also results in higher rates of institutionalization and mortality compared to loss of IADLs (Angel et al., 2004; Caskie et al., 2010; Evans et al., 2012). Thus, for the purpose of this study it was decided that inclusion criteria required caregivers that provided ‘direct personal care’ with ADLs only and who were children of the care recipient. These criteria allowed for the assessment of ADL burden and its influence on the depressive symptoms of the adult child caregiver.

Of the 925 informants interviewed in 2010-2011, the majority were adult children (N = 629) of the elderly subjects. Of the 629 adult children informants, over half provided assistance with household tasks (e.g. preparing meals, transportation, medications, etc.), and/or managing the financial affairs of the subjects (e.g. write checks, pay bills, prepare taxes, etc.). We limit our analysis below to 200 informants who were children of the interviewed subjects and who assisted them with personal ADL care tasks (e.g. bathing, toileting, dressing, etc.).

Measures

The care recipient’s APL disability was assessed with a seven-item scale to determine the degree of assistance needed to perform certain tasks: walking, toileting, bathing, bed to chair transfers, grooming, eating and dressing. The Mini Mental State Examination (MMSE) was utilized to assess cognitive functioning and impairment in the care recipient.(Folstein, Folstein, & McHugh, 1975). The MMSE measure orientation, recall, attention, and calculation, with lower scores (those ranging from 0-30) indicating greater impairment (ranging from 0-30). For the purposes of this study we used a more conservative cut point of ≤17, similar to Black and colleagues to dichotomized between moderate and severe cognitive functioning (Black et al., 1999). The Neuropsychiatric Inventory (NPI) was utilized to assess neuropsychiatric disturbances common in dementia related disorders in the care recipient (Cummings et al., 1994). Caregivers were asked to rate the presence, severity, and frequency of 12 neuropsychiatric symptoms exhibited by their parents over the past month. The sum of individual symptom scores represents the NPI severity. Scores range from 0-36 and the higher the score the more intense the disturbance. Caregiver distress related to specific symptoms was rated on a 0 to 5 point anchored Likert type scale.

The short version of the Perceived Social Stress Scale (PSS) assessed perceived social stress in the caregivers (Cohen, Kamarck, & Mermelstein, 1983). This scale asks respondents (family caregivers) to recount how often (0 = never to 4 = very often) they felt (1) they were unable to control the important things in life, (2) whether difficulties were piling up so high they could not overcome them, (3) whether they were confident about their ability to handle personal problems, (4) and whether things were going their way. The last two positive items were reversed coded and the four items were used to create an index that ranges from 0 to 16. The Cronbach’s alpha for the PSS was 0.61. The main outcome variable, the depressive symptoms of the child caregivers, was assessed with the 20-item Center for Epidemiologic Studies Depression Scale (CES-D). The CESD achieved a Cronbach’s alpha of 0.88. The CESD functions as an index of severity (ranging from 0-60) of experienced depressive symptoms over the course of a week prior to the interview (Radloff, 1977).

Socio-demographic characteristics of the caregiver included age, gender, years of education, living arrangement, marital status, nativity status of care recipient (identified as born in the U.S. or in Mexico), and years of education. Selected health conditions included diabetes, hypertension, and arthritis. Living arrangement of caregiver and care recipient included living with parents (care recipients), living two blocks to one mile and living over one mile from the care recipient. Finally, caregivers’ hours/per day providing care were categorized as two or less hours, 3 to 7 hours and 8 to 24 hours.

Statistical analysis

The characteristics of caregiver and care recipient dyads were summarized using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. To examine the effects of care recipient NPI symptoms, ADL disability, MMSE score, and caregiver perceived stress on caregiver depressive symptoms, a multivariable linear regression analysis was performed. A sensitivity analysis was further carried out using multiple imputation on missing data using the SAS PROC MI and MIANALYZE procedures. All variables included in the analyses were used to impute 200 datasets. All analyses were performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC). All tests of statistical significance were two-sided with significance level, 0.05.

Results

Descriptive statistics of the main study variables are presented in Table 1. Caregivers ranged from 26-74 years of age, a mean age of 56 years. Most were female (78%) and had an average education of approximately 11 years. Approximately half of the sample of caregivers was not married (49%). Notable health conditions of the caregivers included diabetes (20%), hypertension (42%), and arthritis (31%). Important mental health conditions in the caregiver were depressive symptoms with an average score of 5 on the CESD (between the second and third quartile) and caregiver stress as measured by the Perceived Social Stress scale with an average score of 4 (at the second quartile). Approximately 60 percent of the caregivers lived with the care recipient (N = 111), 31 percent lived two blocks to one mile (N = 58) from the care recipient and 9 percent lived over a mile away (N = 16). Seventy-two caregivers provided care for 8 to 24 hours (36%), 63 provided ≤2 hours (32%) of care, and 65 provided 3 to 7 hours (32%).

Table 1.

Description on characteristics of 200 caregiver and care recipient dyads.^a

Caregiver	N
Age (years)	200	56.1 ± 8.2
Gender
Female	200	78.00 (156)
Education (years)	183	10.6 ±4.12
Living Arrangementb
with parents	185	60.0 (111)
Hours providing carec
8-24 hours	200	36.00 (72)
Not Married	185	49.1 (91)
Health Status
Diabetes	198	19.7 (39)
Hypertension	198	41.92 (83)
Arthritis	197	31.47 (62)
Depressive Symptoms (CES-D)	199	4.8 ± 6.3
Perceived Social Stress	200	4.1 ± 2.4
Care Recipient
Age (years)	200	87.2 ± 4.7
Nativity
US born	200	49.0 (98)
Gender
Female	200	75.0 (150)
NPI - caregiver reported	200	2.7 ± 2.7
Number of ADL’s Help	200	3.6 ± 2.5
MMSE ≤17	193	58.5 (113)

CES-D: Center for Epidemiology Studies Depression Scale; NPI: Neuropsychiatric Inventory; ADL: Activities of Daily Livings; MMSE: Mini Mental State Examination.

^aFor continuous variables, mean ± standard deviation was shown and for categorical variables, the percentage and the corresponding frequency within parentheses are presented.

^bLiving arrangement results include caregivers who live two blocks to one mile (N = 58) and in another city (N = 16).

^cHours providing care includes ≤2 hours (N = 63), 3 to 7 hours (N = 65), 8 to 24 (N = 72)

On average care recipients were 87 years old, roughly half (49%) were born in the U.S. and most were female (75%). Caregivers reported that their parents required assistance with an average of 4 ADLs and 59 percent of care recipients scored ≤17 on the MMSE scale for cognitive functioning.

Table 2 presents the effect of caregiver and care recipients’ characteristics on caregiver depressive symptoms. Model 1 includes age, gender, education, marital status, and selected health items. Living arrangements and hours of care provided were not statistically significant predictors of depressive symptoms and were thus omitted. Not being married was positively associated with depressive symptoms as was caregiver reported neuropsychiatric symptoms of recipient (NPI). Model 2 adds number of ADL limitations as reported by care recipients, MMSE score of care recipients and nativity. Marital status and NPI continue to be significant predictors of caregivers’ depressive symptoms. Model 3 includes caregiver Perceived Social Stress which was significantly associated with caregiver depressive symptoms. Caregiver marital status and NPI continued to be positively associated with caregivers’ depressive symptoms. Number of ADL limitations an○MMSE were not significantly associated with caregiver depressive symptoms in either Model 2 or Model 3.

Table 2.

Effect of characteristics of caregivers and care recipients on caregiver depressive symptoms from multivariable linear regression analyses.^a-d

	Model 1	Model 2	Model 3
Caregiver Background
Age	0.04 (0.06)	0.04 (0.07)	0.05 (0.06)
Female	1.25 (1.23)	1.09 (1.27)	1.45 (1.21)
Education	−0.15 (0.12)	−0.12 (0.13)	−0.09 (0.12)
Not Married	2.15* (1.01)	2.37*(1.03)	2.65* (0.99)
Caregiver Health Status
Diabetes	1.17 (1.32)	1.11 (1.39)	1.76 (1.34)
Hypertension	1.37 (1.08)	1.47 (1.10)	1.32 (1.05)
Arthritis	−0.41 (1.14)	−0.33 (1.17)	−0.21 (1.12)
Care Recipient Characteristics
Nativity (US born)		−1.76 (1.03)	−1.77 (0.99)
Number of ADL’s Help		0.04 (0.22)	0.12 (0.21)
MMSE ≤17		−1.69 (1.12)	−1.40 (1.07)
Caregiver Reported NPI	0.44* (0.18)	0.58** (0.20)	0.46* (0.19)
Perceived Social Stress			0.83** (0.20)
R2 (Adjusted R2)	0.08 (0.04)	0.10 (0.05)	0.19 (0.13)

^aStandard errors of parameter estimates were shown in parentheses.

^bDue to the missing information, number of observations used is 178, 172, and 172 in model 1, model 2, and model 3, respectively.

^cThe corresponding R² along with the adjusted R² in each model was shown to present the change of total amount of variance in caregiver depressive symptoms that was explained.

^dThe corresponding correlation matrix between variables was provided in Table 3.

^*p < 0.05

^**p < 0.001.

Discussion

The present findings illustrate significant associations between caregiver reported neuropsychiatric disturbance, marital status, and perceived stress on depressive symptoms of children caregivers of older Mexican Americans with increased neuropsychiatric symptoms. These findings corroborate current literature on the deleterious effects of neuropsychiatric dysfunction on caregiving (Hwang, Masterman, Ortiz, Fairbanks, & Cummings, 2004; Ortiz, Fitten, Cummings, Hwang, & Fonseca, 2006). This finding is noteworthy partly because of the prioritization of family in caregiving among Mexican Americans and that most caregivers are the children of the care recipient. Mexican origin elders are typically more dependent on their adult children for care and are more reluctant to call on other family, friends, or the community for help (Angel, Rote, Brown, Angel, & Markides, 2014; Flores, Torres, Bordnick, Ren, & Haider, 2013; Garcia & Chiu, 2016).

We found that ‘unmarried’ caregivers reported more depressive symptoms compared to married caregivers. This finding is in accord with prior studies documenting the importance of spousal/partner relations in providing both emotional and tangible physical support, thus reducing caregiver depressive symptoms and burden (Annerstedt, Elmstahl, Ingvad, & Samuelsson, 2000; Aranda et al., 2001; Crist et al., 2009; Knight & Sayegh, 2010; National Alliance on Caregiving, 2015). In these studies caregivers credit their spouses/partners with providing essential respite from caregiving responsibilities. Another factor possibly contributing to the difference between married and unmarried caregivers is the role of familismo. Where familial bonds are strong familismo reinforces bonds between spouses and serves as a protective factor against depression (Canino, Vega, Sribney, Warner, & Alegria, 2008). For Mexican American families, the absence or lack of familismo or where it is disjointed or disorganized (as in the case of no availability of spousal support) mayj’serve as a risk factor for depression (Canino et al., 2008). Another consideration is the recent research on the cultural value of marianismo and its influence on caregiving (Angel et al.T2014; Flores et al., 2014; Mendez-Luck & Anthony, 2016). As in many familistic cultures, women historically care for the children, spouses, and aging family members and marianismo the unwavering devotion to caring for a loved one, is grounded in the veneration of the Virgin Mary and is a strong Mexican American cultural value (Flores et al., 2014; Hubbell, 1993; Mendez-Luck & Anthony, 2016). Among Mexican American women socialization begins in early childhood and emphasizes prioritizing the needs of others even at the expense of their own physical and mental health needs. For these women caregiving is viewed as a privilege, obligation, and perceived positively as opposed to a burden. Mexican American caregivers have been found to acquire positive benefits from caregiving including selfesteem, sense of accomplishment, and bonding with loved ones (Aranda & Knight, 1997; Pinquart & Sorensen, 2005; Roberto & Jarrott, 2008; Rote et al., 2014; Tarlow et al., 2004; Werth & Blevins, 2006).

Neuropsychiatric symptoms were by far the most dominant risk factors associated with caregiver depressive symptoms. The NPI remained significantly associated with depressive symptoms throughout all three models even after adjusting for caregiver demographics, caregiver health conditions, as well as care recipient nativity, disability, and cognition. The results are consistent with current literature on neuropsychiatric symptoms and degree of dysfunction associated with depressive symptoms and burden (Gaugler et al., 2000; Hwang et al., 2004; Liken, 2001; Ortiz et al., 2006). This is a particularly important finding given that the Mexican American population is aging rapidly and is at greater risk of early onset cognitive impairment compared to other ethnic groups (Dilworth-Anderson et al., 2008; Manly & Mayeux, 2004; O’Bryant et al., 2013; Salazar et al., 2015). As stated earlier, Mexican Americans suffering from dementia are younger, report more depression, are less educated, perform poorly on the MMSE compared to other ethnicities (Apesoa-Varano et al., 2016; O’Bryant et al., 2007; O’Bryant et al., 2013), and are more likely to be diagnosed at later stages of the disease (Apesoa-Varano et al., 2016; Clark et al., 2005; Salazar et al., 2015).

Neuropsychiatric dysfunction considerably impacts the quality of life of both the caregiver and the care recipient, and thus, is a significant matter of concern. Although Mexican American caregivers are resilient and are determined in their commitment to care for older kin, many are simply unprepared to deal with or understand neuropsychiatric dysfunction. Mexican American families significantly underutilize hospice, long-term care facilities, and professional services therefore compounding depression and frustration with their inability to provide care (Apesoa-Varano et al., 2016). Studies have found that many caregivers lack experience and are unprepared to deal with the behavioral dysfunction resulting from increased neuropsychiatric symptomatology. Unfortunately, this inability to provide care and reluctance to seek outside help leads to a higher probability of premature or unnecessary institutionalization (Gaugler et al., 2000; Hwang et al., 2004; Liken, 2001; Ortiz et al., 2006).

The final variable of significance was caregiver Perceived Social-Stress (PSS). When PSS was entered into the model it was significantly associated with caregiver depressive symptoms. Caregivers who were not married and who reported increased neuropsychiatric symptoms and disturbances in their parents also reported increased social stress compared to Model 2. Increased stress, most likely due to the higher levels of neuropsychiatric disturbance, was significantly associated with depressive symptoms among caregivers. Moreover, part of the neuropsychiatric disturbance was driven by caregiver stress.

Conclusions

Increasingly, individuals today are undertaking the role of the informal caregiving. Projections suggest that a greater portion of individuals will be providing care for elders compared to children (Abramson, 2016). Further, more than ever elders are choosing to ‘age in place’ and due to increased life expectancy and the rising costs of formal caregiving and institutionalization some families have no choice but to take care of a family member at home (Bastawrous, 2013; Collins & Jones, 1997; Deeken, Taylor, Mangan, Yabroff, & Ingham, 2003). Hispanics will continue to be impacted by these challenges of caregiving and cultural values such as familismo will play an important role in the ability and facilitation of Hispanics to care for their elders. In many Hispanic homes caring for older relatives is seen as a positive and accepted cultural obligation, a privilege rather than a ‘burden’ (Aranda & Knight, 1997). Research has highlighted positive benefits from caregiving including increased bonding, reinforcement of traditional values, a sense of accomplishment, personal satisfaction, and increased self-esteem (Aranda & Knight, 1997; Pinquart & Sorensen, 2005; Roberto & Jarrott, 2008; Rote et al., 2014). In our cohort, degree of ADL disability and cognitive impairment in and of themselves were not sufficient to cause significant depressive symptoms among caregivers and this is quite possibly due to strong family ties. However, increased neuropsychiatric disturbances and their resultant dysfunctional behaviors consistently resulted in increased depressive symptoms and stress among their caregivers. Concurrent with the literature, neuropsychiatric dysfunction takes a toll on caregivers and has been shown to be highly associated with depression and an increased likelihood of early institutionalization compared to older adults who do not display neuropsychiatric disturbances (Angel et al., 2004; Caskie et al., 2010; Evans et al., 2012).

Table 3.

Correlation matrix (spearman correlation coefficients) of study variables on Table 2.

Variables	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)	(13)
Caregiver Background
(1) Depressive Symptoms Caregiver Health Status	1.00
(2) Age	0.12	1.00
(3) Female	0.01	0.05	1.00
(4) Education	−0.12	−0.27**	−0.04	1.00
(5) Not Married Caregiver Background	0.09	0.02	−0.20*	0.02	1.00
(6) Diabetes	0.17*	0.16*	0.02	−0.04	−0.09	1.00
(7) Hypertension	0.10	0.27**	0.05	−0.02	−0.15*	0.30**	1.00
(8) Arthritis	0.10	0.35**	0.17*	−0.003	−0.08	0.12	0.22**	1.00
Care Recipient Characteristics
(9) Nativity-US born	−0.08	−0.06	−0.08	0.22**	0.04	0.02	0.09	0.09	1.00
(10) Number of ADL’s help	0.05	0.06	−0.01	−0.10	0.004	0.08	0.06	−0.08	−0.02	1.00
(11) MMSE <17	−0.06	0.16*	−0.06	−0.14	0.08	0.04	0.03	−0.02	−0.06	0.40**	1.00
(12) Caregiver Reported NPI	0.12	−0.03	−0.10	0.15*	−0.07	−0.02	0.03	0.002	0.07	0.19*	0.25**	1.00
(13) Perceived Social Stress	0.40**	−0.07	−0.07	−0.06	−0.12	−0.001	0.02	−0.02	0.01	−0.05	−0.04	0.15*	1.00

^*p < 0.05

^**p < 0.001.

ADL: Activities of Daily Living; MMSE: Mini Mental State Examination; NPI: Neuropsychiatric Inventory.