Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Dec 1.
Published in final edited form as: J Gerontol Nurs. 2020 Dec 1;46(12):31–41. doi: 10.3928/00989134-20201106-04

Informal Caregiving, Poor Mental Health, and Subjective Cognitive Decline: Results from a Population-Based Sample

Monique J Brown 1,2,3,4, Steven A Cohen 5
PMCID: PMC8045765  NIHMSID: NIHMS1687535  PMID: 33232495

Abstract

The current study examined potential gender differences in the associations between informal caregiving, poor mental health, and subjective cognitive decline (SCD). Data were obtained from the U.S. Behavioral Risk Factor Surveillance System Survey (N=16042; 9,410 women and 6,632 men). Multivariable linear and logistic regression models were used to obtain adjusted βs and odds ratios, and 95% confidence intervals depicting the association between informal caregiving, poor mental health and SCD overall, and by gender. Caregiving was positively associated with poor mental health among men (adjusted β = 2.60; 95% CI: 2.59, 2.62) and women (adjusted β = 0.40; 95% CI: 0.23, 0.57). Poor mental health was positively associated with SCD among men (adjusted OR = 1.05; 95% CI: 1.02 – 1.08) and women (adjusted OR = 1.07; 95% CI: 1.04 – 1.10). Poor mental health may be associated with SCD, irrespective of gender, and additional studies are needed that will identify key variables influencing SCD among male and female informal caregivers.

Keywords: cognitive function, epidemiology, mental health, caregiving, cognitive status

Introduction

Subjective cognitive decline (SCD) is a person’s perception of their worsening cognitive functions or more frequent confusion or memory loss in the past 12 months, and is an early symptom of Alzheimer’s disease (Taylor, Bouldin, & McGuire, 2018; Wang & Tian, 2018). Usually there is normal performance on standardized tests for cognition (Studart & Nitrini, 2016). According to Taylor and colleagues, approximately 11% of adults 45 years and older in the U.S. report SCD. In addition, half of these adults report associated functional limitations (Taylor, Bouldin, & McGuire, 2018). SCD has also been found to be positively associated with depression (Zlatar, Muniz, Galasko, & Salmon, 2018; Zlatar, Muniz, Espinoza, et al., 2018); poorer overall (Tales et al., 2015) and health-related quality of life (Roehr et al., 2017) increased risk of mortality (Luck et al., 2015), and significant public health and economic impact (Lin & Neumann, 2013).

Sociodemographic characteristics, health outcomes and behaviors are associated with SCD. SCD is also more common among older adults (Taylor et al., 2018; Zlatar, Muniz, Galasko, et al., 2018). Racial/ethnic differences also exist in SCD where it is more commonly reported among Black, American Indians/Alaska Natives and “Other/Multiracial” adults compared to other racial/ethnic groups (Taylor et al., 2018). Adults with lower educational attainment and those who are unemployed also report more SCD compared to adults with higher educational attainment and are employed, respectively (Taylor et al., 2018). Diabetes (Andersen et al., 2019; Ng et al., 2016; Yin et al., 2016; Zhang, Jiang, Han, Liu, & Zhou, 2019), obesity (Noh et al., 2019; Olivo, Gour, & Schioth, 2019) and smoking (Anstey, von Sanden, Salim, & O'Kearney, 2007; Depp et al., 2015; Hu et al., 2019; Mucha, Stephenson, Morandi, & Dirani, 2006) were found to be positively associated with cognitive impairment. SCD has also been positively associated with depression (Wei et al., 2019; Zlatar, Muniz, Galasko, et al., 2018; Zlatar, Muniz, Espinoza, et al., 2018) and anxiety (Tandetnik et al., 2017) among older adults.

Informal caregiving continues to be an integral component of society, the healthcare system and economy of the U.S. (Schulz & Tompkins, 2010). An informal caregiver is defined as a person who provides care (assistance with activities of daily living [ADLs] or instrumental activities of daily living [IADLs]), usually unpaid, to family or friends (Roth, Fredman, & Haley, 2015; Schulz & Tompkins, 2010). Greater informal caregiving may be associated with health benefits among caregivers (Kim et al., 2018; Roth et al., 2015). Nevertheless, being an informal caregiver can be demanding and may also have detrimental effects on the caregiver’s health and well-being, usually referred to as caregiver burden. Caregiver burden has been linked to reduced life satisfaction (Hajek & Konig, 2018), psychological distress (Abreu, Tolson, Jackson, & Costa, 2018), poorer self-reported health status (Do, Cohen, & Brown, 2014), and lower quality of life (Alltag, Conrad, & Riedel-Heller, 2018; Lethin et al., 2018). Most informal caregivers are themselves either older or middle-aged adults, many of whom must balance competing family and employment obligations (Ryan, Smith, Antonucci, & Jackson, 2012).

Informal caregiving and SCD are linked to physical health and health behaviors. One study found that 82% of caregivers reported at least one chronic condition (Wang, Robinson, & Carter-Harris, 2014) and multiple chronic conditions may lead to adverse emotional and physical health outcomes among caregivers (Polenick et al., 2017). SCD has also been found to be statistically significantly associated with heart disease, stroke and multimorbidity (Yap, Warren, Allotey, & Reidpath, 2018). Previous research using a nationally representative sample found that 15% of respondents with at least one chronic illness reported SCD (Taylor et al., 2018). Another study also showed that caregiving was positively associated with diabetes (Stacey, Gill, Price, & Taylor, 2018). Health behaviors including smoking (Dich, Head, & Hulvej Rod, 2016; Hopps, Iadeluca, McDonald, & Makinson, 2017; Stacey et al., 2018), alcohol use (Dich et al., 2016; Kearns et al., 2017), and physical activity (Cuthbert, King-Shier, Tapp, Ruether, & Culos-Reed, 2017) are associated with caregiving and may act as potential covariates in the relationship between caregiving and SCD.

Informal caregiving has also been linked to better (Bertrand et al., 2012) and worse (Mallya & Fiocco, 2018) objective cognition. Among female caregivers, caregiving was associated with better cognitive function compared to non-caregivers (Bertrand et al., 2012; Zwar et al., 2018) but there was no association among male caregivers (Zwar et al., 2018). The association between informal caregiving and better objective cognitive functioning has also been found among White populations but not among Black populations (Sneed et al., 2019). Among a Canadian population, caregivers were found to experience lower objective cognition, more perceived stress, lower quality of life and depressive symptoms (Mallya & Fiocco, 2018). Based on these findings, it is possible that informal caregiving may be associated with SCD. However, to our knowledge, no study has examined the association between informal caregiving and SCD among a population-based sample. In addition, studies examining gender differences in the relationships between informal caregiving, poor mental health, and SCD among population-based samples are lacking. It is also possible that if there are relationships between SCD and informal caregiving, they may differ for men and women.

One conceptual framework that may help in understanding the association between informal caregiving, poor mental health, and SCD among caregivers is the theoretical model of stress and health/illness (Vitaliano, Zhang, & Scanlan, 2003). This model states that exposure to stress among caregivers may lead to psychological distress and impact health behaviors, which are associated with physiological responses, which increase the likelihood of illness. Informal caregiving may represent exposure to stress, poor mental health as psychological distress, and the related physiological responses may result in or exacerbate existing SCD. Evidence of this model exists in the literature where informal caregiving is associated with cognitive impairment (Brummett, Austin, Welsh-Bohmer, Williams, & Siegler, 2013; Mallya & Fiocco, 2018) among caregivers. Another aspect of this framework considers gender as a moderator. Gender refers to the cultural aspects and roles that distinguish female and male caregivers (Muehlenhard & Peterson, 2011). Findings showed that female caregivers reported worse global health compared to male caregivers (Vitaliano et al., 2003). However, to our knowledge, no study has examined the gender differences in the relationship between informal caregiving and SCD.

Caregiver burden has been found to be associated with SCD but this association has been examined by assessing burden among caregivers and SCD among their caregiving recipients (Dauphinot et al., 2016). Studies examining the relationship between caregiving and SCD among caregivers are lacking. In addition, research assessing the gender differences in the role of poor mental health in SCD and informal caregiving is also sparse. Using the theoretical model of stress and health/illness, it is possible that informal caregiving may be linked to poor mental health, which may impact SCD, and that gender may play a role. Therefore, the aims of this study were to: 1) Determine the association between informal caregiving and poor mental health; 2) Assess the association between poor mental health and SCD; 3) Explore the association between informal caregiving and SCD; and 4) Assess the moderation of these potential associations by gender. We hypothesized that: H1) Informal caregiving would be associated with poor mental health; H2) Poor mental health would be linked to greater SCD; H3) Informal caregiving would be positively associated with SCD; and H4) Differences would be observed for men and women in the relationship between caregiving and SCD where women would have a stronger association between informal caregiving and SCD. By examining the gender differences in poor mental health, caregiving, and SCD, these findings will help to both inform population-based interventions aimed at improving SCD and poor mental health of informal caregivers and inform clinicians if gender differences should be considered in approaches to clinical care.

Methods

Data Source and Study Population

This cross-sectional study used data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS) survey (Centers for Disease Control and Prevention, 2018). Established by the Centers for Disease Control and Prevention (CDC), the BRFSS is a set of health-related surveys administered to residents in the U.S. The cognitive decline module was only asked of participants aged 45 and older. There were 18,357 respondents aged 45 and older in MT, NJ, OR, TN. Respondents who were missing or did not give valid answers on the caregiver and cognitive decline questions were excluded (n=2,310). The (held for review) Institutional Review Board considered the current study “not human subjects research” as deidentified publicly available data were used.

Measures

The question that operationalized caregiving stated: “During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?” This question also measures physical dependence of the caregiving recipient (Perenboom & Chorus et al., 2003). Poor mental health was operationalized by the question: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” This question measures a key component of the CDC’s health related quality of life concept (Yin et al., 2016; CDC-HRQOL). The question that operationalized SCD was only asked of respondents aged 45 and older: “During the past 12 months, have you experienced confusion or memory loss that is happening more often or is getting worse?” This question has been used to operationalize SCD in previous studies (Taylor et al., 2018; Anderson et al., 2015). The total number of respondents who answered “yes” or “no” to both the caregiver and cognitive decline modules, and whose reported gender was known was 16,042 (n= 9,410 women; n= 6,632 men).

Covariates

Sociodemographic characteristics considered as covariates were age (60-69 [young-old], 70-79 [middle-old], 80+ [old-old] (Forman, Berman, McCabe, Baim, & Wei, 1992) vs. 45-59 [middle-aged]); annual household income (<$15,000, $15,000-<$50,000 vs. $50,000+); educational attainment (< high school graduate, high school graduate, > high school graduate); employment (employed, retired vs. unemployed); and race/ethnicity (Black, non-Hispanic; Other, non-Hispanic; and Hispanic vs. White, non-Hispanic). Therefore, additional variables considered as covariates included diabetes (Yes vs. no [including only during pregnancy]); obesity (BMI ≥ 30kg/m2 vs. < 30kg/m2); current smoking (Now smokes every day or some days vs. former smoker/never smoked); alcohol use (number of drinks per day when drinking), and physical activity (“such as running, calisthenics, golf, gardening or walking”) in the past 30 days (yes vs. no). We considered heart disease but several studies found that the risk of heart disease was similar between caregivers and non-caregivers (Buyck et al., 2013; Haley, Roth, Howard, & Safford, 2010; Liu & McDaniel, 2015; Miyawaki et al., 2017). Therefore, heart disease was not included in the fully adjusted model.

Analytic Approach

All analyses considered the BRFSS complex multistage sampling strategy. Weighted prevalence estimates were obtained for informal caregiving and SCD, overall and by sociodemographic characteristics. Chi square p-values were used to compare the distributions of gender, age, income, education, employment, race/ethnicity, heart disease, diabetes, obesity, current smoking, and physical activity by caregiving and SCD status. The distribution of caregiving characteristics was also obtained overall, and among men and women. Covariates that were considered were based on a priori literature review, were associated with caregiving and were independent risk factors for SCD. Simple and multiple linear regression models were used to determine the crude and adjusted βs and 95% confidence intervals (CIs) depicting the associations between informal caregiving and poor mental health. Crude and multivariable logistic regression models were also used to determine crude and adjusted odds ratios (aORs) and 95% CIs for the association between poor mental health and SCD, and between caregiving and SCD. Model 1 was the unadjusted or crude model. Model 2 was the fully adjusted model, which controlled for all sociodemographic and health characteristics: age, income, educational attainment, work, race/ethnicity, diabetes, obesity, current smoking, alcohol use and physical activity. Based on prior research, where a higher percentage of caregivers are women (National Alliance for Caregiving and AARP Public Policy Institute, 2015), models were stratified by gender. All analyses considered the complex multistage sampling design by using weighted data using sample weights provided in the BRFSS sample and were conducted with SAS software Version 9.4 (SAS Institute, Cary, NC).

Results

Overall, 24% of respondents reported being caregivers in the past 30 days and 11% of respondents reported SCD. Approximately 21% of men and 26% of women reported to be caregivers in the past 30 days. However, 11% of both men and women reported SCD. The overall mean (SD) number of days of poor mental health in the past month was 12.3 (0.28), 12.4 (0.48) and 12.3 (0.33) for men and women, respectively.

Table 1 shows the sociodemographic characteristics, physical health and risk behaviors of respondents 45 years and older and the distribution of reported caregiving, SCD, and poor mental health. There were statistically significant differences by gender, age, educational attainment, employment, race/ethnicity, obesity, and current smoking status in caregiving (p < 0.05). The difference in informal caregiving by physical activity status was not statistically significant (p = 0.058). Respondents who reported caregiving tended to be women, younger (age 45-59), have higher educational attainment, employed or unemployed (not retired), White, BMI ≥ 30kg/m2, and current smokers. There were also statistically significant differences by annual household income, educational attainment, employment, race/ethnicity, heart disease, diabetes, BMI ≥ 30kg/m2, current smoking and physical activity in SCD (p = 0.05). Respondents who reported SCD tended to report an annual household income of less than $50,000 per year, lower educational attainment, unemployment, were of “Other, non-Hispanic” race or Hispanic ethnicity, and reported heart disease, diabetes, obesity, current smoking and no physical activity. Statistically significant differences existed in poor mental health by income, education, employment, heart disease, diabetes, obesity, current smoking, alcohol use and physical activity (p < 0.05).

Table 1.

Sociodemographic Characteristics of Adults 45 Years and Older, Behavioral Risk Factor Surveillance System, 2016

Characteristic Overall
N=16, 042
Weighted
%		 Caregiving
N=3,552
Weighted
%		 No Caregiving
N=12,490
Weighted %		 P-value SCD
N=1,738
Weighted
%		 No SCD
N=14, 304
Weighted
%		 P-
value		 Poor Mental
Health (Days)
Weighted Mean
(SD)		 P-value
Sex <0.001 0.811 0.824
 Men 46.3 40.7 48.1 46.8 46.3 12.4 (0.48)
 Women 53.7 59.3 51.9 53.2 53.7 12.3 (0.33)
Age <0.001 0.206 0.693
 45-59 45.1 50.2 43.5 43.5 45.3 11.4 (0.59)
 60-69 29.0 29.9 28.7 29.0 29.0 12.8 (0.40)
 70-79 17.7 14.3 18.7 17.3 17.7 12.1 (0.55)
 80+ 8.3 5.6 9.1 10.2 8.0 11.2 (0.64)
Income 0.274 <0.001 <0.001
 <$15,000 9.5 8.5 9.8 22.0 8.0 17.4 (0.69)
 $15,000-<$50,000 40.2 39.9 40.4 48.9 39.2 12.9 (0.44)
 $50,000+ 50.2 51.7 49.8 29.0 52.7 9.6 (0.45)
Education 0.002 <0.001 <0.001
 <HS Graduate 13.5 10.5 14.4 25.7 12.0 16.8 (0.77)
 HS Graduate 30.2 30.4 30.2 30.4 30.2 12.9 (0.54)
 >HS Graduate 56.3 59.1 55.4 43.9 57.8 10.6 (0.33)
Employment 0.009 <0.001 <0.001
 Employed 47.1 48.1 46.8 25.2 49.8 9.71 (0.43)
 Unemployed 20.0 22.0 19.3 42.3 17.2 16.5 (0.46)
 Retired 32.9 29.9 33.9 32.5 33.0 11.3 (0.49)
Race/Ethnicity 0.023 0.035 0.152
 White, NH 76.2 78.6 75.5 72.6 76.6 12.1 (0.31)
 Black, NH 9.3 9.8 9.2 8.4 9.4 11.3 (0.95)
 Other, NH 6.0 5.4 6.2 8.1 5.7 15.2 (1.12)
 Hispanic 8.5 6.2 9.2 10.8 8.2 12.8 (1.07)
Heart Disease 0.981 <0.001 <0.001
 Yes 11.6 11.6 11.6 21.8 10.4 11.9 (0.31)
 No 88.4 88.4 88.4 78.2 89.6 14.9 (0.65)
Diabetes 0.561 <0.001 <0.001
 Yes 16.7 16.2 16.8 24.8 15.7 14.3 (0.61)
 No 83.3 83.8 83.2 75.2 84.3 11.9 (0.31)
Obesity 0.039 0.001 0.002
 Yes 32.9 35.2 32.1 38.6 32.2 13.5 (0.46)
 No 67.1 64.8 67.9 61.4 67.8 11.6 (0.35)
Current Smoking <0.001 <0.001 <0.001
 Yes 33.9 40.0 31.9 42.7 32.4 16.5 (0.60)
 No 66.1 60.0 68.1 57.3 67.6 11.8 (0.45)
Alcohol Use (Mean, SD) 2.00 (0.04) 1.95 (0.07) 2.01 (0.04) 0.100 2.16 (0.11) 1.98 (0.04) 0.400 0.106a <0.001b
Physical Activity 0.058 <0.001 <0.001
 Yes 69.2 71.3 68.5 52.2 71.3 10.2 (0.32)
 No 30.8 28.7 31.5 47.8 28.7 15.9 (0.51)
Open in a new tab

Abbreviations: HS – high school; NH – non-Hispanic; SCD – subjective cognitive decline

a

Pearson correlation coefficient

b

P-value is based on ∣r∣.

Note: P-values are based on Chi-square statistic except for p-value for ∣r∣ between alcohol use and mental distress.

Bolded p-values are statistically significant at p<0.05.

Table 2 shows the distribution of caregiving characteristics overall and among men and women. Statistically significant differences by gender existed in relationship to caregiving recipient and time spent caregiving. For example, a higher percent of women compared to men cared for a parent (33.6 vs. 27.3%), while a higher percent of men cared for their spouse or partner (22.4 vs. 16.7%). Women also tended to report more caregiving hours per week compared to men (40 or more hours: 23.7 vs. 18.5%).

Table 2.

Caregiving Characteristics Overall and among Men and Women

Caregiving Characteristic Overall
Weighted %		 Men
Weighted %		 Women
Weighted %		 P-value
Caregiver Relationship 0.008
  Parent 37.1 27.3 33.6
  Child 10.4 26.2 24.2
  Spouse/Partner 22.7 22.4 16.7
  Other relative 29.8 24.1 25.6
Hours Spent per Week 0.034
  ≤ 8 hours 54.1 58.6 50.9
  9-19 13.1 12.8 13.4
  20-39 11.2 10.2 12.0
  ≥ 40 21.6 18.5 23.7
Open in a new tab

Bolded p-values are statistically significant at p<0.05.

Table 3 shows the overall association between informal caregiving, poor mental health and SCD among respondents age 45 years and older for the overall sample, and among men and women. After adjusting for sociodemographic characteristics, physical health and health behaviors, respondents who reported informal caregiving reported one additional day of poor mental health per month (adjusted β: 1.26; 95% CI: 0.87– 1.64). In addition, a one-day increase in poor mental health in the past month was associated with a 5% increase in the odds of reporting SCD (adjusted OR: 1.05; 95% CI: 1.03 – 1.07). After adjustment for covariates, the association between caregiving and SCD was not statistically significant.

Table 3.

Overall Association between Caregiving, Mental Distress, and Subjective Cognitive Decline (SCD) among the Overall Sample, Men and Women Aged 45 Years and Older, Behavioral Risk Factor Surveillance System, 2016

Associations Model 1: Model 2:
OVERALL SAMPLE (N=16,042)
Crude OR/β (95%CI) p-value Adjusted OR/βa (95% CI) p-value
Caregiving and Poor Mental Health (β) 1.52 (0.35, 2.70) 0.011 1.26 (0.87, 1.64) <0.001
Mental Distress and SCD 1.05 (1.04 – 1.06) <0.001 1.05 (1.03 – 1.07) <0.001
Caregiving and SCD 1.32 (1.11 – 1.58) 0.002 1.36 (0.92 – 1.78) 0.127
MEN (N=6,632)
Caregiving and Poor Mental Health(β) 3.26 (2.51, 4.01) <0.001 2.60 (2.59, 2.62) <0.001
Mental Distress and SCD 1.04 (1.03 – 1.06) <0.001 1.05 (1.02 – 1.08) 0.004
Caregiving and SCD 1.58 (1.20 – 2.08) 0.001 1.56 (0.93 – 2.63) 0.094
WOMEN (N=9,410)
Caregiving and Poor Mental Health (β) 0.60 (−0.78, 1.98) 0.396 0.40 (0.23, 0.57) <0.001
Mental Distress and SCD 1.06 (1.05 – 1.07) <0.001 1.07 (1.04 – 1.10) <0.001
Caregiving and SCD 1.15 (0.91 – 1.45) 0.246 1.34 (0.74 – 2.42) 0.336
Open in a new tab
a

Adjusted models controlled for age, income, educational attainment, work, race/ethnicity, heart disease, diabetes, obesity, current smoking, and physical activity.

Bolded odds ratios and 95% confidence intervals are statistically significant at p<0.05.

After adjusting for sociodemographic characteristics, physical health and health behaviors in the fully adjusted model, men who reported informal caregiving reported approximately three additional days of poor mental health in the past month (adjusted β: 2.60; 95% CI: 2.59 – 2.62). A one-day increase in poor mental health in the past month was associated with a 5% increase in the odds of reporting SCD (adjusted OR: 1.05; 95% CI: 1.02 – 1.08). In addition, men who reported informal caregiving had statistically similar odds of reporting SCD when compared to men who did not report informal caregiving (adjusted OR: 1.56; 95% CI: 0.93 – 2.63). Fully adjusted models also showed that women who reported caregiving reported more time of poor mental health in the past month compared to women who did not report informal caregiving (adjusted β: 0.40; 95% CI: 0.23 – 0.57). A one-day increase in poor mental health in the past month was associated with a 7% increase in the odds of reporting SCD (adjusted OR: 1.07; 95% CI: 1.04 – 1.10). However, the association between caregiving and SCD was not statistically significant among women (adjusted OR: 1.34; 95% CI: 0.74 – 2.42).

Discussion

To our knowledge, this is the first study examining the association between informal caregiving, poor mental health and SCD among caregivers among U.S. adults. The main findings of this study were that informal caregiving was positively associated with poor mental health, and poor mental health was positively associated with SCD among both men and women. This study is among the first to show that the association between informal caregiving and SCD was not statistically significant among men or women.

The conceptual framework by Vitaliano and colleagues suggests that exposure to stress among caregivers may lead to psychological distress and increased illness and female caregivers tend to report worse global health compared to male caregivers (Vitaliano et al., 2003). Our results partially supported this model. Informal caregiving was associated with poor mental health and a stronger association was seen among men compared to women. This finding supports previous research, which shows that a higher proportion of male caregivers report greater mental health symptoms such as anxiety or depressive symptoms compared to their female counterparts (Oechsle, Goerth, Bokemeyer, & Mehnert, 2013). However, the relationship between informal caregiving and SCD was not statistically significant in this population. Another study among a German population found that looking after someone was associated with better cognitive functioning among women but there was no statistically significant association in men (Zwar, Konig, & Hajek, 2018), which partially supports our results as the association between informal caregiving and SCD was not statistically significant among women or men. Different populations and varying cultural expectations may have played a role in these disparate findings.

Poor mental health was associated with SCD among men and women in the current study. Psychological distress was associated with subjective cognitive complaints among brain tumor patients (Pranckeviciene et al., 2017) and a potential reciprocal relationship has been found between depression and subjective cognitive impairment (Hill et al., 2016), which supports the current study’s findings. A relationship has also been found between SCD and anxiety, which seems to be driven by concerns about functional impairment (Hill et al., 2016).

There are some limitations to consider in the context of these findings. The study was cross-sectional. Respondents were asked about their informal caregiving responsibilities in the past 30 days and about their SCD in the past 12 months. Therefore, it is possible that SCD may have occurred before informal caregiving. As a result, causation cannot be inferred. Therefore, these results highlight the need for longitudinal studies determining the relationship between these key variables. Data were also self-reported, which may result in overreporting or underreporting of key variables such as informal caregiving or SCD. These alterations may result in underestimates or overestimates of the “true” association. The study sample was a population-based sample from four states in the US (MT, NJ, OR, TN), and may not be generalizable to other states or countries. Only a few questions were used to quantify informal caregiving and poor mental health. Indeed, the definition of caregiver in the BRFSS does not require that the caregiver provides ADL or IADL tasks, which are key components of caregiving. We were unable to include number of care hours and caregiving recipient in the model due to high correlations and these variables being a subset of the caregiving (exposure) variable due to skip patterns in the survey. Lastly, as it was only possible to control for several well-established confounding variables, such as age, income, education, employment, and race/ethnicity, chronic illnesses and health behaviors, there may be residual confounding due to unmeasured variables (for e.g., hypertension) not used as covariates in this analysis.

Nevertheless, the study did have notable strengths. The study sample size was large (N=16,042) and was population-based. All analyses also considered the BRFSS complex multistage sampling strategy. Adjusted analyses controlled for sociodemographic covariates, which may alter the association between informal caregiving and SCD. In addition, findings were stratified by gender. This strategy is crucial in helping to inform the importance of the consideration of gender differences in examining informal caregiving, poor mental health and SCD, which may have potential importance in the development of theory-based interventions and programs designed to reduce caregiver burden and improve caregiver quality of life among middle aged and older adults.

Conclusions

The association between informal caregiving and SCD was not statistically significant, though stronger for men than women. Informal caregiving was associated with poor mental health among men and women, with a stronger association among men. Poor mental health was associated with SCD with similar associations among men and women. Additional studies are needed that will identify key variables influencing SCD among male and female informal caregivers. The findings also warrant longitudinal mediation studies where the temporal sequence between caregiving, poor mental health and SCD may be established to determine target populations and focal points of intervention and prevention programs. Qualitative studies may also assess potential reasons for the apparent differences in the relationship between informal caregiving and poor mental health among men and women.

Acknowledgments

Funding: This work was partially supported by the National Institute of Mental Health of the National Institutes of Health under Award Number K01MH115794. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

  1. Abreu W, Tolson D, Jackson GA, & Costa N (2018). A cross-sectional study of family caregiver burden and psychological distress linked to frailty and functional dependency of a relative with advanced dementia. Dementia (London), [Epub ahead of print]. [DOI] [PubMed] [Google Scholar]
  2. Alltag S, Conrad I, & Riedel-Heller SG (2019). [Caregiver burden among older informal caregivers of patients with dementia and its influence on quality of life: A systematic literature review. Zeitschrift für Gerontologie und Geriatrie, 52, 477–486. [DOI] [PubMed] [Google Scholar]
  3. Andersen SL, Sweigart B, Sebastiani P, Drury J, Sidlowski S, & Perls TT (2019). Reduced Prevalence and Incidence of Cognitive Impairment Among Centenarian Offspring. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 74, 108–113. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Anderson LA, Deokar A, Edwards VJ, Bouldin ED, & Greenlund KJ (2015). Demographic and health status differences among people aged 45 or older with and without functional difficultires related to increased confusion or memory loss, 2011, Behavioral Risk Factor Surveillance System. Preventing Chronic Disease, 12, E30. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Anstey KJ, von Sanden C, Salim A, & O'Kearney R (2007). Smoking as a risk factor for dementia and cognitive decline: A meta-analysis of prospective studies. American Journal of Epidemiology, 166, 367–378. [DOI] [PubMed] [Google Scholar]
  6. Bertrand RM, Saczynski JS, Mezzacappa C, Hulse M, Ensrud K, & Fredman L (2012). Caregiving and cognitive function in older women: Evidence for the healthy caregiver hypothesis. Journal of Aging and Health, 24, 48–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Brummett BH, Austin SB, Welsh-Bohmer KA, Williams RB, & Siegler IC (2013). Long-term impact of caregiving and metabolic syndrome with perceived decline in cognitive function 8 years later: A pilot study suggesting important avenues for future research. Open Journal of Medical Psychology, 2, 23–28. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Buyck JF, Ankri J, Dugravot A, Bonnaud S, Nabi H, Kivimaki M, & Singh-Manoux A (2013). Informal caregiving and the risk for coronary heart disease: the Whitehall II study. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 68, 1316–1323. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Centers for Disease Control and Prevention (2018). Behavioral Risk Factor Surveillance System. Retrieved from https://www.cdc.gov/brfss/index.html
  10. Cuthbert CA, King-Shier K, Tapp D, Ruether D, & Culos-Reed SN (2017). Exploring gender differences in self-reported physical activity and health among older caregivers. Oncology Nursing Forum, 44, 435–445. [DOI] [PubMed] [Google Scholar]
  11. Dauphinot V, Ravier A, Novais T, Delphin-Combe F, Mouchoux C, & Krolak-Salmon P (2016). Risk factors of caregiver burden evolution for patients with subjective cognitive decline or neurocognitive disorders: A longitudinal analysis. Journal of the American Medical Directors Association, 17, 1037–1043. [DOI] [PubMed] [Google Scholar]
  12. Depp CA, Bowie CR, Mausbach BT, Wolyniec P, Thornquist MH, Luke JR, … Harvey PD (2015). Current smoking is associated with worse cognitive and adaptive functioning in serious mental illness. Acta Psychiatrica Scandinavica, 131, 333–341. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Dich N, Head J, & Hulvej Rod N (2016). Role of psychosocial work factors in the relation between becoming a caregiver and changes in health behaviour: Results from the Whitehall II cohort study. Journal of Epidemiology and Community Health, 70, 1200–1206. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Do EK, Cohen SA, & Brown MJ (2014). Socioeconomic and demographic factors modify the association between informal caregiving and health in the Sandwich Generation. BMC Public Health, 14, 362. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Flatt JD, Johnson JK, Karpiak SE, Seidel L, Larson B, & Brennan-Ing M (2018). Correlates of subjective cognitive decline in lesbian, gay, bisexual, and transgender older adults. Journal of Alzheimer's Disease, 64(1), 91–102. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Forman DE, Berman AD, McCabe CH, Baim DS, & Wei JY (1992). PTCA in the elderly: The "young-old" versus the "old-old". Journal of the American Geriatrics Society, 40, 19–22. [DOI] [PubMed] [Google Scholar]
  17. Fredman L, Cauley JA, Hochberg M, Ensrud KE, & Doros G (2010). Mortality associated with caregiving, general stress, and caregiving-related stress in elderly women: Results of caregiver-study of osteoporotic fractures. Journal of the American Geriatric Society, 58, 937–943. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Hajek A, & Konig HH (2018). The relation between personality, informal caregiving, life satisfaction and health-related quality of life: Evidence of a longitudinal study. Quality of Life Research, 27, 1249–1256. [DOI] [PubMed] [Google Scholar]
  19. Haley WE, Roth DL, Howard G, & Safford MM (2010). Caregiving strain and estimated risk for stroke and coronary heart disease among spouse caregivers: Differential effects by race and sex. Stroke, 41, 331–336. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Hill NL, Mogle J, Wion R, Munoz E, DePasquale N, Yevchak AM, & Parisi JM (2016). Subjective cognitive impairment and affective symptoms: A systematic review. The Gerontologist, 56, e109–e127. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hopps M, Iadeluca L, McDonald M, & Makinson GT (2017). The burden of family caregiving in the United States: Work productivity, health care resource utilization, and mental health among employed adults. Journal of Multidisciplinary Healthcare, 10, 437–444. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Hu M, Yin H, Shu X, Jia Y, Leng M, & Chen L (2019). Multi-angles of smoking and mild cognitive impairment: Is the association mediated by sleep duration? Neuroloical Sciences, 40, 1019–1027. [DOI] [PubMed] [Google Scholar]
  23. Kareholt I, Lennartsson C, Gatz M, & Parker MG (2011). Baseline leisure time activity and cognition more than two decades later. International Journal of Geriatric Psychiatry, 26, 65–74. [DOI] [PubMed] [Google Scholar]
  24. Kearns NT, Blumenthal H, Rainey EE, Bennett MM, Powers MB, Foreman ML, & Warren AM (2017). Discrepancy in caregiving expectations predicts problematic alcohol use among caregivers of trauma injury patients six months after ICU admission. Psychology of Addictive Behaviors, 31, 497–505. [DOI] [PubMed] [Google Scholar]
  25. Kim G, Allen RS, Wang SY, Park S, Perkins EA, & Parmelee P (2018). The relation between multiple informal caregiving roles and subjective physical and mental health status among older adults: Do racial/ethnic differences exist? The Gerontologist. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lethin C, Leino-Kilpi H, Bleijlevens MH, Stephan A, Martin MS, Nilsson K, … Karlsson S (2018). Predicting caregiver burden in informal caregivers caring for persons with dementia living at home - A follow-up cohort study. Dementia (London), [Epub ahead of print]. [DOI] [PubMed] [Google Scholar]
  27. Lin PJ, & Neumann PJ (2013). The economics of mild cognitive impairment. Alzheimer's and Dementia, 9(1), 58–62. [DOI] [PubMed] [Google Scholar]
  28. Liu LW, & McDaniel SA (2015). Family caregiving for immigrant seniors living with heart disease and stroke: Chinese Canadian perspective. Health Care for Women International, 36(12), 1327–1345. [DOI] [PubMed] [Google Scholar]
  29. Luck T, Roehr S, Jessen F, Villringer A, Angermeyer MC, & Riedel-Heller SG (2015). Mortality in individuals with subjective cognitive decline: Results of the Leipzig Longitudinal Study of the Aged (LEILA75+). Journal of Alzheimer's Disease, 48 Suppl 1, S33–42. [DOI] [PubMed] [Google Scholar]
  30. Mallya S, & Fiocco AJ (2018). Impact of informal caregiving on cognitive function and well-being in Canada. International Psychogeriatrics, 30, 1049–1055. [DOI] [PubMed] [Google Scholar]
  31. Marquez DX, Bustamante EE, Kozey-Keadle S, Kraemer J, & Carrion I (2012). Physical activity and psychosocial and mental health of older caregivers and non-caregivers. Geriatric Nursing, 33, 358–365. [DOI] [PubMed] [Google Scholar]
  32. Miyawaki A, Tomio J, Kobayashi Y, Takahashi H, Noguchi H, & Tamiya N (2017). Impact of long-hours family caregiving on non-fatal coronary heart disease risk in middle-aged people: Results from a longitudinal nationwide survey in Japan. Geriatrics and Gerontology International, 17(11), 2109–2115. [DOI] [PubMed] [Google Scholar]
  33. Mucha L, Stephenson J, Morandi N, & Dirani R (2006). Meta-analysis of disease risk associated with smoking, by gender and intensity of smoking. Gend Med, 3, 279–291. [DOI] [PubMed] [Google Scholar]
  34. Muehlenhard CL, & Peterson ZD (2011). Distinguishing between sex and gender: History, current conceptualizations, and implications. Sex Roles, 64(11-12), 791–803. [Google Scholar]
  35. National Alliance for Caregiving and AARP Public Policy Institute (2015). Caregiving in the US. Retrieved from http://www.caregiving.org/wp-content/uploads/2015/05/2015_CaregivingintheUS_Final-Report-June-4_WEB.pdf
  36. Ng TP, Feng L, Nyunt MS, Feng L, Gao Q, Lim ML, … Yap KB (2016). Metabolic syndrome and the risk of mild cognitive impairment and progression to dementia: Follow-up of the Singapore Longitudinal Ageing Study Cohort. JAMA Neurology, 73(4), 456–463. [DOI] [PubMed] [Google Scholar]
  37. Noh HM, Han J, Kim YJ, Jung JH, Roh YK, & Song HJ (2019). Sex differences in the relationship between cognitive impairment and overweight or obesity in late life: A 3-year prospective study. Medicine (Baltimore), 98, e14736. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Oechsle K, Goerth K, Bokemeyer C, & Mehnert A (2013). Anxiety and depression in caregivers of terminally ill cancer patients: Impact on their perspective of the patients' symptom burden. Journal of Palliative Medicine, 16, 1095–1101. [DOI] [PubMed] [Google Scholar]
  39. Olivo G, Gour S, & Schioth HB (2019). Low neuroticism and cognitive performance are differently associated to overweight and obesity: A cross-sectional and longitudinal UK Biobank study. Psychoneuroendocrinology, 101, 167–174. [DOI] [PubMed] [Google Scholar]
  40. Perenboom RJM, & Chorus AMJ (2003). Measuring participation according to the International Classification of Functioning, Disability and Health (ICF). Disability and Rehabilitation, 25, 577–587. [DOI] [PubMed] [Google Scholar]
  41. Polenick CA, Leggett AN, Webster NJ, Han BH, Zarit SH, & Piette JD (2017). Multiple chronic conditions in spousal caregivers of older adults with functional disability: Associations with caregiving difficulties and gains. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences [Epub ahead of print]. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Pranckeviciene A, Deltuva VP, Tamasauskas A, Bunevicius A (2017). Association between psychological distree, subjective cognitive complaints and objective neuropsychological functioning in brain tumor patients. Clinical Neurology and Neurosurgery, 163, 18–23. [DOI] [PubMed] [Google Scholar]
  43. Roehr S, Luck T, Pabst A, Bickel H, Konig HH, Luhmann D, … Riedel-Heller SG (2017). Subjective cognitive decline is longitudinally associated with lower health-related quality of life. International Psychogeriatrics, 29(12), 1939–1950. [DOI] [PubMed] [Google Scholar]
  44. Roth DL, Fredman L, & Haley WE (2015). Informal caregiving and its impact on health: A reappraisal from population-based studies. The Gerontologist, 55(2), 309–319. doi: 10.1093/geront/gnu177 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Ryan LH, Smith J, Antonucci TC, & Jackson JS (2012). Cohort differences in the availability of informal caregivers: Are the Boomers at risk?. The Gerontologist, 52(2), 177–188. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Schulz RT, Tompkins CA (2010). Informal caregivers in the United States: Prevalence, caregiver characteristics, and ability to provide care. In Council NR (Ed.), The Role of Human Factors in Home Health Care: Workshop Summary: Washington, D.C. [Google Scholar]
  47. Sneed RS, & Schulz R (2019). Grandparent caregiving, race, and cognitive funcioning in a population-based sample of older adults. Journal of Aging and Health, 31, 415–438. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Stacey AF, Gill TK, Price K, & Taylor AW (2018). Differences in risk factors and chronic conditions between informal (family) carers and non-carers using a population-based cross-sectional survey in South Australia. BMJ Open, 8(7), e020173. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Studart AN, & Nitrini R (2016). Subjective cognitive decline: The first clinical manifestation of Alzheimer's disease? Dementia and Neuropsychologia, 10(3), 170–177. doi: 10.1590/s1980-5764-2016dn1003002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Tales A, Jessen F, Butler C, Wilcock G, Phillips J, & Bayer T (2015). Subjective cognitive decline. Journal of Alzheimer's Disease, 48 Suppl 1, S1–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Tandetnik C, Hergueta T, Bonnet P, Dubois B, & Bungener C (2017). Influence of early maladaptive schemas, depression, and anxiety on the intensity of self-reported cognitive complaint in older adults with subjective cognitive decline. International Psychogeriatrics [Epub ahead of print]. [DOI] [PubMed] [Google Scholar]
  52. Taylor CA, Bouldin ED, & McGuire LC (2018). Subjective Cognitive Decline Among Adults Aged >/=45 Years - United States, 2015-2016. Morbidity and Mortality Weekly Report, 67, 753–757. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Vitaliano PP, Zhang J, & Scanlan JM (2003). Is caregiving hazardous to one's physical health? A meta-analysis. Psychological Bulletin, 129(6), 946–972. [DOI] [PubMed] [Google Scholar]
  54. Wang L, & Tian T (2018). Gender differences in elderly with subjective cognitive decline. Frontiers in Aging Neuroscience, 10, 166. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Wang XR, Robinson KM, & Carter-Harris L (2014). Prevalence of chronic illnesses and characteristics of chronically ill informal caregivers of persons with dementia. Age and Ageing, 43(1), 137–141. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Wei YC, Huang LY, Chen CK, Lin C, Shyu YC, Chen YL, … Lin, C. P. (2019). Subjective cognitive decline in the community is affected at multiple aspects of mental health and life quality: A cross-sectional study of the community medicine of Keelung Chang Gung Memorial Hospital. Dementia and Geriatric Cognitive Disorders Extra, 9(1), 152–162. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Yap KH, Warren N, Allotey P, & Reidpath DD (2018). Chronic disease profiles of subjective memory complaints: a latent class analysis of older people in a rural Malaysian community. Aging and Mental Health [Epub ahead of print]. [DOI] [PubMed] [Google Scholar]
  58. Yin Z, Yan Z, Liang Y, Jiang H, Cai C, Song A, … Qiu C (2016). Interactive effects of diabetes and impaired kidney function on cognitive performance in old age: A population-based study. BMC Geriatrics, 16, 7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Zhang X, Jiang X, Han S, Liu Q, & Zhou J (2019). Type 2 diabetes mellitus is associated with the risk of cognitive impairment: A meta-analysis. Journal of Molecular Neuroscience, 68, 251–260. [DOI] [PubMed] [Google Scholar]
  60. Zlatar ZZ, Muniz M, Galasko D, & Salmon DP (2018). Subjective cognitive decline correlates with depression symptoms and not with concurrent objective cognition in a clinic-based sample of older adults. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 73, 1198–1202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Zlatar ZZ, Muniz MC, Espinoza SG, Gratianne R, Gollan TH, Galasko D, & Salmon DP (2018). Subjective cognitive decline, objective cognition, and depression in older Hispanics screened for memory impairment. Journal of Alzheimer's Disease, 63, 949–956. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Zwar L, Konig HH, & Hajek A (2018). The impact of different types of informal caregiving on cognitive functioning of older caregivers: Evidence from a longitudinal, population-based study in Germany. Social Science and Medicine, 214, 12–19. [DOI] [PubMed] [Google Scholar]

RESOURCES