Daniel M. Keller, PhD

June 04, 2013

TAIPEI, Taiwan — Depressed caregivers are at risk of lashing out in words or behavior at elderly demented family members in their care, particularly in more severe cases of dementia. High expressed emotion (EE) by the caregiver is a warning sign of depressed mood that can signal stresses in the relationship between the care provider and the patient, a new study suggests.

The results, from researchers led by Chao-Yin Li, PhD, from the School of Nursing at Fooyin University in Kaohsiung, Taiwan, were reported here at the Alzheimer's Disease International (ADI) 28th International Conference.

EE is a qualitative measure of the amount of emotion displayed, typically by a caregiver or the family, usually assessed through answers to questions and nonverbal cues. Another aspect is the patient's view of how the family feels about him or her and the disorder. Previous studies in the literature have shown that with high EE, caregivers of patients with Alzheimer's disease tended to be more depressed and had lower satisfaction in life compared with caregivers with low EE.

This cross-sectional study investigated the relations between EE and caregiver sex and depression in a sample of 65 caregivers of older adults with dementia in southern Taiwan. EE was assessed by using the Level of Expressed Emotion (LEE) scale, and depression was measured by the Center for Epidemiologic Studies-Depression (CES-D) scale. Researchers conducted surveys of caregivers in their homes or other preferred location.

Participants were included if they cared for people with any stage or severity of dementia with whom they lived and had daily contact with for at least 3 months before the study. Potential participants were excluded if they identified themselves as having any mental illness other than depression, were paid to provide care, hired other paid caregivers, or provided care for more than 1 person with a chronic illness.

Heavy Burden of Care

Caregivers were the patient's spouse (38.5%), adult child (56.9%), or other relation (4.6%). Seventy-one percent provided care for more than 40 hours/week, and only half had family help with care-giving.

The mean age was 59.7 years (range, 29 to 85 years), and the mean time spent giving care was 4.5 years. Seventy-two percent were women, and slightly more than 60% had at least a high school education. Only one quarter were employed full or part time, 89% were married, and half had monthly household incomes less than the equivalent of $1340.

Patients had a mean age of 78.8 years (range, 64 to 98 years). Two thirds were women, and most were in fair (52.3%) or poor (29.2%) health, as rated by the care providers.

"The total score for care giver EE was positively correlated with care giver depression," Dr. Li reported (P < .001). Similarly, the EE subscales of intrusiveness, emotional response, and patients' tolerance and expectations of caregivers correlated with caregiver depression (all P < .001).

The only EE domain that was not significantly associated with depression was the caregivers' attitudes toward the illness (P = .328). There was also no significant difference between male and female caregivers on the overall EE or any of its subscales.

"We hope this study can give healthcare providers a way to assess caregiver and patients' interactions and possibly to develop and test some interventions like support services," Dr. Li said.

For the future, she hopes to develop a useful clinical cutoff point for the LEE scores; test the directionality of the relationship between EE and depression; and examine the relation between EE and other patient variables, such as disruptive behavior, functional abilities, or the severity of the disease.

Session moderator David Troxel, MPH, a long-term care consultant and writer in the field of dementia in Sacramento, California, commented to Medscape Medical News on the importance of this kind of study.

"When people who are caring [for someone else] are themselves agitated, upset, and angry, and expressing so much despair, I think it goes against a therapeutic environment," he said.

Thinking about the importance of supporting people with dementia, he advised that care providers need to learn skills to be able to "create a therapeutic environment, keep the person engaged, not argue, not correct, not be despaired. I think it actually lifts the person with dementia up, helps them operate at their best, and reduces the very behaviors that are upsetting you."

The idea is not "just about being nice to your mother and father," he advised, but "how to reduce troubling behavior and improve cooperation."

Dr. Li has disclosed no relevant financial relationships. Mr. Troxel is a dementia consultant to Atria Senior Living, Home Instead, American Baptist Homes of the West, and Prestige Care, and he previously consulted for Genentech Roche.

Alzheimer's Disease International (ADI) 28th International Conference,. Abstract OC021. Presented April 19, 2013.


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