Genuine Smiles by Patients During Marital Interactions are Associated with Better Caregiver Mental Health.

ObjectiveProviding care for a spouse with dementia is associated with an increased risk for poor mental health. To determine whether this vulnerability in caregivers is related to the expression of positive emotion, we examined 57 patients with Alzheimer's disease and behavioral variant frontotemporal dementia and their spouses as they discussed a marital conflict.MethodFacial behavior during the discussion was objectively coded to identify Duchenne (i.e., genuine) smiles and non-Duchenne (i.e., polite) smiles. Caregiver mental health was measured using the Medical Outcomes Survey.ResultsGreater expression of Duchenne smiles by patients was associated with better caregiver mental health, even when accounting for covariates (i.e., diagnosis, patient cognitive functioning, and caregiver marital satisfaction). Greater expression of non-Duchenne smiles by patients was associated with worse caregiver health, but only when covariates were entered in the model. Expression of Duchenne and non-Duchenne smiles by caregivers was not associated with caregiver mental health.DiscussionPatients' expression of Duchenne and non-Duchenne smiles may reveal important aspects of the emotional quality of the patient-caregiver relationship that influence caregiver burden and mental health

Empathic Accuracy Deficits in Patients with Neurodegenerative Disease: Association with Caregiver Depression.

OBJECTIVES:To investigate whether deficits in empathic accuracy (i.e., ability to recognize emotion in others) in patients with neurodegenerative disease are associated with greater depression in their caregivers. DESIGN:Two cross-sectional studies. SETTING:Academic medical center and research university. PARTICIPANTS:Two independent samples (N = 172, N = 63) of patients with a variety of neurodegenerative diseases and their caregivers; comparison group of healthy couples. MEASUREMENT:Patients' empathic accuracy was assessed in the laboratory using a novel dynamic tracking task (rating another person's changing emotions over time) and more traditional measures (recognizing the emotion expressed in photographs of facial expressions and by characters in films). Caregivers completed self-report inventories of depression. RESULTS:Lower empathic accuracy in patients was associated with greater depression in caregivers in both studies. In study 1, this association was found when empathic accuracy was measured using the dynamic tracking measure but not when measured using the more traditional photograph and film measures. In study 2, we found preliminary support for our theoretical model wherein lower empathic accuracy in patients is associated with increased caregiver stress (loneliness, strain, and burden), which in turn is associated with greater caregiver depression. CONCLUSIONS:Caring for a patient with deficits in empathic accuracy is associated with greater loneliness, strain, and burden for caregivers, and increased depression. Caregivers may benefit from interventions designed to compensate for the stress and interpersonal loss associated with patients' declining empathic accuracy

Lower activity linkage between caregivers and persons with neurodegenerative diseases is associated with greater caregiver anxiety.

Physiological linkage refers to the degree to which two individuals' central/peripheral physiological activities change in coordinated ways. Previous research has focused primarily on linkage in the autonomic nervous system in laboratory settings, particularly examining how linkage is associated with social behavior and relationship quality. In this study, we examined how linkage in couples' daily somatic activity (e.g., synchronized movement measured from wrist sensors)-another important aspect of peripheral physiology-was associated with relationship quality and mental health. We focused on persons with neurodegenerative diseases (PWNDs) and their spousal caregivers, whose linkage might have direct implications for the PWND-caregiver relationship and caregiver's health. Twenty-two PWNDs and their caregivers wore wristwatch actigraphy devices that provided continuous measurement of activity over 7 days at home. PWND-caregiver activity linkage was quantified by the degree to which activity was "in-phase" or "anti-phase" linked (i.e., coordinated changes in the same or opposite direction) during waking hours, computed by correlating minute-by-minute activity levels averaged using a 10-min rolling window. Caregivers completed well-validated surveys that assessed their mental health (including anxiety and depression) and relationship quality with the PWND. We found that lower in-phase activity linkage, but not anti-phase linkage, was associated with higher caregiver anxiety. These dyad-level effects were robust, remaining significant after adjusting for somatic activity at the individual level. No effects were found for caregiver depression or relationship quality. These findings suggest activity linkage and wearables may be useful for day-by-day monitoring of vulnerable populations such as family caregivers. We offered several possible explanations for our findings

Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia.

ImportanceCurrent attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management.ObjectiveTo determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia.Design, setting, and participantsThis longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis.ExposuresCaregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy.Main outcomes and measuresThe primary outcome was the number of ED visits in a 6-month period.ResultsAmong the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99).Conclusions and relevanceAmong patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population

The costs of dementia subtypes to California Medicare fee-for-service, 2015.

IntroductionDementia is among the costliest of medical conditions, but it is not known how these costs vary by dementia subtype.MethodsThe effect of dementia diagnosis subtype on direct health care costs and utilization was estimated using 2015 California Medicare fee-for-service data. Potential drivers of increased costs in Lewy body dementia (LBD), in comparison to Alzheimer's disease, were tested.Results3,001,987 Medicare beneficiaries were identified, of which 8.2% had a dementia diagnosis. Unspecified dementia was the most common diagnostic category (59.6%), followed by Alzheimer's disease (23.2%). LBD was the costliest subtype to Medicare, on average, followed by vascular dementia. The higher costs in LBD were explained in part by falls, urinary incontinence or infection, depression, anxiety, dehydration, and delirium.DiscussionDementia subtype is an important predictor of health care costs. Earlier identification and targeted treatment might mitigate the costs associated with co-occurring conditions in LBD

Variations in Costs of a Collaborative Care Model for Dementia.

ObjectivesCare coordination programs can improve patient outcomes and decrease healthcare expenditures; however, implementation costs are poorly understood. We evaluate the direct costs of implementing a collaborative dementia care program.DesignWe applied a micro-costing analysis to calculate operational costs per-participant-month between March 2015 and May 2017.SettingThe University of California, San Francisco (UCSF) and the University of Nebraska Medical Center (UNMC).ParticipantsParticipants diagnosed with dementia, enrolled in Medicare or Medicaid, 45 years of age or older, residents of California, Nebraska or Iowa, and having a caregiver. The sample was 272 (UCSF) and 192 (UNMC) participants.InterventionA collaborative dementia care program provided by care team navigators (CTNs), advanced practice nurses, a social worker, and a pharmacist, focusing on caregiver support and education, medications, advance care planning, and behavior symptom management.MeasurementsWe measured costs (personnel, supplies, equipment, and training costs) during three program periods, Start-up, Early Operations, and Continuing Operations, and estimated the effects of caseload variation on costs.ResultsStart-up and Early Operations costs were, respectively, $581 and$328 (California), and $501 and$219 (Nebraska) per-participant-month. Average costs decreased across phases to $241 (California) and$142 (Nebraska) per-participant-month during Continuing Operations. We estimated that costs would range between $75 (UNMC) and$92 (UCSF) per-participant-month with the highest projected caseloads (90).ConclusionWe found that CTN caseload is an important driver of service cost. We provide strategies for maximizing caseload without sacrificing quality of care. We also discuss current barriers to broad implementation that can inform new reimbursement policies. J Am Geriatr Soc 67:2628-2633, 2019

White Female Bystanders’ Responses to a Black Woman at Risk for Incapacitated Sexual Assault

We investigated White female college students’ responses to risk for an incapacitated sexual assault involving a Black potential victim. Participants (N = 160) read about attending a party where they saw a man lead an intoxicated woman into a private bedroom. The potential victim was referred to as having either a distinctively Black name (e.g., LaToya) or a non-distinct control name (e.g., Laura). After random assignment to one of these two conditions, participants reported on their intent to intervene and their perceptions of the situation and the potential victim. As expected, participants assigned to the Black potential victim condition reported less intent to intervene, less personal responsibility to intervene, and greater perceived victim pleasure than participants assigned to the control condition. Neither the certainty of risk nor the perceived victim blame differed as a function of the potential victim’s race. In path analyses, personal responsibility to intervene mediated the relationship between victim race and intent to intervene. The current results suggest that White women in college may choose not to help Black women at risk for sexual assault. Bystander education programs should explicitly address race as a potential barrier to helping others in need

Long-term digital device-enabled monitoring of functional status: Implications for management of persons with Alzheimer's disease.

IntroductionInformal caregiving is an essential element of health-care delivery. Little data describes how caregivers structure care recipients' lives and impact their functional status.MethodsWe performed observational studies of community dwelling persons with dementia (PWD) to measure functional status by simultaneous assessment of physical activity (PA) and lifespace (LS). We present data from two caregiver/care-recipient dyads representing higher and average degrees of caregiver involvement.ResultsWe acquired >42,800 (subject 1); >41,300 (subject 2) PA data points and >154,500 (subject 1); >119,700 (subject 2) LS data points over 15 months of near continuous observation. PA and LS patterns provided insights into the caregiver's role in structuring the PWD's day-to-day function and change in function over time.DiscussionWe show that device-enabled functional monitoring (FM) can successfully gather and display data at resolutions required for dementia care studies. Objective quantification of individual caregiver/care-recipient dyads provides opportunities to implement patient-centered care

Long-term digital device-enabled monitoring of functional status: Implications for management of persons with Alzheimer's disease.

IntroductionInformal caregiving is an essential element of health-care delivery. Little data describes how caregivers structure care recipients' lives and impact their functional status.MethodsWe performed observational studies of community dwelling persons with dementia (PWD) to measure functional status by simultaneous assessment of physical activity (PA) and lifespace (LS). We present data from two caregiver/care-recipient dyads representing higher and average degrees of caregiver involvement.ResultsWe acquired >42,800 (subject 1); >41,300 (subject 2) PA data points and >154,500 (subject 1); >119,700 (subject 2) LS data points over 15 months of near continuous observation. PA and LS patterns provided insights into the caregiver's role in structuring the PWD's day-to-day function and change in function over time.DiscussionWe show that device-enabled functional monitoring (FM) can successfully gather and display data at resolutions required for dementia care studies. Objective quantification of individual caregiver/care-recipient dyads provides opportunities to implement patient-centered care

Using care navigation to address caregiver burden in dementia: A qualitative case study analysis.

IntroductionMany caregivers of people with dementia experience burden and resulting health effects due to the intensive nature of caregiving. Phone- and web-based care navigation is an innovative model of care that may be useful in addressing caregiver burden in dementia.MethodsQualitative methods (interviews, focus groups, and case study analysis) were used to identify care navigator approaches used to address caregiver burden in dementia as part of a dementia care navigation program.ResultsCare navigators targeted caregiver burden by focusing on strategies to reduce caregiver guilt and frustration, manage patient-related behavior, address caregiver depression, and improve the relationship between the caregiver and person with dementia. The case studies presented demonstrate the ways that care navigators identified patient and caregiver needs and tailored their approaches to meet the specific social, cultural, economic, and geographic contexts of the dyads with which they worked.DiscussionFindings provide insights into strategies used to address caregiver burden through care navigation. Care navigators who speak the same language as the caregivers with whom they work and who have an in-depth understanding of the symptoms of different dementia syndromes may be particularly effective