Caregiver burden

Caregiver burden is the stress which is perceived by caregivers due to the home care situation. The subjective burden is considered to be one of the most important predictors of negative outcomes from the home care situation.

## Contents

* 1 Theory
* 2 Triggers for caregiver burden
* 3 Meaning of subjective burden
* 3.1 Impact on health
* 3.2 Risk of mortality
* 3.3 Caring style
* 4 Ending home care
* 5 Measuring caregiver burden
* 5.1 Burden Scale for Family Caregivers (BSFC)
* 5.1.1 Development
* 5.1.2 Scale
* 5.2 Caregivers´ Daily Issues (CDIs)
* 6 Interventions
* 6.1 Interventions and services
* 6.2 Implications to strengthen and develop the informal caregiving
* 7 References

## Theory

From a scientific perspective, caregiver burden is a theoretical construct. The conceptual basis for the appraisal of the care situation is the Transactional Model of Lazarus and Folkman.[1] The subjective evaluation of the care situation (stressor) by the caregivers is critical for the development and maintenance of subjective burden.

According to the Transactional Model, people deal with stressful situations by appraisals of stressor and resources. The primary appraisal deals with the individual meaning of the specific stressor, which is the care situation in this case. The secondary appraisal analyzes the own abilities and resources to cope with that situation. On this basis, the individual coping efforts are used to deal with the stressful situation. As per Carver,[2] these efforts can focus on problem management or emotional regulation. Dysfunctional strategies are possible, too. Studies[3][4] found that a high caregiver burden often comes along with dysfunctional strategies what means activities which don’t solve the problem but worsen it (e.g. self-criticism, substance abuse).

The (dis)balance between burden/vulnerabilities and resources of the caregiver determines the consequences of a care situation.[5] Home care can result in positive as well as negative experiences.

Regardless of the caregiver burden, relatives can experience benefits - positive consequences - of the home care situation.[6] This may be the feeling of being needed or the knowledge that they have acquired new skills etc.[7]

## Triggers for caregiver burden

Caregiver burden comes out when the caregiver perceives the home care situation as a negative experience. Caregivers are typically not trained. Caring is a serious challenge for them. An intensive adaptiation to the care situation is necessary.[5]

The caregiver burden can be based on a variety of aspects of the care situation (e.g. lack of recovery time, challenging behavior of the care requiring person, limitation of social activities and contacts). Studies[8][9][10] showed that four aspects are particularly burdensome:

* Care costs much energy
* Desire for recovery
* Too little time for own interests
* Sadness over the fate of the supported person

## Meaning of subjective burden

Negative outcomes are often not determined by the specifics of the caregiving situation itself, but by the reaction and response of the caregiver. The term “caregiver burden” refers to the high level of stress that some caregivers may feel in response to the situation. Because the caregiver burden may be felt strongly by one person and not at all by another, regardless of the caregiving situation, it is considered to be subjective and it may be called the “subjective burden”. The subjective burden is considered to be one of the most important predictors of negative outcomes from the home care situation.[5]

### Impact on health

Pinquart and Sörensen (2003)[11] researched the health of caregivers compared to the health of non-caregiving relatives. The researchers found that while caregivers are generally only slightly less physically healthy than non-caregiving relatives, they reported depressive symptoms significantly more often, pointing to a negative effect on their mental health.

This meta-analysis did not consider the impact of subjective burden. In another extensive meta-analysis[12] Pinquart and Sörensen could show that the subjective burden is an important predictor of the health of carers.

### Risk of mortality

Studies[13][14] found an increased mortality of caregiving spouses. This effect was only found for spouses who felt burdened due to the care situation. Thus, it is not the home care per se that is a risk but the subjective burden.

Without consideration of the caregiver burden, the mortality of caregivers is even slightly reduced compared to non-caregivers.[15][16][17]

### Caring style

People who experience caregiver burden can display a wide range of behaviors towards the person in need of care, from loving devotion to abusive behavior (which can manifest as neglect and/or mistreatment). The most common form of abusive behavior is verbal aggression,[18] mainly due to challenging behaviour of the person in need of care.[19] Researchers found that people experiencing caregiver burden are more likely to display abusive behavior and other negative caring styles toward the individuals they care for than those who are not experiencing caregiver burden. [19][20][21]

## Ending home care

The caregiver burden often influences the caregiver’s decision to eventually institutionalize (or, “put someone in a nursing home”. Caregiver burden is particularly associated with the care of people with dementia, meaning that the likelihood of institutionalization is especially heightened in those experiencing caregiver burden who care for people suffering from dementia.[22] In the care of people with dementia, there is consistent evidence: The higher the caregiver burden, the more likely is the institutionalization.[23][24][25][26]

## Measuring caregiver burden

The assessment of caregiver burden enables to judge the situation of the caregiver. The correct measurement of subjective burden is necessary to draw conclusions about the effectiveness of family interventions.

The care situation is an important, highly specific stressor which should be treated with specific interventions. A measurement with general stress-scales is therefore not useful, because in this case the score represents all kind of stress, indiscriminately of its origin. Valid, economic and internationally standardized measurement tools for the specific stressful situation of family caregivers are therefore inevitable.

In Anglo-American countries, a number of burden scales have been developed; e.g. the Burden Interview,[27] the Caregiver Strain Index[28] and the Cost of Care Index.[29] The Burden Scale for Family Caregivers, which has been developed in Germany, is now available in 20 languages.

### Burden Scale for Family Caregivers (BSFC)

The BSFC exists in a detailed version with 28 items, and in a short, more efficient version (BFSC-s) with ten items.

Compared to other burden scales, the BSFC has two benefits. There is a long and a short version, both validated in separate studies. Furthermore, both versions are free in 20 languages inclusive introduction for evaluation and interpretation.

#### Development

A first, reliable and valid version of the German version was published in 1993.[30] In 2001, the validity was tested and confirmed to a large sample of both dementia and for other causes of care requirement again.[31] In 2003, the English version has been validated.[32] In 2014, the validation study for the short version[33] and an extended validation of the original version[34] have been published.

#### Scale

The BSFC consists of 28 items in the detailed or 10 items in the short version. The caregivers have to rate these items on a four-point scale from “strongly agree” to “strongly disagree”.

An evaluation is possible both on item level and on score level. A differentiated detection of the critical aspects of home care is possible with the analysis on item level. The score measures the total burden. This is an important factor to judge the caregiver's situation.

### Caregivers´ Daily Issues (CDIs)

The CDIs is dealing with 9 main issues of caregivers based on the topical analysis of caregivers´ social media communication. A longitudinal analysis of 100 dyads (caregiver vs person with Alzheimer disease) revealed following structure of issues.[35]

Caregivers´ Daily Issues[35] Daily issue category  | The main issues related to the category

|

Change of a health state of the person with disease  | Entering a new stage of the disease and coping with this new situation; associated emotions of caregivers. Patients (usually parents in the past) are becoming to be like children and children like parents. Description of a new specific health issue of the patient: physical (dry skin, rash, bedsores) and mental ones (agitation, frustration, murmuring, complaining teeth grinding, walking back and forth in the house).
Physical recognition of close relatives  | Temporary or total non-recognition of a close person (life partner and children), forgetting the name. Comments on disappointment and other emotions associated. Fear of caregivers (often children) that they will not be recognized.
Exhaustion, feeling of giving up, guilt  | Effects of caregiving activity performed 24/7 with no breaks, health issues of caregivers. Potential caregivers’ hostility towards the patient. Caregivers’ impossibility of having their “my time”. Loneliness. Guilt coming from not sufficient/successful work of caregivers (patient’s health state is not getting better).
Fear of the future  | What the situation will look like in the future if the current situation is hard? Losing personal life and time (relationships, hobbies, and friends) because of caregiving and fear of the future. Concerns about the future health state of the person with the disease.
Violent behavior towards to the caregiver  | Psychical (insults, cursing, shouting) and physical violence (hitting, throwing objects) of the person with the disease. The person is rude when the caregiver wants to leave. Unexpected turns of a person’s behavior.
Caregiver’s success and positive feelings  | Person’s thanks and love expression towards the caregivers. Finding pleasure in nature of caregiving work. Pleasure from the gifts received from the person with AD.
Financial issues  | Absence/presence of medical/financial POA and/or patient’s will, communication between the person with AD and family about financial affairs, costs of health facilities and what is/is not covered by state medical care, paying of home health providers/caregivers, future concerns on financial matters. Accusations from patients/relatives about disuse of money; quarrel about money. Difficult financial family situations, tips on the ways of fundraising (for example crowdfunding), and proposals on how to change a health insurance system.
Group membership  | Appreciation for group membership and support; opportunity to express emotions; get advice; resolve the situation; communicate with people who have the same problem, searching for someone in the group physically living nearby.
Relationship with the health-services providers  | Certified nurse assistance (CNA) quality assessment, patient’s rejection of external services, complaints about hospital services and its communication about the patient’s health state.

## Interventions

Due to the high importance of the caregiver burden with regard to the care giving process, it is necessary to develop interventions to reduce this burden and to examine their effectiveness. Successful interventions should be available to as many caregivers as possible. "The usefulness of an intervention is the multiplication of effectiveness and usage.” (Elmar Gräßel[5]) It is therefore both necessary to develop interventions and to improve and to find ways to strengthen the awareness and use of these interventions.

### Interventions and services

Unburdening interventions for caregivers should consider four central aspects:[36]

1. Information and training
2. Professional support
3. Effective communication
4. Public and financial support

There are different supporting services, e.g. caregiver counselling, professional training, self-help groups, ambulant nursing services or technical help like intelligent light to preserve the autonomy of the person in need of care.[37]

Another effective relief is the support given to caregivers by family members, friends and acquaintances. They provide emotional and instrumental support and are an important source to access supporting services.[38]

A 2021 Cochrane review found that remotely delivered interventions including support, training and information may reduce the burden for the informal caregiver and improve their depressive symptoms.[39] However, there is no certain evidence that they improve health-related quality of life. The findings are based on moderate certainty evidence from 26 studies.

### Implications to strengthen and develop the informal caregiving

1. Services should be made better known.
2. The regional availability of support services should be made increased.
3. Case management services should increase the effectivity of unburdening concepts.
4. Public financial support should be made more available.
5. The basic conditions of caregiving should allow the combination of care and occupation.
6. Job conditions should be developed. No disadvantages should arise for caregivers who restrict the scope of their employment or temporarily give it up completely.
7. Language barriers should be reduced. Low-threshold offers in information, counselling and support should be intercultural orientated.
8. Internet based support should be extended.
9. There is a lack of qualitative empirical studies on the impact of unburdening interventions. Evidence based health services research should focus on that point.[40]

## References

1. ↑ R. S. Lazarus, S. Folkman: Stress, appraisal, and coping. Springer, New York 1984.
2. ↑ C. S. Carver: You want to measure coping but your protocol's too long: Consider the brief COPE. In: International Journal of Behavioral Medicine. 1997, 4(1), pp. 92–100.
3. ↑ C. Cooper, C. Katona, M. Orrell, G. Livingston: Coping strategies, anxiety and depression in caregivers of people with alzheimer's disease. In: International Journal of Geriatric Psychiatry. 2008, 23(9), pp. 929–936. doi:10.1002/gps.2007
4. ↑ V. E. Di Mattei, A. Prunas, L. Novella, A. Marcone, S. F. Cappa, L. Sarno: The burden of distress in caregivers of elderly demented patients and its relationship with coping strategies. In: Neurological Sciences. 2008, 29(6), pp. 383–389. doi:10.1007/s10072-008-1047-6
5. ↑ 5.0 5.1 5.2 5.3 E. Gräßel, R. Adabbo: Perceived burden of informal caregivers of a chronically ill older family member: Burden in the context of the transactional stress model of Lazarus and Folkman. In: Journal of Gerontopsychology and Geriatric Psychiatry. 2011, 24(3), pp. 143–154. doi:10.1024/1662-9647/a000042
6. ↑ T. M. Liew, N. Luo, W. Y. Ng, H. L. Chionh, J. Goh (2010): Predicting gains in dementia caregiving. In: Dementia and Geriatric Cognitive Disorders, 29(2), pp. 115-122. doi:10.1159/000275569
7. ↑ A. M. Baronet (2003): The impact of family relations on caregivers' positive and negative appraisal of their caregiving activities. In: Family Relations, 52(2), pp. 137-142. doi:10.1111/j.1741-3729.2003.00137.x
8. ↑ E. Gräßel: Belastung und gesundheitliche Situation der Pflegenden. Querschnittuntersuchung zur häuslichen Pflege bei chronischem Hilfs- oder Pflegebedarf im Alter. Hänsel-Hohenhausen, Egelsbach/ Frankfurt am Main/ Washington 1997. German Study: Burden and health situation of caregivers. A cross-sectional examination about the home care of chronically care requiring elderlies.
9. ↑ E. Gräßel: Subjektive Belastung und deren Auswirkungen bei betreuenden Angehörigen eines Demenzkranken - Notwendigkeit der Entlastung. In: G. Stoppe, G. Stiens (Eds.): Niedrigschwellige Betreuung von Demenzkranken. Grundlagen und Unterrichtsmaterialien. 2009, pp. 42–47. German book section: Subjective burden and its effects in caring relatives of dementia patients - Need for relief. In: Low-threshold care of people with dementia. Basics and teaching materials.
10. ↑ M. Grossfeld-Schmitz, C. Donath, R. Holle, J. Lauterberg, S. Ruckdaeschel, H. Mehlig, P. Marx, S. Wunder, E. Gräßel: Counsellors contact dementia caregivers - predictors of utilisation in a longitudinal study. In: BMC Geriatrics. 2010, 10:24. doi:10.1186/1471-2318-10-24
11. ↑ M. Pinquart, S. Sörensen: Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. In: Psychology and Aging. 2003, 18(2), pp. 250–267. doi:10.1037/0882-7974.18.2.250
12. ↑ M. Pinquart, S. Sörensen: Correlates of physical health of informal caregivers: A meta-analysis. In: Journal of Gerontology: Psychological Sciences. 2007, 62B(2), pp. 126–137.
13. ↑ Schulz, R., Beach, S. R. (1999). Caregiving as a risk factor for mortality: The caregiver health effects study. In: The Journal of the American Medical Association. 1999, 282(23), pp. 2215–2219.
14. ↑ M. Perkins, V. J. Howard, V. G. Wadley, M. Crowe, M. M. Safford, W. E. Haley, G. Howard, D. L. Roth (2013). Caregiving strain and all-cause mortality: Evidence from the REGARDS study. In: The Journal of Gerontology: Series B. 68(4), pp. 504-512.
15. ↑ D. O'Reilly, S. Connolly, M. Rosato, C. Patterson (2008). Is caring associated with an increased risk of mortality? A longitudinal study. In: Social Science & Medicine. 67(8), pp. 1282-1290. doi:10.1016/j.socscimed.2008.06.025
16. ↑ D. L. Roth, W. E. Haley, M. Hovater, M. Perkins, V. G. Wadley, S. Judd (2013). Family caregiving and all-cause mortality: Findings from a population-based propensity-matched analysis. In: American Journal of Epidemiology. 178(10), pp. 1571-1578. doi:10.1093/aje/kwt225
17. ↑ D. L. Roth, L. Fredman, W. E. Haley (2015). Informal caregiving and its impact on health: A reappraisal from population-based studies. In: The Gerontologist. (2015). doi:10.1093/geront/gnu177
18. ↑ C. Cooney, R. Howard, B. Lawlor (2008). Abuse of vulnerable people with dementia by their carers: Can we identify those most at risk? In: International Journal of Geriatric Psychiatry 21(6), pp. 564-571. doi:10.1002/gps.1525
19. ↑ 19.0 19.1 M. R. Hansberry, E. Chen, M. J. Gorbien: Dementia and elder abuse. In: Clinics in Geriatric Medicine. 2005, 21(2), pp. 315–332.
20. ↑ M. Grafström, A. Nordberg, B. Winblad: Abuse is in the eye of the beholder. Report by family members about abuse of demented persons in home care. A total population-based study. In: Scandinavian Journal of Social Medicine. 1993, 21(4), pp. 247–255.
21. ↑ R.-M. Karrasch, M. Reichert: Subjektive Beurteilungen und Wahrnehmungen von Pflegenden und Gepflegten in der Partnerpflege. In: Zeitschrift für Gerontopsychologie und -psychiatrie. 2008, 21(4), pp. 259–265. German Study: Subjective evaluation and perception of caregivers and cared persons in the spouse care setting.
22. ↑ S. Kurasawa, K. Yoshimasu, M. Washio, J. Fukumoto, S. Takemura, K. Yokoi, Y. Arai, K. Miyashita (2012): Factors influencing caregivers’ burden among family caregivers and institutionalization of in-home elderly people cared for by family caregivers. In: Environmental Health and Preventive Medicine. 17(6), pp. 474-483. doi:10.1007/s12199-012-0276-8
23. ↑ K. Eska, E. Gräßel, C. Donath, L. Schwarzkopf, J. Lauterberg, R. Holle: Predictors of institutionalization of dementia patients in mild and moderate stages: A 4-year prospective analysis. In: Dementia and Geriatric Cognitive Disorders Extra. 2013, 3(1), pp. 426–445.
24. ↑ N. Hirono, N. Tsukamoto, M. Inoue, Y. Moriwaki, E. Mori: Predictors of long-term institutionalization in patients with alzheimer's disease: Role of caregiver burden. In: No To Shinkei. 2002, 54(9), pp. 812–818.
25. ↑ A. Nobili, E. Riva, M. Tettamanti, U. Lucca, M. Liscio, B. Petrucci, G. S. Porro: The effect of a structured intervention on caregivers of patients with dementia and problem behaviors: a randomized controlled pilot study. In: Alzheimer disease and associated disorders. 18(2), pp. 75–82
26. ↑ K. Yaffe, P. Fox, R. Newcomer, L. Sands, K. Lindquist, K. Dane, K. E. Covinsky: Patient and caregiver characteristics and nursing home placement in patients with dementia. In: The Journal of the American Medical Association. 2002, 287(16), pp. 2090–2097.
27. ↑ S. H. Zarit, K. E. Reever, J. Bach-Peterson: Relatives of the impaired elderly: Correlates of feelings of burden. In: The Gerontologist. 1980, 20(6), pp. 649–655.
28. ↑ B. C. Robinson: Validation of a caregiver strain index. In: Journal of Gerontology. 1983, 38(3), pp. 344–348.
29. ↑ J. I. Kosberg, R. E. Cairl, D. M. Keller: Components of burden: Interventive implications. In: The Gerontologist. 1990, 30(2), pp. 236–242.
30. ↑ E. Gräßel, M. Leutbecher: Häusliche Pflege-Skala HPS zur Erfassung der Belastung bei betreuenden oder pflegenden Personen. Vless, Ebersberg 1993. German publication: Burden Scale for Family Caregivers to measure the burden of caregivers.
31. ↑ E. Gräßel: Häusliche Pflege-Skala HPS zur Erfassung der Belastung bei betreuenden oder pflegenden Personen. 2nd, revised edition. Vless, Ebersberg 2001.
32. ↑ E. Gräßel, T. Chiu, R. Oliver: Development and validation of the Burden Scale for Family Caregivers. Comprehensive Rehabilitation and Mental Health Services, Toronto (Canada) 2003.
33. ↑ E. Gräßel, H. Berth, T. Lichte, H. Grau: Subjective caregiver burden: Validity of the 10-item short version of the burden scale for family caregivers BSFC-s. In: BMC Geriatrics. 2014, 14, S. 23.
34. ↑ H. Grau, E. Gräßel, H. Berth: The subjective burden of informal caregivers of persons with dementia: extended validation of the German language version of the Burden Scale for Family Caregivers (BSFC). In: Aging & Mental Health. 2014, pp. 1–10, doi:10.1080/13607863.2014.920296.
35. ↑ 35.0 35.1 Bachmann, Pavel (2020-06-19). "Caregivers' Experience of Caring for a Family Member with Alzheimer's Disease: A Content Analysis of Longitudinal Social Media Communication" (in en). International Journal of Environmental Research and Public Health 17 (12): 4412. doi:10.3390/ijerph17124412. ISSN 1660-4601. PMID 32575455. Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License.
36. ↑ A. L. Silva, H. J. Teixeira, M. J. Teixeira, S. Freitas (2013). The needs of informal caregivers of elderly people living at home: An integrative review. In: Scandinavian Journal of Caring Sciences. 27(4), pp. 792-803. doi:10.1111/scs.12019.
37. ↑ H. Mollenkopf (2007): Technik hilft pflegen - Möglichkeiten technischer Unterstützung. In: Demenz, 4/2007, pp. 7-11. German publication: Technology helps to care - possible technical assistance.
38. ↑ G. Lamura, E. Mnich, B. Wojszel, M. Nolan, B. Krevers, L. Mestheneos, H. Döhner (2006). Erfahrungen von pflegenden Angehörigen älterer Menschen in Europa bei der Inanspruchnahme von Unterstützungsleistungen: Ausgewählte Ergebnisse des Projektes EUROFAMCARE. In: Zeitschrift für Gerontologie und Geriatrie. 39(6), pp. 429-442. doi:10.1007/s00391-006-0416-0. German publication: The experience of family carers of older people in the use of support services in Europe: selected findings from the EUROFAMCARE project.
39. ↑ González-Fraile, Eduardo; Ballesteros, Javier; Rueda, José-Ramón; Santos-Zorrozúa, Borja; Solà, Ivan; McCleery, Jenny (2021-01-04). "Remotely delivered information, training and support for informal caregivers of people with dementia". Cochrane Database of Systematic Reviews 1: CD006440. doi:10.1002/14651858.cd006440.pub3. ISSN 1465-1858. PMID 33417236. PMC 8094510. https://doi.org/10.1002/14651858.CD006440.pub3.
40. ↑ E. Gräßel, E.-M. Behrndt: Belastungen und Entlastungsangebote für pflegende Angehörige. In: Pflege-Report 2016, in press. Stuttgart: Schattauer. German book section: Burden and unburdening interventions for caregivers.

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