The effects of a salutogenic strength-based intervention on sense of coherence and health outcomes of dementia family carers: A randomized controlled trial.

INTRODUCTION: Dementia caregiving is associated with notable impacts on the health of family carers. Although sense of coherence (SOC), as a core dimension of inner strength, has been found to have health-protecting effects in stressful encounters, few studies have designed a strength-based intervention to optimise SOC and thereby the health of carers. OBJECTIVES: To identify the effects of a strength-based intervention on SOC, coping, health-related quality of life (HRQoL), perceived burden and depression among Chinese family carers of people with dementia and to examine whether the health effects, if any, are mediated through an enhanced SOC and effective coping. DESIGN: A double-blind randomised controlled trial comparing a strengths-based intervention with a general education control. INTERVENTION: A 14-session strengths-based intervention which combined the use of narrative and empowerment strategies to support the carers of people with dementia to optimise the use of their generalised resistance resources in coping with the caregiving situation. SETTING: Older people community centres in Hong Kong. RESULTS: A total of 350 family carers participated in the study (mean age: 65.0 (SD = 12.3); female: 84.6%). Participants who received the strength-based intervention reported significantly greater improvements in their SOC, mental health, perceived burden and depression, than those in the education group, over a 22-week evaluation period. Path analysis models revealed that an SOC wholly mediated the relationship between the strength-based intervention and mental HRQoL (covering energy/vitality and psychosocial functioning) and partially mediated the relationship between the strength-based intervention and depression. We did not identify any harm from the intervention. CONCLUSION: A strength-based intervention is effective in improving the perceived burden and mental health of family caregivers of persons with dementia, and an SOC plays an important role in accounting for the mental health benefits. TRIAL REGISTRATION: The trial was registered in the World Health Organization International Clinical Trials Registry Platform (Main ID: ChiCTR-IIC-17011097).

The Positive Aspects of Caregiving Scale can be shortened to six items: application of item response theory.

OBJECTIVE: For nearly two decades, with one exception, researchers have used the Positive Aspects of Caregiving Scale (PACS) without a close examination of how the items behave. This study examined PACS' measurement model and item response characteristics, including differential item functioning (DIF) by race. METHODS: Item response theory was used to analyze the baseline data of the Resources for Enhancing Alzheimer's Caregiver Health (REACH) I trial (N = 1229). Bifactor confirmatory models were estimated to assess dimensionality, and whether the items behaved differently in African Americans and Hispanics, with Whites serving as the comparison, were examined using the multiple-indicators multiple-causes model. RESULTS: For both 9- and 11-item versions, 1-factor and bifactor solutions supported a unidimensional structure. However, the items performed generally poorly in differentiating levels of the latent construct, especially between moderate and high true scores. Additionally, five items were found to have DIF, which were unrelated to relationship differences among racial groups. While African Americans and Hispanics reported higher positive gains than Whites, their differences were accentuated by the DIF items as a whole. A 6-item version called PACS-II was created by removing the DIF items. Besides reducing estimated racial differences, PACS-II removed race-based heterogeneity of variance that was evidenced in the original, longer versions. CONCLUSIONS: Being free of racial bias, PACS-II is preferred over the original versions, though the ceiling effect of measurement (prevalence of extreme scores on the high end) remains to be an issue for improvement.

Benefit-finding buffers the effects of home confinement and centralized quarantine (HCCQ) on late midlife and older adults' mental health during the COVID-19 pandemic.

Objective: Older adults' well-being may suffer due to prolonged social isolation leading to loneliness and increased stress during the COVID-19 pandemic. The current study aimed to address the role of benefit-finding, defined as the capacity to derive meaning and positive aspects from stressful situations, in late midlife and older adults' adaptation to the effects of home confinement and centralized quarantine (HCCQ).Methods: 421 participants aged 50 or above in mainland of China participated in an online survey to study the effects of HCCQ on loneliness, stress, anxiety, depression and life satisfaction, as well as the moderating role of benefit-finding.Results: Correlational analysis showed that a history of HCCQ was basically unrelated to any outcome. However, the effect actually varied by levels of benefit-finding. Among late midlife and older people with lower benefit-finding, those who had experienced HCCQ reported more loneliness, perceived stress, as well as more anxiety and depressive symptoms; no such relationships were found when benefit-finding was moderate or high.Conclusion: The findings extended our understanding of the role of benefit-finding in buffering the negative impact of adversity. By mitigating the effects of prolonged social isolation, benefit-finding served as a protective factor in late midlife and older people's adaptation to the sequelae of this pandemic.

Typology of family caregivers of older persons: A latent profile analysis using elder mistreatment risk and protective factors.

This study sought to identify subpopulations of caregivers of older persons based on their profiles of individual characteristics and caregiving contexts and aimed at examining the associations between caregiver profiles and elder mistreatment. A convenient sample of 600 adult caregivers of community-dwelling older people in Hong Kong participated. Results of latent profile analysis support a typology of 3 distinctive caregiver profiles: (a) non-vulnerable caregivers; (b) isolated, vulnerable caregivers; and (c) traumatized, vulnerable caregivers. Isolated and traumatized caregivers reported greater risk factors related to elder mistreatment: They had higher levels of caregiver stress and burden, lower levels of social support and resilience, greater neurotic personality orientation and problematic gambling behavior, and more severe childhood traumatic experiences. The two groups also display significantly higher level of abusive behaviors than non-vulnerable caregivers.

Are Care-Recipient Outcomes Attributable to Improved Caregiver Well-Being? A Cluster-Randomized Controlled Trial of Benefit-Finding Intervention.

OBJECTIVES: The benefit-finding therapeutic (BFT) intervention, training cognitive reappraisal, and alternative thinking to construct positive aspects of caregiving have been found to reduce caregiver depression. This study examines BFT effects on care-recipient outcomes via reduced caregiver depression. DESIGN: Cluster-randomized double-blind controlled trial. SETTING: Social centers and clinics. PARTICIPANTS: A total of 129 caregivers. Inclusion criteria were 1) primary caregiver aged 18+, 2) without cognitive impairment, 3) providing ≥14 care hours weekly to a relative with mild-to-moderate Alzheimer's disease, and 4) scoring ≥3 on the Hamilton Depression Rating Scale. Exclusion criterion was care-recipient having Parkinsonism or other forms of dementia. INTERVENTIONS: BFT was evaluated against two forms of psychoeducation-standard and simplified (lectures only) psychoeducation. MEASUREMENTS: Care-recipient outcomes included neuropsychiatric symptoms (NPS), functional impairment, and global dementia severity (Clinical Dementia Rating sum-of-box), measured at baseline, postintervention, and 4- and 10-month follow up. RESULTS: Mixed-effects regressions showed a significant effect on NPS when compared with simplified psychoeducation only, with BFT participants reporting fewer NPS (especially mood symptoms) at 4-month follow-up (d = -0.52). Furthermore, longitudinal path analysis (using changes in caregiver depression scores at postintervention to predict changes in care-recipient NPS at follow-up) found that this effect was mediated by improved caregiver depression. No other intervention or mediation effects were found or were consistent across analyses. CONCLUSIONS: Less depressed caregivers may be able to provide better care and more positive interactions, leading to reduced NPS in care-recipients. However, this benefit of BFT was limited to the comparison with simplified psychoeducation only.

Two sides of the same coin? Revisiting the relationship between burden and positive aspects of caregiving in dementia.

OBJECTIVES: Studies have shown that items on the Zarit Burden Interview (ZBI) purported to measure self-criticism do not correlate well with the other items. Examination of item content suggests they may be measuring mixed sentiments-both positive and negative-about caregiving. This study examined whether self-criticism is related to positive aspects of caregiving (PAC) in a way that is different from caregiver strain, and if so, which types of PAC. METHODS/DESIGN: The baseline data of two Alzheimer caregiver intervention studies were merged (N = 225). Based on previous factor analysis, 2 ZBI items formed the self-criticism measure while 16 ZBI items measured global strain. PAC was assessed by coding caregivers' narratives about positive gains into seven themes (relationship gains, growth, insights, competence/mastery, purpose, emotional rewards, and miscellaneous). RESULTS: Global strain was mildly associated with fewer total PAC, in a way consistent with the literature, and with less competence/mastery. However, self-criticism was associated with stronger relationship gains and purpose. Younger caregivers reported more relationship gains but less emotional rewards. Longer caregiving duration was associated with more growth, but the reverse was true for chronic illnesses. Additionally, relationship closeness was associated with more emotional rewards, whereas care-recipient neuropsychiatric symptoms and functional impairment were associated with fewer relationship gains and emotional rewards respectively. CONCLUSION: Thinking one is not doing enough may indicate feelings of inadequacy/guilt but may also signal devotion to the relative and a sense of purpose in the caregiving role. Analyzing total burden and PAC scores may obscure the relationships between their components.

Typology of pain coping and associations with physical health, mental health, and pain profiles in Hong Kong Chinese older adults.

OBJECTIVES: To identify typology of pain coping in older adults and to see whether the coping types or patterns were associated with pain, physical health, and mental health outcomes. METHODS: Six hundred and fifty six Chinese older adults were recruited on a convenience basis from social centers in Hong Kong. A 14-item Brief Pain Coping Scale (BPCS) was constructed on the basis of the Chronic Pain Coping Inventory. Outcome measures included pain intensity, pain disability, pain-related cognitions, depressive symptoms, health-related quality of life, and health and physical functioning (in terms of chronic illnesses, basic and instrumental activities of daily living, and self-rated health). Coping typology was identified using latent class analysis. RESULTS: A 3-class solution based on BPCS provided the best fit to data. Class 1 used almost all coping strategies on a daily basis, Class 2 used the strategies less frequently, whereas Class 3 adopted few strategies. Yet, Class 3 was basically indistinguishable from Class 1 across the outcome variables, even though the participants had more chronic illnesses and poorer instrumental activities of daily living than those in Class 1. Class 2, however, had the poorest outcome profiles, reporting more pain, disability, depression, and health-related quality of life than the other two classes. The differences in coping could not be explained by the differential effectiveness of coping strategies across groups. CONCLUSION: The way coping was used, and the way it was related to pain, mood, health and functioning outcomes, varied substantially across individuals. Implications for coping skills interventions are discussed.

Developing and testing of an integrative theoretical model to predict positive aspects of caregiving among family caregivers of persons with dementia: A study protocol.

AIMS: The aim is to develop and test an integrative model based on the stress and coping paradigm and the existential paradigm, to explain positive aspects of caregiving among family caregivers of persons with dementia. DESIGN: A mixed method research, comprises a longitudinal exploratory study and a descriptive qualitative study. METHODS: A total of 370 family caregivers will be recruited from community elderly centres. Questionnaires on positive aspects of caregiving and its predictors (including active dementia management strategies, meaning-focused coping, and self-efficacy) and contextual factors (including social support, religiosity, continuous good dyadic relationship quality, and intrinsic motivation towards caregiving) will be administered. Positive aspects of caregiving will be reassessed six months later. Path analysis will be used to test the hypothesized model. A subsample of 30 family caregivers will be interviewed individually to explore how positive aspects of caregiving develop from the caregiving experience. Inductive thematic analysis will be used to for the qualitative data analysis. The funding was approved in January 2018. DISCUSSION: Positive aspects of caregiving represents the extent to which the caregiving experience is seen as enriching an individual's life space and resulted in health protective effects. With the increasing evidence to indicate its associating factors, it is imperative to identify the theoretical model to comprehensively elucidate the process for its development. IMPACT: Theoretically, this study will advance the knowledge of dementia caregiving by generating a comprehensive theory-driven predictive model to explain how positive aspects of caregiving is developed among the family caregivers. In terms of nursing practice, the findings can inform the development of intervention to improve positive aspects of caregiving and thereby acts as a catalyst to promote the paradigm shift from 'reducing limitations' to 'optimizing strengths' in family caregivers support services.

A comprehensive meta-review of systematic reviews and meta-analyses on nonpharmacological interventions for informal dementia caregivers.

BACKGROUND: Many reviews with conflicting findings on dementia caregiver interventions have been published. A meta-review was conducted to synthesize the findings of systematic reviews and meta-analyses. METHODS: MEDLINE, PsycINFO, CINAHL and Cochrane Library were searched to identify reviews published during 2006-2018. RESULTS: Sixty reviews covering > 500 intervention studies were selected and appraised with Assessment of Multiple Systematic Reviews (AMSTAR) II. The great majority of studies were of low quality according to AMSTAR II, but quality factors appeared unrelated to the conclusions obtained. Depression was most modifiable, with effects found across a spectrum of interventions (psychoeducation, counseling/psychotherapy, occupational therapy, mindfulness-based interventions, multicomponent interventions, etc.). Evidence of intervention effect was also found for quality of life (psychoeducation), mastery (psychoeducation, occupational therapy and multicomponent interventions) and communication skills (communication training). Null or weak results were found for anxiety, social support and burden. Support groups and respite were generally ineffective. There was no evidence that dyadic programs were better than caregiver-only programs, or that programs delivered individually or in groups would differ in their impacts. The evidence also does not support multicomponent interventions to have broader impacts than single-component programs. Methodological issues in the existing reviews (e.g., selective use of studies to serve different research purposes and inconsistent classification of interventions) were noted and taken into account when interpreting findings. CONCLUSIONS: This meta-review clarified variations in review methodology and identified a few potent groups of intervention (most notably psychoeducation, psychotherapy, occupational therapy, and multicomponent interventions), although no intervention type had broad effects on caregiver outcomes. We note that improvements are needed in the reporting of intervention studies and in making the classification of interventions more transparent and consistent. We further recommend fewer and larger-scale reviews and more attention to positive outcomes in order to better inform the field. Developing interventions with broader impacts and packaging them to meet caregivers' changing needs in the course of dementia should be a priority for researchers and practitioners.

Does exposure to information about dementia change stigma? An experimental study.

Objectives: Educational programs on dementia may backfire, as recipients could feel more negatively about people with dementia after exposure to the alarming symptoms (e.g., behavioral and psychological symptoms of dementia, or BPSD). This study aimed to investigate whether such exposures had any effect on stigma.Methods: 200 adults aged 18-83 years were randomly assigned to three groups. The first group read vignettes describing fictitious older adults with memory impairment. The second group read the same vignettes that were expanded to include descriptions of BPSD (i.e., memory impairment cum BPSD). After reading the vignettes, both groups answered questions about stigma, while the third group directly responded to this questionnaire without reading any vignette (i.e., not exposed to experimental manipulation). ANOVA was performed to analyze the effect of experimental manipulation, as well as that of age, education, whether having relatives with dementia, and belief about treatability of dementia.Results: At posttest, the level of stigma was moderate and was comparable across the three groups, suggesting that exposures to information about cognitive and behavioral symptoms did not change people's stigmatizing attitude. The absence of group effect in stigma did not vary by age, education, whether having a relative with dementia, or belief about prognosis. Only the main effects of age and education were significant, where younger and least educated participants reported higher stigma.Conclusion: There was no evidence that stigma would be affected by exposure to information about symptoms of dementia, including the more disturbed ones (i.e., BPSD).

Effects of strength-based intervention on health outcomes of family caregivers of persons with dementia: A study protocol.

AIMS: This study aims at identifying the health effects of a strength-based intervention on family caregivers of persons with dementia and to explore the underlying mechanism. The perception of family caregivers on the strength-based intervention will also be explored. DESIGN: This sequential mixed-method study comprises a double-blind randomized controlled trial and a descriptive qualitative study. METHODS: A group of 372 family caregivers of persons with dementia will be recruited from community settings. They will be randomized to receive the strength-based intervention or a dementia education program. Based on Antonovksy's theory of salutogenesis, the strength-based intervention integrates skills of narrative therapy and empowerment strategies. It comprises 14 weekly group-based sessions and two bi-weekly follow-up telephone calls. The education program serves as the control intervention. Validated instruments are used to measure sense of coherence, coping, caregiver burden, and health-related quality of life at baseline, 14 weeks, and 22 weeks. Mixed-effects models and path analysis will be used to identify the treatment effect and the mediating mechanism. A subsample of 30 caregivers who report differential changes in the health outcome will be engaged in qualitative interviews. The study was funded in 2017. DISCUSSION: This study marks the first attempt to adopt a theory-driven strength-based approach to improve the health outcomes of family caregivers of persons with dementia. The stringent and comprehensive evaluation will inform its effects and the underlying mechanism. IMPACT: This study will have important theoretical and public health implications. Theoretically, the study will enhance understanding of Antonovsky's theory of salutogenesis by examining the modifiability of sense of coherence and the way it enhances health-related outcomes. In terms of public health implications, the strength-based intervention focusing on optimizing the inner strength can provide a new paradigm to promote the adjustment of family caregivers of persons with dementia. TRIAL REGISTRATION: This project was registered in the Clinical Trials Registry of the Centre for Clinical Research and Biostatistics (registration number: CUHK_CCRB00551; date registered: 6 April 2017).

Long-Term Outcomes of the Benefit-Finding Group Intervention for Alzheimer Family Caregivers: A Cluster-Randomized Double-Blind Controlled Trial.

OBJECTIVES: To examine the effects of the group benefit-finding therapeutic intervention (BFT) for Alzheimer family caregivers up to 10-month follow-up. METHODS: This was a cluster-randomized double-blind controlled trial in social centers and clinics. Participants included 129 caregivers. Inclusion criteria were 1) primary caregiver aged 18 years and older and without cognitive impairment, 2) providing 14 or more care hours per week to a relative with mild-to-moderate Alzheimer disease, and 3) scoring 3 or more on the Hamilton Depression Rating Scale. Exclusion criterion was care-recipient having parkinsonism or other forms of dementia. BFT (using cognitive reappraisal to find positive meanings) was evaluated against two forms of psychoeducation as controls-standard and simplified (lectures only) psychoeducation. All interventions had eight weekly sessions of 2 hours each. Primary outcome was depressive symptoms, whereas secondary outcomes were global burden, role overload, and psychological well-being. Measures were collected at baseline, postintervention, and 4- and 10-month follow-up. RESULTS: Mixed-effects regression showed that BFT's effect on depressive symptoms conformed to a curvilinear pattern, in which the strong initial effect leveled out after postintervention and was maintained up to 10-month follow-up; this was true when compared against either control group. The effect on global burden was less impressive but moderate effect sizes were found at the two follow-ups. For psychological well-being, there was an increase in the BFT group at 4-month follow-up and a return to baseline afterward. No effect on role overload was found. CONCLUSION: Benefit-finding reduces depressive symptoms as well as global burden in the long-term and increases psychological well-being in the medium-term.

Psychological Interventions for Dementia Caregivers: What We Have Achieved, What We Have Learned.

With the rising dementia population, more and more programs have been developed to help caregivers deal with the care-recipient as well as their own frustrations. Many interventions aim to enhance caregiver's ability to manage behavior problems and other deteriorations in functioning, with less direct emphasis placed on caring for the caregivers. We argue that techniques based on psychotherapy are strategically important in assistance provided to caregivers because of their utility for promoting emotional health. This article provides a focused review of such methods used in evidence-based intervention programs, along with the mechanisms of change associated with these methods. While cognitive-behavioral therapy (CBT) has a strong evidence base, there is also a growing trend to package CBT techniques into various psychoeducational programs. These programs, which we call psychoeducation with psychotherapeutic programs, have been consistently found to be effective in reducing caregiver distress and are suited for delivery in group format, even by paraprofessionals, to lower the cost of intervention. A recent trend is the effective use of technological aids (e.g., the internet) to deliver CBT and psychoeducation, reaching more caregivers. As for therapeutic mechanisms, the use of coping skills, reduced dysfunctional thoughts, and increased self-efficacy in controlling upsetting thoughts has received support in studies. We conclude that psychotherapeutic techniques are increasingly being used effectively and efficiently to assist caregivers, aided by successful adaptation for educational or technologically advanced means of delivery. More research on therapeutic mechanisms is needed to understand how the techniques work and how they can be further refined.

A brief measure of predeath grief in dementia caregivers: the Caregiver Grief Questionnaire.

OBJECTIVE: The study of predeath grief is hampered by measures that are often lengthy and not clearly differentiated from other caregiving outcomes, most notably burden. We aimed to validate a new 11-item Caregiver Grief Questionnaire (CGQ) assessing two dimensions of predeath grief, namely relational deprivation and emotional pain. DESIGN: Cross-sectional survey. SETTING: Community and psychogeriatric clinics. PARTICIPANTS: 173 Alzheimer (AD) caregivers who cared for relatives with different degrees of severity (63 mild, 60 moderate, and 50 severe). MEASUREMENTS: Besides the CGQ, measures of caregiver burden and depressive symptoms, and care-recipients' neuropsychiatric symptoms and functional impairment were assessed. RESULTS: Confirmatory factor analysis supported the hypothesized 2-factor over the 1-factor model, and both subscales were only moderately correlated with burden. Two-week test-retest reliabilities were excellent. Caregivers for mild AD reported less grief than those caring for more severe relatives. Z tests revealed significantly different correlational patterns for the two dimensions, with emotional pain more related to global burden and depressive symptoms, and relational deprivation more related to care-recipients' functional impairment. Both dimensions were mildly correlated with neuropsychiatric symptoms (especially disruptive behaviors and psychotic symptoms) of the care-recipient. CONCLUSIONS: Results supported the reliability and validity of the two-dimensional measure of predeath grief. As a brief measure, it can be readily added to research instruments to facilitate study of this important phenomenon along with other caregiving outcomes.

The Pain Catastrophizing Scale-short form: psychometric properties and threshold for identifying high-risk individuals.

OBJECTIVE: The Pain Catastrophizing Scale (PCS) measures three aspects of catastrophic cognitions about pain-rumination, magnification, and helplessness. To facilitate assessment and clinical application, we aimed to (a) develop a short version on the basis of its factorial structure and the items' correlations with key pain-related outcomes, and (b) identify the threshold on the short form indicative of risk for depression. DESIGN: Cross-sectional survey. SETTING: Social centers for older people. PARTICIPANTS: 664 Chinese older adults with chronic pain. MEASUREMENTS: Besides the PCS, pain intensity, pain disability, and depressive symptoms were assessed. RESULTS: For the full scale, confirmatory factor analysis showed that the hypothesized 3-factor model fit the data moderately well. On the basis of the factor loadings, two items were selected from each of the three dimensions. An additional item significantly associated with pain disability and depressive symptoms, over and above these six items, was identified through regression analyses. A short-PCS composed of seven items was formed, which correlated at r=0.97 with the full scale. Subsequently, receiver operating characteristic (ROC) curves were plotted against clinically significant depressive symptoms, defined as a score of ≥12 on a 10-item version of the Center for Epidemiologic Studies-Depression Scale. This analysis showed a score of ≥7 to be the optimal cutoff for the short-PCS, with sensitivity = 81.6% and specificity = 78.3% when predicting clinically significant depressive symptoms. CONCLUSIONS: The short-PCS may be used in lieu of the full scale and as a brief screen to identify individuals with serious catastrophizing.

Improving diagnostic communication in dementia.

In many countries around the world, owing to the lack of specialists and equipment, delay up to a few years in help-seeking and getting diagnostic examinations for dementia is not uncommon (Sayegh and Knight, 2013), and this situation is considerably more serious in "atypical dementias" due to the challenge they present for differential diagnosis. For instance, a survey in the USA showed that misdiagnosis was common in patients with Lewy body dementia who, on average, saw at least three physicians over a year's time or more before getting the proper diagnosis (Lewy Body Dementia Association, 2010). Furthermore, in multiethnic communities, cultural and language barriers between practitioners and patients may lead to substantial delay as well (Sayegh and Knight, 2013).

Savoring moderates the association between cancer-specific physical symptoms and depressive symptoms.

BACKGROUND: This study investigated the associations of savoring with cancer-specific physical symptoms, psychological distress, and psychological well-being and the moderating effect of savoring in the associations between physical symptoms and psychological outcomes among cancer patients. METHODS: A total of 263 Chinese adults recently diagnosed with cancer (mean time since diagnosis = 43.72 days, SD = 38.20) were recruited and administered a questionnaire assessing cancer-specific physical symptoms, perceived capability of savoring the moment, psychological distress, and psychological well-being within six months following diagnosis. RESULTS: Structural equation modeling revealed significant associations of savoring with physical symptoms and psychological distress and well-being (ß = -0.41-0.54, p < 0.0001). Savoring significantly moderated the association between physical symptoms and depressive symptoms. Simple slope tests revealed that the association was not significant at higher levels of savoring (estimate = 0.15, z = 0.49, p = 0.62) whereas it was stronger at lower (estimate = 1.11, z = 4.81, p < 0.001) and medium (estimate = 0.63, z = 3.04, p < 0.01) levels of savoring. The effects of demographic and medical covariates were controlled for in all models. CONCLUSIONS: The findings suggest that savoring is positively associated with physical and psychological functioning among people with cancer. The link between physical symptoms and depressive symptoms could be exacerbated at lower levels of savoring. Fostering savoring beliefs and practices could be a significant psychological component of symptom management among cancer patients. Copyright © 2016 John Wiley & Sons, Ltd.

Dementia Caregiver Burden: a Research Update and Critical Analysis.

PURPOSE OF REVIEW: This article provides an updated review of the determinants of caregiver burden and depression, with a focus on care demands and especially the differential effects of various neuropsychiatric symptoms or symptom clusters. Moreover, studies on caregivers for frontotemporal and Lewy body dementias were referred to in order to identify differences and similarities with the mainstream literature based largely on Alzheimer caregivers. RECENT FINDINGS: As a group, neuropsychiatric symptoms are most predictive of caregiver burden and depression regardless of dementia diagnosis, but the effects appear to be driven primarily by disruptive behaviors (e.g., agitation, aggression, disinhibition), followed by delusions and mood disturbance. Disruptive behaviors are more disturbing partly because of the adverse impact on the emotional connection between the caregiver and the care-recipient and partly because they exacerbate difficulties in other domains (e.g., caring for activities of daily living). In behavioral variant frontotemporal dementia, not only are these disruptive behaviors more prominent but they are also more disturbing due to the care-recipient's insensitivity to others' feelings. In Lewy body dementia, visual hallucinations also appear to be distressing. The disturbing nature of disruptive behaviors cuts across dementia conditions, but the roles played by symptoms that are unique or particularly serious in a certain condition need to be explored further.

Aberrant interhemispheric functional connectivity within default mode network and its relationships with neurocognitive features in cognitively normal APOE ε 4 elderly carriers.

BACKGROUND: Default mode network (DMN) is vulnerable to the effects of APOE genotype. Given the reduced brain volumes and APOE ε 4-related brain changes in elderly carriers, it is less known that whether these changes would influence the functional connectivity and to what extent. This study aimed to examine the functional connectivity within DMN, and its diagnostic value with age-related morphometric alterations considered. METHODS: Whole brain and seed-based resting-state functional connectivity (RSFC) analysis were conducted in cognitively normal APOE ε 4 carriers and matched non-carriers (N=38). The absolute values of mean correlation coefficients (z-values) were used as a measure of functional connectivity strength (FCS) between DMN subregions, which were also used to estimate their diagnostic value by receiver-operating characteristic (ROC) curves. RESULTS: APOE ε 4 carriers demonstrated decreased interhemispheric FCS, particularly between right hippocampal formation (R.HF) and left inferior parietal lobular (L.IPL) (t=3.487, p<0.001). ROC analysis showed that the FCS of R.HF and L.IPL could differentiate APOE ε 4 carriers from healthy counterparts (AUC value=0.734, p=0.025). Moreover, after adjusting the impact of morphometry, the differentiated value of FCS of R.HF and L.IPL was markedly improved (AUC value=0.828, p=0.002). CONCLUSIONS: Our findings suggest that APOE ε 4 allele affects the functional connectivity within posterior DMN, particularly the atrophy-corrected interhemispheric FCS before the clinical expression of neurodegenerative disease.