Levenson, Robert W.

Abstract Caregivers for people with neurodegenerative disease (PWNDs) often experience mental and physical health problems, especially when caring for PWNDs who have deficits in emotional functioning. We studied 65 PWNDs and their caregivers both during active caregiving and after caregiving had ended to determine: (a) how caregiver health changes after caregiving ends; and (b) whether PWNDs’ emotional functioning predicts these changes. PWND emotional functioning was assessed in the laboratory by measuring their generation of preparatory physiological activity (e.g., increased heart rate) to an upcoming emotional event (i.e., emotion eliciting films). Caregiver mental and physical health were measured using the Short-Form Health Survey (SF36) during active caregiving and again after caregiving had ended. Results indicated that, overall, caregivers reported increases in mental health, (t(36) = 2.58, p = .014, 95% CI [1.31, 10.93]) but decreases in physical health (t(36) = -2.35, p = .025, 95% CI [-7.26, -0.53]) across the two measurement periods. Using latent change score models, PWNDs’ preparatory physiological response impairments were associated with better caregiver mental health trajectories (β = -0.37, SE = 0.04, p = .003) such that smaller PWND preparatory responses predicted greater improvements in caregiver mental health (β = 9.92, SE = 2.84, p < .001). There was no association with changes in caregiver physical health. Smaller preparatory physiological responses in PWNDs may indicate diminished emotional responding, which is linked with lower caregiver mental health during active caregiving. Once caregiving ends, these caregivers may be most likely to “rebound” and show improvements in mental health.

Abstract As a group, family caregivers of people with dementia (PWDs) have substantially elevated levels of depression and anxiety, compared to same-aged non-caregiving adults. However, there is striking variation in mental health among individual caregivers. Previous research on predictors of the sources of these individual differences has focused on characteristics of individual caregivers and PWDs (rather than on the caregiver-PWD relationship), self-report measures (rather than behavioral measures), and negative emotion (rather than positive emotion). We examined 185 caregiver-PWD dyads who had an unrehearsed 10-minute conversation about an area of conflict in the laboratory. Video recordings were coded for Behavioral Indicators of Positivity Resonance (BIPR), which derives from Positivity Resonance Theory and assesses dyad-level behavioral expressions of positive affect, mutual warmth, and synchrony. Caregivers reported their level of depression, anxiety, and emotional well-being and PWDs underwent a comprehensive neurological and neuropsychological evaluation. Pearson’s correlations revealed that greater dyad-level BIPR was associated with caregivers’ higher emotional well-being (r(181) = .19, p = .008), lower depression (r(179) = -.17, p = .025), and lower anxiety (r(180) = -.15, p = .045). Regression analyses revealed that these associations were still obtained after controlling for caregiver age and sex and PWD dementia severity, cognitive impairment, and neuropsychiatric behavior (emotional well-being ß = .18, p = .012; depression ß = -.15, p = .039; anxiety ß = -.15, p = .044). Future studies should determine whether interventions that increase co-experienced positive emotions among caregiver-PWD dyads help buffer caregivers from adverse mental health consequences.

Abstract Objectives There are striking differences among caregivers of people with dementia in their health and well-being during active caregiving and after caregiving has ended. A key factor influencing caregiver health is the emotional quality of the caregiver–care recipient relationship, which may be reflected in the emotional language caregivers use when describing this relationship. The present study assessed whether caregivers’ positive and negative language is associated with their current and future depression trajectories. Methods Active caregivers responded to an open-ended question about a recent time they felt connected to the care recipient. We summed the number of positive and negative emotion words and divided them by the total words in the response. We evaluated whether caregivers’ emotional language (a proxy for the emotional quality of the caregiver–care recipient relationship) was associated with their depression assessed both concurrently (N = 347 active caregivers) and longitudinally (N = 224 former caregivers). Results Neither positive nor negative emotional language significantly correlated with caregiver depression during active caregiving. Structural equation modeling revealed caregivers’ greater positive emotional language (accounting for baseline depression) was associated with less steep increases in depression after the care recipient’s death. Results were robust when accounting for negative emotional language and covariates. Negative emotional language was not significantly associated with changes in caregiver depression. Discussion Caregivers who use more positive words when describing their connection with the care recipient may be more resilient, underscoring the potential role of positive emotional qualities of the caregiving relationship in preserving caregivers’ mental health after caregiving ends.

Abstract Objectives Emotional impairments in people with dementia can be taxing for family caregivers. However, caregivers differ in their resilience to these challenges. We previously found that, compared to healthy controls and people with Alzheimer’s disease, people with frontotemporal lobar degeneration (FTLD) have smaller physiological responses when anticipating upcoming emotional stimuli. This impairment may leave these people with FTLD unprepared for upcoming emotional stimuli because they cannot mount responses needed for appropriate behaviors, which may create stress and difficulties for caregivers. We examined (a) whether smaller preparatory physiological responses in people with dementia are associated with lower emotional well-being and physical functioning in caregivers; and (b) whether these associations are moderated by the dyads’ relationship quality. Methods A total of 158 individuals with FTLD or Alzheimer’s disease and their family caregivers participated. Preparatory physiological responses in people with dementia were quantified as decreases in cardiac interbeat intervals from baseline to an instruction period, during which they were told they would be watching an upcoming emotional film. Caregivers self-reported their emotional well-being, physical functioning, and relationship quality with the people with dementia. Results Smaller preparatory physiological responses in people with dementia were associated with lower emotional well-being (but not physical functioning) in caregivers. This association was moderated by relationship quality (i.e., weakened for caregivers in higher-quality relationships). Discussion Findings advance understanding of risk and resilience factors for negative caregiver outcomes. Positive interpersonal processes in high-quality relationships (e.g., positive appraisal of aberrant behaviors) may buffer caregivers from the impact of emotional impairments in people with dementia.

Abstract Dementia caregivers are at heightened risk for developing mental and physical health problems. Interventions designed to protect caregiver health often create additional demands on time and energy (e.g., exercise programs). Technology-based interventions (e.g., remote monitoring) can be effective, scalable, and do not add greatly to caregiver burden. Through a collaboration with a local technology company, Care Daily, we conducted two randomized controlled trials to evaluate People Power Caregiver (PPCg), a system of sensors in the home connected to cloud-based AI that alerts caregivers about worrisome deviations from normal patterns (e.g., care-recipient’s falls, wandering). Across two studies (study 1: 9-month duration with professional installation of PPCg; study 2: 6-month duration with caregiver self-installing the PPCg using remote tech support), 284 caregivers were recruited; 261 completed initial study deployment (e.g., system installation); and 235 completed the entire study protocol. Use of PPCg was associated with (a) reduced caregiver anxiety in study 1; (b) greater protection from declines in sleep efficiency in studies 1 and 2. These findings underscore the promise of technology-based intervention to mitigate health problems in dementia caregivers. However, challenges and complexities in recruitment (e.g., remote consenting both caregivers and care recipients), retention (e.g., due to changes in home environment or caregiving status), system installation (e.g., working with caregivers with less experience using technology), data quality assurance (e.g., invalid sensor data) as well as our efforts to overcome these challenges have been instructive. Lessons learned from these studies can provide useful guidance for future large-scale, technology-based interventions for dementia caregivers.

Abstract There are striking differences among caregivers of people with dementia (PWDs) in how their health and well-being changes during active caregiving; however, less is known about these differences after caregiving has ended. One important factor influencing caregiver health is the emotional quality of the caregiver-PWD relationship. The present study evaluated caregivers’ emotional connection to the PWD (during caregiving) and associations with caregivers’ depression both concurrently (N = 326 active caregivers) and longitudinally (n = 91 former caregivers). Active caregivers described a recent time they felt connected to the PWD, and their responses were transcribed verbatim. Caregivers’ emotional connection to the PWD was operationalized by summing the number of positive and negative emotion words from the transcripts using text analysis software and dividing each figure by the total number of words in the response. Results indicated that neither positive nor negative emotional language was significantly correlated with caregivers’ concurrent depression. However, two-wave latent change score modeling revealed that caregivers’ greater positive emotional language (adjusting for caregivers’ baseline depression and negative emotional language) predicted steeper declines in depression (i.e., improvements in depression trajectories) after the death of the PWD (ß = -.11, SE(ß) = 0.04, p = .033). Negative emotional language was not significantly associated with changes in caregivers’ depression. This finding highlights positive emotion expressed by caregivers when describing their connection with the PWD as a potential resilience factor and underscores the important role that positive emotional qualities of the caregiving relationship play in improving caregivers’ mental health after caregiving ends.

Abstract Lower income in familial caregivers has been shown to associate with increased distress, depression, and burden during active caregiving. However, findings are less clear on whether lower income associates with changes in well-being that occur after caregiving ends. To investigate this question further, we recruited familial caregivers (CGs) of people with neurodegenerative diseases (PWD; N=36). Emotional well-being was assessed using the SF-36 Emotional Well-being and Energy scales both during active caregiving and after caregiving had ended (predominantly due to the PWD’s death or transition to institutional care, ~10 years later). Household income was measured after active caregiving had ended. Overall, CG’s emotional well-being and energy improved between active caregiving and after caregiving had ended (emotional well-being change: t(35) = 2.22, p = .033; energy change: t(35) = 2.88, p = .007). However, this improvement associated with household income, such that when controlling for levels during active caregiving, income associated with worse emotional well-being (B = -6.72, t(33) = -4.56, p < .001) and energy (B = -8.07, t(33) = -4.99, p < .001) in caregivers after caregiving had ended. During the adjustment period after caregiving ends, lower income may limit opportunities for caregivers to take time away from work to mourn the loss of their loved one or address their own health concerns adequately. Thus, low-income caregivers may experience fewer of the benefits associated with these activities. These findings underscore the importance of providing support for lower income caregivers during the critical period after caregiving ends.