A body of work, a missed opportunity: Dyadic research in older adults

To the Editor: As dyadic researchers we read with great interest Riffin and colleagues study exploring patient and caregiver experiences, preferences, and attitudes toward the provision and receipt of caregiving assistance with medical tasks. We wholeheartedly support the publication of qualitative work of this caliber in the Journal of the American Geriatrics Society (JAGS). Conducting the interviews with both care partners present was a particular strength, and their findings that these caregiving relationships could be grouped into supportive and conflicted types support our earlier work. Given this connection, we were surprised that well-known dyadic studies were missing from the article. This “missed opportunity” slows down the advancement of the science, and we would like to discuss it further. Dyadic care typologies have been previously examined both qualitatively and quantitatively. In Buck et al, 2013, four types were qualitatively characterized as patient, caregiver, collaborative, and/or complementary oriented. A fifth type, incongruent, in which the two partners disagreed on who was responsible for the care, was found, which exhibited similar themes with the conflicted caregiving relationship group noted by Riffin et al. This earlier typology has been subsequently tested across multiple studies. Similarly, Lee and colleagues, using multilevel and mixture modeling on patient and caregiver data, quantitatively measured dyadic contributions to the patient’s care. This study identified three distinct dyadic types, which were labeled as novice and complementary (both partners contributed to the care but did so poorly), inconsistent and compensatory (caregivers contributed more to the care as the patient contributed less), and expert and collaborative (both partners contributed to the care with high relationship quality). Unfortunately, Riffin et al missed the opportunity to position their typology in reference to this earlier work and add additional or confirmatory understanding of how dyads manage multiple chronic conditions at home. A proliferation of typologies makes synthesizing and advancing the science difficult when researchers use their own terms and studies are not cross-referenced. Dyadic effects while managing multiple conditions have also been previously examined. In the work most closely aligned with Riffin et al, degree of relational mutuality, disagreement or incongruence, and dyadic contributions to self-care are well documented (see Supplemental material for further dyadic studies). We acknowledge that this work has been primarily carried out in heart failure. However, close examination of each study illustrates that heart failure coexisted with other chronic conditions, as established in a recent international review of common co-occurring conditions interconnected with heart failure. Furthermore, while Riffin et al argued that selecting study participants more broadly somehow influenced the knowledge gained, we would suggest that this shows a lack of understanding of the population (primarily older adults) and their daily lives. Between 25% and 50% of older adults have multiple chronic conditions, and they generally do not think of their chronic conditions discretely but rather as a function of the symptoms that they must manage. Therefore, the studies mentioned here are salient and should have been discussed. Finally, we highlight the absence of both the dyadic theoretical and review literature from this article. From a key theoretical article (cited 500+) by Berg and Upchurch in which a developmental and contextual dyadic chronic illness model was introduced to a recent international systematic review of dyadic interventions in which intervention components, contexts, and outcomes were examined, there is a rich body of work that was not brought to the attention of the readers of this article. One particular article, by Lyons and Lee, exemplifies this issue. Over a decade of dyadic studies were examined to develop a theoretical model of dyadic illness management. The basic premise of this model is that management is a dyadic, interdependent phenomenon. One of the key contextual risk factors is dyadic incongruence. In work conducted separately and together, Lyons and Lee have examined incongruence and found dyadic heterogeneity in two particularly important areas—symptom and physical function appraisal. This heterogeneity involves variability across time and type of dyad, suggesting the complexity of the dyadic experience. In summary, important dyadic work has been conducted across multiple disciplines and countries. While we acknowledge that the Riffin et al article was a Brief Report and so had certain journal-specific constraints, we would still like JAGS readers to be aware of the breadth and depth of existing dyadic research.