Positive aspects of caregiving as a moderator of treatment outcome over 12 months.

As the longevity of the population increases, so does the prevalence of age-related disorders such as Alzheimer’s disease. Recent research conducted through the Centers for Disease Control and Prevention estimates prevalence rates of Alzheimer’s disease and related disorders (ADRD) in the United States at nearly 4.5 million, with expected escalation to 13.2 million by the year 2050 (Hebert, Scherr, Bienias, Bennett, & Evans, 2003). Care for individuals with ADRD is provided predominantly by family members and friends in the community or home; however, to date, the role of positive appraisals of the caregiving experience has been largely marginal in caregiving research (Roff et al., 2004; Tarlow et al., 2004). Moreover, no studies have examined the role of positive caregiving appraisal and responsiveness to caregiver interventions. Psychological distress and increased risk for depression are consistently associated with caregiving (e.g., Haley, Levine, Brown, & Bartolucci, 1987; Hooker et al., 2002; Levine, 2003; Schulz, Visintainer, & Williamson, 1990). Although many of the hardships encountered by Alzheimer’s caregivers are shared with those caring for individuals with any chronic illness, caring for an individual with Alzheimer’s can be especially detrimental (Ory, Yee, Tennestedt, & Schulz, 1999). The functional impairments that are a fundamental part of dementia are accompanied by a number of behavior problems that make caring for a loved one particularly challenging. These unique functional and behavioral impairments can contribute substantially to the psychological and physical morbidity of the caregiver (e.g., Hooker et al., 2002). Stress process models of coping have frequently been applied to the caregiving role to explain individual differences in the ability to manage the many stressors that caregivers face and to predict physical and emotional outcomes based on these factors (Haley et al., 1987, 1996; Pearlin, Mullan, Semple, & Skaff, 1990). For example, Lazarus and Folkman’s (1984) original stress process model explained stress within an individual as a process that is influenced by a number of contextual factors affecting how the individual appraises and copes with a given event. Similarly, Pearlin’s stress process framework (Pearlin et al., 1990) focused on contextual variables in terms of primary and secondary stressors, making a distinction between stressors that are directly related to the caregiving role (e.g., care recipient problem behaviors) and sources of stress that are indirectly related (e.g., financial strain). After additional research involving individuals caring for partners with AIDS, Folkman (1997) revised the original stress and coping model, incorporating positive psychological appraisals, specifically with respect to their beneficial effects on the maintenance of the coping process. When stressed caregivers do not engage in positive, or meaning-based, reappraisals, negative emotional outcomes may diminish the coping response. Therefore, intervention targeted at increasing positive reappraisal of caregiving outcomes may reinforce and facilitate continued emotional coping. Positive aspects of caregiving (PAC) have been identified in a variety of ways, but they are typically defined as the rewards and satisfaction derived from the caregiving relationship (Kramer, 1997; Tarlow et al., 2004). Satisfaction with caregiving and rewarding appraisals of caregiving may reduce caregiving stress and improve emotional outcomes (Kinney & Stephens, 1989; Roff et al., 2004). C. A. Cohen, Colantonio, and Vernich (2002) asked 289 Canadian caregivers if they could identify and describe at least one positive aspect within their caregiving relationship. Results revealed that 73% of caregivers could identify at least one PAC, mentioning a range of positive experiences from feeling fulfilled, important, and responsible, to finding a sense of companionship and meaning within the relationship. Individuals with higher PAC reported less depression, burden, and better subjective health than those who did not endorse PAC. C. A. Cohen and colleagues concluded that the ability to identify positive aspects within the caregiving relationship might serve as a buffer against negative consequences. Notably, this research was cross-sectional, limiting the causal attributions that can be gleaned from the results. Findings have recently emerged on cultural variations in the report of positive aspects of the caregiving experience (Burgio, Stevens, Guy, Roth, & Haley, 2003; Roff et al., 2004). Roff and colleagues explored racial differences in the report of PAC at baseline within White and African American Alzheimer’s caregivers from the original Resources for Enhancing Alzheimer’s Caregiver Health I (REACH I) project (National Institutes of Health [NIH], 2002). Like previous research in this area (Picot, Debanne, Namazi, & Wykle, 1997), Roff and colleagues observed higher levels of PAC in African American caregivers than in White caregivers. Moreover, religiosity partially mediated the relationship between PAC and race. Although symptoms of depression were not associated with baseline PAC, these researchers also found that lower anxiety levels, less behavioral bother, and lower socioeconomic status (SES) among African American caregivers appeared to contribute to their higher levels of PAC. However, this research was cross-sectional, leaving open the question of whether PAC is a time-varying individual difference variable that may be targeted, in itself, for intervention. Notably, Tennen and Affleck (2002) cautioned that identifying positive aspects of stressful situations does not necessarily indicate that individuals use these appraisals to cope. They stated that the ability to recognize positive aspects or find benefits in adversity when prompted during an interview should be distinguished from active reliance on these coping mechanisms on a daily basis as a means of reducing stress. Tennen and Affleck framed this as a methodological weakness in the coping literature that has not yet been adequately addressed. Absent from the literature is evidence that PAC is, in itself, modifiable across time or, potentially, that PAC may moderate individuals’ effective use of interventions. Specifically, perhaps persons with fewer identified positive aspects of the caregiving role would benefit differentially than those already receiving some level of benefit from the caregiving context. The current study was designed to address four limitations in the caregiving literature as it relates to PAC. Specifically, we (a) examined the impact of time-varying depression, behavioral bother, and daily care burden on time-varying PAC over 12 months; (b) examined the impact of time-varying PAC on negative emotional outcomes over 12 months; (c) explored the interaction between PAC and participation in intervention on time-varying negative emotional outcomes; and (d) examined whether the relations among these variables varied by race, limiting our sample to a comparison of White/Caucasian to Black/African American caregivers. By examining the potential of time-varying negative affect to serve as a predictor of time-varying PAC and the potential of PAC to serve as a moderator of the effects of intervention on time-varying depression, behavioral bother, and daily care burden associated with caregiving, we may provide evidence that positive appraisal of the caregiving experience does indeed reinforce the coping process, as predicted by Folkman’s (1997) revised stress and coping model. Our conceptual model of the interrelationship of PAC, depression, behavioral bother, and daily care burden as they unfold over time is depicted in Figure 1. Figure 1 Model depicting the relation between baseline control variables, predictor variables, and time-varying emotional outcomes. Asterisks indicate time-varying variables (i.e., values at baseline, 6 months, and 12 months are in the model); variables without ... For this project, data from the Philadelphia site of the original REACH I program (NIH, 2002), supported through the National Institute of Nursing Research and the National Institute on Aging, were chosen for the site’s successful intervention (Gitlin, Winter, et al., 2003), inclusion of a usual care control group, and roughly equal representation of White and African American participants. This usual care condition consisted of information and referral for services, which arguably resembled typical resources given to Alzheimer’s caregivers in the community. The intervention used at this site is described next.