Family Caregiving

Family caregivers provide more than 80% of the long-term care for older adults in this country. Caregiving can be difficult, time-consuming work added on top of job and other family responsibilities. If the caregiver suffers negative consequences from the caregiving role and these are not mitigated, increased morbidity and mortality may result for the caregiver. Not all outcomes from caregiving are negative; there are many caregivers who report rewards from caregiving.

 

A.  Definitions

  1. Family caregiving is broadly defined and refers to a broad range of unpaid care provided in response to illness or functional impairment to a chronically ill or functionally impaired older family member, partner, friend, or neighbor that exceeds the support usually provided in family relationships (Rabarison et al., 2018; Schumacher, Beck, et al., 2006).
  2. Caregiver role transitions: Caregiver role acquisition is a family role transition that occurs through situated interaction as part of a role-making process (Schumacher, 1995). This is the process of taking on the caregiving role at the beginning of caregiving or when a significant change in the caregiving context occurs. Role transitions occur when a role is added to or deleted from the role set of a person or when the behavioral expectations for an established role change significantly (NAC & AARP, 2015).
  3. Indicators of healthy caregiver role transitions: The broad categories of indicators of healthy transitions include subjective well-being, role mastery, and well-being of relationships. These are the subjective, behavioral, and interpersonal parameters of health most likely to be associated with healthy role transitions (Geary & Schumacher, 2012; NAC & AARP, 2015; Naylor et al., 2017).
  4. Family caregiving activities include assistance with day-to-day activities, illness-related care, care management, and invisible aspects of care. Day-to-day activities include personal care activities (bathing, eating, dressing, mobility, transferring from bed to chair, and using the toilet) and IADL (meal preparation, grocery shopping, making telephone calls, and money management; NAC & AARP, 2015; NASEM, 2016). Illness-related activities include managing symptoms, coping with illness behaviors, carrying out treatments, and performing medical or nursing procedures that include an array of medical technologies (Schumacher, Beidler, et al., 2006; Schumacher et al., 2000). Care management activities include accessing resources, communicating with and navigating the healthcare and social services systems, and acting as an advocate (Schumacher et al., 2000). Invisible aspects of care are protective actions the caregiver takes to ensure the older adult’s safety and well-being without the elder’s knowledge (Bowers, 1987; Schumacher, Beck, et al., 2006).
  5. Caregiving roles can be classified into a hierarchy according to who takes on the bulk of responsibilities versus only intermittent supportive assistance. Primary caregivers tend to provide most of the everyday aspects of care, whereas secondary caregivers help out as needed to fill the gaps (Cantor & Little, 1985; Penning, 1990; Tennstedt et al., 1989). Among caregivers who live with their care recipients, spouses account for the bulk of primary caregivers, whereas adult children are more likely to be secondary caregivers. The range of the family caregiving role includes protective caregiving, like “keeping an eye on” an older adult who is currently independent but at risk, to full-time, around-the-clock care for a severely impaired family member. Healthcare providers may fail to assess the full scope of the family caregiving role if they associate family caregiving only with the performance of tasks.
  6. Caregiver assessment refers to an ongoing iterative process of gathering information that describes a family caregiving situation and identifies the particular issues, needs, resources, and strengths of the family caregiver.

B.  Etiology and/or epidemiology of risk factors associated with unhealthy caregiving transitions

  1. Just being a caregiver puts an individual at increased risk of higher levels of stress and depression and lower levels of subjective well-being and physical health (Pinquart & Sörensen, 2006a, 2007; Vitaliano et al., 2003).
  2. Female caregivers on average provide more direct care and report higher levels of burden and depression (Cohen et al., 2017; Cook & Cohen, 2018; Gitlin et al., 2003; Riffin et al., 2019). LGBTQ caregivers report more financial concerns, loneliness, and declining physical health than non-LGBTQ caregivers and are wary of revealing their orientation/gender to their providers (Fredriksen-Goldsen et al., 2011).
  3. Ethnic minority caregivers provide more care, use less formal services, and report worse physical health than White caregivers (Cohen et al., 2017; Cook & Cohen, 2018; Cook et al., 2018; Dilworth-Anderson et al., 2002; NAC & AARP, 2015; Pinquart & Sörensen, 2006a, 2007).
  4. African American caregivers experience less stress and depression and get more rewards from caregiving than White caregivers (Cohen et al., 2017; Cook et al., 2018; Cuellar, 2002; Dilworth-Anderson et al., 2002; Gitlin et al., 2003; Haley et al., 2004; Pinquart & Sörensen, 2004), but younger or nonspouse caregivers do not respond as well to interventions (Belle et al., 2006; C. C. Lee et al., 2010).
  5. Hispanic and Asian American caregivers exhibit more depression (Gitlin et al., 2003; Pinquart & Sörensen, 2004) and emotional drain (Anthony et al., 2017), particularly among young Hispanic caregivers (C. C. Lee et al., 2010). But Hispanic and African American caregivers report more positive aspects of caregiving (Roth et al., 2015).
  6. Less-educated caregivers report more depression (Buckwalter et al., 1999; Gitlin et al., 2003).
  7. Spouse caregivers report higher levels of depression than nonspouse caregivers (Pinquart & Sörensen, 2004; Pruchno & Resch, 1989), but appear to benefit more from interventions (Elliott et al., 2010).
  8. Caregivers who have a poor-quality relationship with the care recipient report more strain (Archbold et al., 1990; Croog et al., 2006; Flannery, 2002).
  9. Caregivers who lack preparedness for the caregiving role also have increased strain (Archbold et al., 1990, 1992; Moon, 2017; NAC & AARP, 2015).
  10. Caregivers of care recipients who have dementia have more strain and burden (Pinquart & Sörensen, 2003).

PARAMETERS OF ASSESSMENT

A.  Caregiving context

  1. Caregiver relationship with care recipient (spouse, nonspouse; Elliott et al., 2010; Gitlin et al., 2003; NAC & AARP, 2015; Sörensen et al., 2002)
  2. Caregiver roles and responsibilities
    • Duration of caregiving (Sörensen et al., 2002)
    • Employment status (work/home/volunteer; Pinquart & Sörensen, 2004)
    • Household status (number in home, etc.; Pinquart & Sörensen, 2004)
    • Existence and involvement of extended family and social support (Pinquart & Sörensen, 2004)
  3. Physical environment (home, facility; Gitlin et al., 2010; Vitaliano et al., 2003)
  4. Financial status (Vitaliano et al., 2003)
  5. Potential resources that caregiver could choose to use—list (Pinquart & Sörensen, 2004)
  6. Family’s cultural background (Browne et al., 2017; Dilworth-Anderson et al., 2002; Goins et al., 2011)

B.  Caregiver’s perception of health and functional status of care recipient

  1. List activities care receiver needs help with; include both ADL and IADL (Pinquart & Sörensen, 2004)
  2. Presence of cognitive impairment—if yes, any behavioral problems (Gitlin et al., 2003; Sörensen et al., 2002)
  3. Presence of mobility problems—assess with single question (Archbold et al., 1990)

C.  Caregiver preparedness for caregiving

  1. Does caregiver have the skills, abilities, or knowledge to provide care recipient with needed care (see PCGS at consultgerirn.org/resources)?

D.  Quality of family relationships

  1. The caregiver’s perception of the quality of the relationship with the care receiver (see Mutuality scale; Archbold et al., 1990; Messecar et al., 2011)

E.  Indicators of problems with quality of care

  1. Unhealthy environment
  2. Inappropriate management of finances
  3. Lack of respect for older adult (see EAI at www.consultgerirn.org/resources)

F.   Caregiver’s physical and mental health status

  1. Self-rated health: single item—asks what the caregiver’s perception of his or her health is (Pinquart & Sörensen, 2006a, 2007).
  2. Health conditions and symptoms
    • Depression or other emotional distress (e.g., anxiety; Pinquart & Sörensen, 2003, 2006a, 2007; Sörensen et al., 2002; see cesd-r.com/cesdr)
    • Reports of burden or strain (Schulz & Beach, 1999; Vitaliano et al., 2003; see Caregiver Strain Index at www.consultgerirn.org/resources—Family Caregiving topic)
  3. Rewards of caregiving
    • List perceived benefits of caregiving (Archbold et al., 1995)
    • Satisfaction of helping family member
    • Developing new skills and competencies
    • Improved family relationships
  4. Self-care activities for caregiver
    • Attending to own healthcare needs
    • Getting exercise
    • Taking time off
    • Seeking support
    • Getting proper rest and nutrition

NURSING CARE STRATEGIES

A.  Identify content and skills needed to increase preparedness for caregiving (Acton & Winter, 2002; Boltz, Kuzmik, et al., 2018; Farran et al., 2003; Gitlin et al., 2003; Pusey & Richards, 2001; Schumacher, Beidler, et al., 2006; Schumacher et al., 2000; Sörensen et al., 2002).

B.  Form a partnership with the caregiver before generating strategies to address issues and concerns (Boltz, Kuzmik, et al., 2018; Brodaty et al., 2003; Gitlin et al., 2003; Harvath et al., 1994).

C.  Invite participation in care while in the hospital using the Family Preferences Index, a 14-item approach to exploring caregivers’ personal choices for participating in the care of hospitalized older adult family members to determine preferences to provide care (Messecar, Powers, & Nagel, 2008).

D.  Identify the caregiving issues and concerns on which the caregiver wants to work and generate strategies (Acton & Winter, 2002; Boltz, Kuzmik, et al., 2018; Gitlin et al., 2003; Schumacher, Beidler, et al., 2006; Sörensen et al., 2002).

E.  Assist the caregiver in identifying strengths in the caregiving situation (Archbold et al., 1995).

F.   Assist the caregiver in finding and using resources (Archbold et al., 1995; Boltz, Kuzmik, et al., 2018; Farran et al., 2004; Schumacher et al., 2002).

G.  Help caregivers identify and manage their physical and emotional responses to caregiving (Schulz & Beach, 1999). Screen for strain using the MCSI (Onega, 2018).

H.  Use an interprofessional approach when working with family caregivers (Acton & Winter, 2002; Farran et al., 2003, 2004; Gitlin et al., 2003; Sörensen et al., 2002).

EVALUATION OF EXPECTED OUTCOMES

A.  Outcomes specific to caregiving transitions

  1. Lower caregiver strain
  2. Decreased depression
  3. Improved physical health

B.  Outcomes specific to patient

  1. Quality of family caregiving
  2. Care recipient’s functional status, nutrition, hygiene, and symptom management
  3. Care recipient’s emotional well-being
  4. Decreased occurrence of adverse events such as increased frequency of emergent care

ABBREVIATIONS

ADL            Activities of daily living

EAI             Elder Assessment Instrument

IAD             Instrumental activities of daily living

PCGS          Preparedness for Caregiving Scale

----

Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 14:  Messecar, D. (2021) Family Caregiving.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 191-221).  New York: Springer.

REFERENCES

Acton, G. J., & Winter, M. A. (2002). Interventions for family members caring for an elder with dementia. Annual Review of Nursing Research, 20, 149–179. doi:10.1891/0739-6686.20.1.149. Evidence Level I.

Anthony, K. P., John Geldhof, G., & Mendez-Luck, C. A. (2017). Characterizing caregiving intensity among Mexican-origin women caregivers. Gerontologist, 57, 1084–1092. doi:10.1093/geront/gnw090. Evidence Level IV.

Archbold, P. G., Stewart, B. J., Greenlick, M. R., & Harvath, T. A. (1990). Mutuality and preparedness as predictors of caregiver role strain. Research in Nursing & Health, 13(6), 375–384. doi:10.1002/nur.4770130605. Evidence Level II.

Archbold, P. G., Stewart, B. J., Greenlick, M. R., & Harvath, T. A. (1992). Clinical assessment of mutuality and preparedness in family caregivers to frail older people. In S. G. Funk, E. M. Tornquist, M. T. Champagne, & L. A. Copp (Eds.), Key aspects of elder care (pp. 332–337). New York, NY: Springer Publishing Company. Evidence Level II.

Archbold, P. G., Stewart, B. J., Miller, L. L., Harvath, T. A., Greenlick, M. R., Van Buren, L., … Schook, J. E. (1995). The PREP system of nursing interventions: A pilot test with families caring for older members. Preparedness (PR), enrichment (E) and predictability (P). Research in Nursing & Health, 18(1), 3–16. doi:10.1002/nur.4770180103. Evidence Level II.

Belle, S. H., Burgio, L., Burns, R., Coon, D., Czaja, S. J., -Gallagher-Thompson, D., … Zhang, S; Resources for Enhancing Alzheimer’s Caregiver Health (REACH) II Investigators. (2006). Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: A randomized, controlled trial. Annals of Internal Medicine, 145(10), 727–738. doi:10.7326/0003-4819-145-10-200611210-00005. Evidence Level II.

Boltz, M., Kuzmik, A., Resnick, B., Trotta, R., Mogle, J., BeLue, R., … Galvin, J. E. (2018). Reducing disability via a family centered intervention for acutely ill persons with Alzheimer’s disease and related dementias: Protocol of a cluster-randomized controlled trial (Fam-FFC study). Trials, 19(1), 496. doi:10.1186/s13063-018-2875-1. Evidence Level I.

Bowers, B. J. (1987). Intergenerational caregiving: Adult caregivers and their aging parents. Advances in Nursing Science, 9(2), 20–31. doi:10.1097/00012272-198701000-00006. Evidence Level IV.

Brodaty, H., Green, A., & Koschera, A. (2003). Meta-analysis of psychosocial interventions for caregivers of people with dementia. Journal of the American Geriatrics Society, 51(5), 657–664. doi:10.1034/j.1600-0579.2003.00210.x. Evidence Level I.

Browne, C. V., Ka’opua, L. S., Jervis, L. L., Alboroto, R., & Trockman, M. L. (2017). United States indigenous populations and dementia: Is there a case for culture-based psychosocial interventions? Gerontologist, 57, 1011–1019. doi:10.1093/geront/gnw059. Evidence Level V.

Buckwalter, K. C., Gerdner, L., Kohout, F., Hall, G. R., Kelly, A., Richards, B., & Sime, M. (1999). A nursing intervention to decrease depression in family caregivers of persons with dementia. Archives of Psychiatric Nursing, 13(2), 80–88. doi:10.1016/S0883-9417(99)80024-7. Evidence Level II.

Cantor, M. H., & Little, V. (1985). Aging and social care. In R. H. Binstock & E. Shanas (Eds.), Handbook of aging and the social sciences (2nd ed., pp. 745–781). New York, NY: Van Nostrand Reinhold. Evidence Level V.

Cohen, S. A., Cook, S. K., Sando, T. A., Brown, M. J., & Longo, D. R. (2017). Socioeconomic and demographic disparities in caregiving intensity and quality of life in informal caregivers: A first look at the National Study of Caregiving. Journal of Gerontological Nursing, 43(6), 17–24. doi:10.3928/00989134-20170224-01. Evidence Level IV.

Cook, S. K., & Cohen, S. A. (2018). Sociodemographic disparities in adult child informal caregiving intensity in the United States: Results from the New National Study of Caregiving. Journal of Gerontological Nursing, 44, 15–20. doi:10.3928/00989134-20180808-05. Evidence Level V.

Cook, S. K., Snellings, L., & Cohen, S. A. (2018). Socioeconomic and demographic factors modify observed relationship between caregiving intensity and three dimensions of quality of life in informal adult children caregivers. Health & Quality of Life Outcomes, 16, 169. doi:10.1186/s12955-018-0996-6. Evidence Level IV.

Croog, S. H., Burleson, J. A., Sudilovsky, A., & Baume, R. M. (2006). Spouse caregivers of Alzheimer patients: Problem responses to caregiver burden. Aging & Mental Health, 10(2), 87–100. doi:10.1080/13607860500492498. Evidence Level IV.

Cuellar, N. G. (2002). A comparison of African American & -Caucasian American female caregivers of rural, post-stroke, bedbound older adults. Journal of Gerontological Nursing, 28(1), 36–45. doi:10.3928/0098-9134-20020101-08. Evidence Level IV.

Dilworth-Anderson, P., Williams, I. C., & Gibson, B. E. (2002). Issues of race, ethnicity, and culture in caregiving research: A 20-year review (1980–2000). The Gerontologist, 42(2), 237–272. doi:10.1093/geront/42.2.237. Evidence Level I.

Elliott, A. F., Burgio, L. D., & Decoster, J. (2010). Enhancing caregiver health: Findings from the resources for enhancing Alzheimer’s caregiver health II intervention. Journal of the American Geriatrics Society, 58(1), 30–37. doi:10.1111/j.1532-5415.2009.02631.x. Evidence Level II.

Farran, C. J., Gilley, D. W., McCann, J. J., Bienias, J. L., Lindeman, D. A., & Evans, D. A. (2004). Psychosocial interventions to reduce depressive symptoms of dementia caregivers: A randomized clinical trial comparing two approaches. Journal of Mental Health and Aging, 10(4), 337–350. Evidence Level II.

Farran, C. J., Loukissa, D., Perraud, S., & Paun, O. (2003). Alzheimer’s disease caregiving information and skills. Part I: Care recipient issues and concerns. Research in Nursing & Health, 26(5), 366–375. doi:10.1002/nur.10101. Evidence Level IV.

Flannery, R. B., Jr. (2002). Disrupted caring attachments: Implications for long-term care. American Journal of Alzheimer’s Disease and Other Dementias, 17(4), 227–231. doi:10.1177/153331750201700407. Evidence Level VI.

Fredriksen-Goldsen, K. I., Kim, H.-J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C.P., … Petry, H. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle, WA: Institute for Multigenerational Health. Evidence Level V.

Geary, C. R., & Schumacher, K. L. (2012). Care transitions: Integrating transition theory and complexity science concepts. Advances in Nursing Science, 35, 236–248. doi:10.1097/ANS.0b013e31826260a5. Evidence Level VI.

Gitlin, L. N., Belle, S. H., Burgio, L. D., Czaja, S. J., Mahoney, D., Gallagher-Thompson, D., … Ory, M. G. (2003). Effect of multicomponent interventions on caregiver burden and depression: The REACH multisite initiative at 6-month follow-up. Psychology & Aging, 18(3), 361–374. doi:10.1037/0882-7974.18.3.361. Evidence Level I.

Gitlin, L. N., Winter, L., Dennis, M. P., Hodgson, N., & Hauck, W. W. (2010). A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: The COPE randomized trial. Journal of the American Medical Association, 22, 983–991. doi:10.1001/jama.2010.1253. Evidence Level II.

Goins, R. T., Spencer, S. M., McGuire, L. C., Goldberg, J., Wen, Y., & Henderson J. A. (2011). Adult caregiving among American Indians: The role of cultural factors. The Gerontologist, 51, 310–320. doi:10.1093/geront/gnq101. Evidence Level IV.

Haley, W. E., Gitlin, L. N., Wisniewski, S. R., Mahoney, D. F., Coon, D. W., Winter, L., … Ory, M. (2004). Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: Findings from the REACH study. Aging & Mental Health, 8(4), 316–329. doi:10.1080/13607860410001728998. Evidence Level II.

Harvath, T. A., Archbold, P. G., Stewart, B. J., Gadow, S., Kirschling, J. M., Miller, L., … Schook, J. (1994). Establishing partnerships with family caregivers: Local and cosmopolitan knowledge. Journal of Gerontological Nursing, 20(2), 29–35. doi:10.3928/0098-9134-19940201-07. Evidence Level V.

Lee, C. C., Czaja, S. J., & Schulz, R. (2010). The moderating influence of demographic characteristics, social support, and religious coping on the effectiveness of a multicomponent psychosocial caregiver intervention in three racial ethnic groups. Journals of Gerontology. Series B, Psychological Sciences & Social Sciences, 65B(2), 185–194. doi:10.1093/geronb/gbp131. Evidence Level II.

Messecar, D. C., Parker Walsch, C., & Lindauer, A. (2011). Family caregiving. In V. Hirth (Ed.), Case-based geriatrics: A global approach (pp. 225–243). Burr Ridge, IL: McGraw-Hill. Evidence Level VI.

Messecar, D. C., Powers, B. A., & Nagel, C. L. (2008). The Family Preferences Index: Helping family members who want to participate in the care of a hospitalized older adult. American Journal of Nursing, 108(9), 52–59. doi:10.1097/01.NAJ.0000334527.52341.bd. Evidence Level VI.

Moon, M. (2017). The unprepared caregiver. The Gerontologist, 57(1), 26–31. doi:10.1093/geront/gnw080. Evidence Level V.

National Academies of Sciences, Engineering, and Medicine. (2016). Families caring for an aging America. Washington, DC: The National Academies Press. Evidence Level I.

National Alliance for Caregiving & American Association of Retired Persons. (2015). Caregiving in the U.S. Bethesda, MD: National Alliance for Caregiving. Evidence Level IV.

Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J., … Williams, M. V. (2017). Components of comprehensive and effective transitional care. Journal of the American Geriatrics Society, 65, 1119–1125. doi:10.1111/jgs.14782. Evidence Level IV.

Onega, L. L. (2018). The Modified Caregiver Strain Index (MCSI). Retrieved from https://consultgeri.org/try-this/general-assessment/issue-14. Evidence Level V.

Penning, M. J. (1990). Receipt of assistance by elderly people: Hierarchical selection and task specificity. The Gerontologist, 30, 220–227. doi:10.1093/geront/30.2.220. Evidence Level IV.

Pinquart, M., & Sörensen, S. (2003). Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. Psychology and Aging, 18(2), 250–267. doi:10.1037/0882-7974.18.2.250. Evidence Level I.

Pinquart, M., & Sörensen, S. (2004). Associations of caregiver stressors and uplifts with subjective well-being and depressive mood: A meta-analytic comparison. Aging & Mental Health, 8(5), 438–449. doi:10.1080/13607860410001725036. Evidence Level I.

Pinquart, M., & Sörensen, S. (2006a). Gender differences in caregiver stressors, social resources, and health: An updated meta-analysis. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 61(1), P33–P45. doi:10.1093/geronb/61.1.p33. Evidence Level I.

Pinquart, M., & Sörensen, S. (2007). Correlates of physical health of informal caregivers: A meta-analysis. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 62(2), P126–P137. doi:10.1093/geronb/62.2.p126. Evidence Level I.

Pruchno, R. A., & Resch, N. L. (1989). Mental health of caregiving spouses: Coping as mediator, moderator, or main effect? Psychology and Aging, 4(4), 454–463. doi:10.1037/0882-7974.4.4.454. Evidence Level I.

Pusey, H., & Richards, D. (2001). A systematic review of the effectiveness of psychosocial interventions for carers of people with dementia. Aging & Mental Health, 5(2), 107–119. doi:10.1080/13607860120038302. Evidence Level I.

Rabarison, K. M., Bouldin, E. D., Bish, C. L., McGuire, L. C., -Taylor, C. A., & Greenlund, K. J. (2018). The economic value of informal caregiving for persons with dementia: Results from 38 states, the District of Columbia, and Puerto Rico, 2015 and 2016 BRFSS. American Journal of Public Health, 108(10), 1370–1377. doi:10.2105/AJPH.2018.304573. Evidence Level I.

Riffin, C., Van Ness, P. H., Wolff, J. L., & Fried, T. (2019). Multifactorial examination of caregiver burden in a national sample of family and unpaid caregivers. Journal of the American Geriatrics Society, 67(2), 277–283. doi:10.1111/jgs.15664. Evidence Level II.

Roth, D. L., Dilworth-Anderson, P., Huang, J., Gross, A. L., & Gitlin, L. N. (2015). Positive aspects of family caregiving for dementia: Differential item functioning by race. Journals of Gerontology Series B-Psychological Sciences & Social Sciences, 70, 813–819. doi:10.1093/geronb/gbv034. Evidence Level IV.

Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality: The caregiver health effects study. Journal of the American Medical Association, 282(23), 2215–2219. doi:10.1001/jama.282.23.2215. Evidence Level II.

Schumacher, K. L. (1995). Family caregiver role acquisition: Role-making through situated interaction. Scholarly Inquiry for Nursing Practice, 9(3), 211–226. Evidence Level IV.

Schumacher, K. L., Beck, C. A., & Marren, J. M. (2006). Family caregivers: Caring for older adults, working with their families. American Journal of Nursing, 106(8), 40–49. doi:10.1097/00000446-200608000-00020. Evidence Level VI.

Schumacher, K. L., Beidler, S. M., Beeber, A. S., & Gambino, P. (2006). A transactional model of cancer family caregiving skill. Advances in Nursing Science, 29(3), 271–286. Retrieved from https://journals.lww.com/advancesinnursingscience/Abstract/2006/07000/A_Transactional_Model_of_Cancer_Family_Caregiving.9.aspx. Evidence Level II.

Schumacher, K. L., Koresawa, S., West, C., Hawkins, C., Johnson, C., Wais, E., … Miaskowski, C. (2002). Putting cancer pain management regimens into practice at home. Journal of Pain and Symptom Management, 23(5), 369–382. doi:10.1016/S0885-3924(02)00385-8. Evidence Level IV.

Schumacher, K. L., Stewart, B. J., Archbold, P. G., Dodd, M. J., & Dibble, S. L. (2000). Family caregiving skill: Development of the concept. Research in Nursing & Health, 23(3), 191–203. doi:10.1002/1098-240X(200006)23:33.0.CO;2-B. Evidence Level IV.

Sörensen, S., Pinquart, M., & Duberstein, P. (2002). How effective are interventions with caregivers? An updated meta-analysis. The Gerontologist, 42(3), 356–372. doi:10.1093/geront/42.3.356. Evidence Level I.

Tennstedt, S. L., McKinlay, J. B., & Sullivan, L. M. (1989). Informal care for frail elders: The role of secondary caregivers. The Gerontologist, 29(5), 677–683. doi:10.1093/geront/29.5.677. Evidence Level IV.

Vitaliano, P. P., Zhang, J., & Scanlan, J. M. (2003). Is caregiving hazardous to one’s physical health? A meta-analysis. Psychological Bulletin, 129(6), 946–972. doi:10.1037/0033-2909.129.6.946. Evidence Level I.

Protocols

Symptoms

More Information