Emotional and physical health of spouse caregivers of persons with Alzheimer’s disease and stroke

Emotional and physical health of spousecaregivers of persons with Alzheimer'sdisease and stroke

Lore K. Wright PhD RN CS

Professor and Chair, Department of Mental Health-Psychiatric Nursing,

School of Nursing, Medical College of Georgia, Augusta, Georgia

Joanne V. Hickey PhD RN CS FAAN

Professor, School of Nursing, University of Texas-Houston, Houston, Texas

Kathleen C. Buckwalter PhD RN FAAN

Professor, College of Nursing and Associate Provost for Health Sciences,

University of Iowa, Iowa City, Iowa

Shirley A. Hendrix MSN RN

Clinical Nurse Specialist, College of Nursing, Medical University

of South Carolina, Charleston, South Carolina

and Teresa Kelechi MSN RN

Clinical Nurse Specialist, Center for the Study of Aging,

Medical University of South Carolina, Charleston, South Cardina, USA

Accepted for publication 4 November 1998

WRIGHT K.L.,WRIGHT K.L., HICKEYHICKEY J.V.,J.V., BUCKWALTERBUCKWALTER K.C.,K.C., HENDRIXHENDRIX S.A. &S.A. & KELECHIKELECHI T. (1999)T. (1999)

Journal of Advanced Nursing 30(3), 552±563

Emotional and physical health of spouse caregivers of persons

with Alzheimer's disease and stroke

Providing care for a cognitively impaired spouse can adversely affect caregivers'

health. It is not known how early in the caregiver's `career' emotional and

physical health deteriorates. The progressive deterioration associated with

Alzheimer's disease (AD) may have different effects on caregivers' health when

compared with the potential recovery following a stroke. An exploratory study

was conducted with 42 couples, equally divided among early phase AD,

ischaemic stroke after hospital discharge, and well controls. Couples were

evaluated at baseline (time 1), 6 months (time 2) and 1 year (time 3). At time 1,

depression was signi®cantly higher in AD and stroke caregivers when compared

to controls. Over time, depression increased signi®cantly for AD caregivers with

21% evidencing moderate to severe depression at time 1 and 50% at time 3. For

stroke caregivers there was a signi®cant interaction effect with race: white stroke

caregivers' depression increased over time while African American stroke

caregivers' depression decreased. Physical health was not signi®cantly different

for the three groups and remained stable over time. Cognitive and functional

impairment levels of care recipients were signi®cantly related to stroke

Correspondence: Dr Lore K. Wright, School of Nursing, EB-100,

Medical College of Georgia, Augusta, Georgia, 30912-4220.

Journal of Advanced Nursing, 1999, 30(3), 552±563 Issues and innovations in nursing practice

552 Ó 1999 Blackwell Science Ltd

caregivers' but not AD caregivers' depression. Long-term counselling and

support to family caregivers is advocated.

Keywords: Alzheimer's disease, dementia, stroke, caregiving, carer, spouses,

depression, health, illness trajectory, longitudinal

INTRODUCTION

Providing care for a cognitively and functionally impaired

spouse can adversely affect the caregiver's emotional and

physical health (Wright et al. 1993, Schulz et al. 1995,

Carers National Association 1997). Few researchers,

however, have documented how early in the caregiver's

`career' negative health consequences occur, and whether

emotional and physical health continues to decline over

time, as well as whether caregiving responsibilities asso-

ciated with different illnesses have similar or different

effects on caregivers' health (Schulz & Williamson 1991,

Pearlin 1992). This longitudinal study was designed to

explore the course of caregivers' emotional and physical

health at the beginning and along two divergent illness

trajectories: Alzheimer's disease (AD) and stroke.

Many behavioural disturbances in AD and stroke

victims are similar, but caregiving responsibilities along

these two trajectories diverge. AD is characterized by

irreversible, progressive cognitive and functional decline

leading to loss of mutual give and take between spouses

and increasing caregiver responsibilities over time. A

stroke, by contrast, results in sudden cognitive and

functional disabilities, but unlike persons af¯icted with

AD, 50±75% of stroke victims can recover to some degree,

and most of the recovery tends to occur during the ®rst 6

months following an acute stroke (Gresham et al. 1995,

Hickey 1997). This recovery is likely to result in regaining

reciprocal exchanges between spouses and decreased

caregiving responsibilities over time (Wright et al. 1995).

The focus of this study was on loss experienced by

caregivers whose spouses were af¯icted with AD or who

had suffered a stroke (for ease of reference, the terms AD

caregivers and stroke caregivers will be used throughout

this paper). A spouse's diagnosis of AD or stroke leads to

losses such as no longer being able to count on the

partner's help or mutual give and take in daily interac-

tions. This loss is different from grief associated with the

death of a spouse because a cognitively impaired spouse's

dependency needs can extend over many years and

increase or ¯uctuate over time. Although many caregiving

responses have been documented, reactions of interest in

this study were dysphoric moods which may escalate to

depression and over time affect physical health (Kiecolt-

Glaser et al. 1991). With AD caregiving, loss continues,

and caregivers' emotional health can be expected to

decline over time. With stroke caregiving, loss may abate,

and improvement in caregivers' emotional health can be

expected. Given the focus on early phases of the

caregiver's career in this study, negative physical health

consequences for caregivers were not expected to be

evident; they are more likely to occur at later points in

the caregiver's career.

Previous studies

To date, simultaneous comparisons of AD and stroke

caregivers have been reported in only two studies, and in

these studies the early phase of each illness was not

targeted (Draper et al. 1992, Reese et al. 1994). In both

studies, there were no signi®cant differences between AD

and stroke caregivers in emotional health (psychological

morbidity or depression). However, the Reese et al. (1994)

study included a non-caregiver control group, and signif-

icantly higher depression scores in both caregiver groups

were found compared to the control group. Physical

health indicators (a questionnaire in the Draper et al.

study and immunological measures in the Reese et al.

study) showed no differences between AD and stroke

caregivers or controls. For rates of illness, 46% of care-

givers reported signi®cant psychiatric morbidity, and 45%

rated their physical health as fair or poor in the Draper

et al. (1992) study. Reese et al. (1994) did not report how

many caregivers were depressed or rated their health as

fair or poor.

The majority of studies focusing exclusively on either

AD or stroke caregivers' emotional and physical health

have been cross-sectional. For dementia caregivers,

reported rates of depression varied with type of sample

selection: 25% among randomly selected caregivers from

a central Alzheimer's disease registry (Neundorfer 1991);

36% among non-help-seeking caregivers versus 68%

among self-referred, help-seeking caregivers (Gallagher

et al. 1989); and 70% among caregivers with a previous

history of depression (Russo et al. 1995). Among stroke

caregivers, reported rates of depression have been

slightly lower, ranging from 11% to 37% (Wade et al.

1986, Schulz et al. 1988, Matson 1994). However, in a

later study, 42% of stroke caregivers had high depres-

sion scores 1 year post-infarct (Anderson et al. 1995).

Both stroke and dementia caregivers' rates of depression

are higher than the 2±4% of major depression observed

in the general populations of older adults (Gurland

1991).

Racial differences in depression among caregivers are

not well researched. Though limited, available studies

Issues and innovations in nursing practice AD stroke caregiver health

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(3), 552±563 553

suggest lower rates among African American than white

caregivers (Haley et al. 1995, Miller et al. 1995). It is not

known whether African American caregivers' depression

varies at different phases of the AD and stroke illness

trajectories.

Reports of caregivers' physical health show a wide range

(Stone et al. 1987, Wright et al. 1993). Based on United

States (US) national data, 44% of spouse caregivers above

age 65 perceived their health as poor in contrast to 30% of

same-aged peers in the US population (Stone et al. 1987).

In several studies, caregivers attributed a decline in health

to caregiving responsibilities. Black and Asian caregivers

and older women were more likely to report health

problems as a result of caregiving than white caregivers

and men (Silliman et al. 1986, Young & Kahana 1989,

Anderson et al. 1995, CNA 1997, National Alliance for

caregiving & American Association of Retired Persons

1997).

The progression from depression to declining physical

health was documented by Pruchno et al. (1990). The

researchers tested a causal structural model with 200

Alzheimer's disease spouse caregivers and found that for

female spouse caregivers, baseline depression predicted

physical health decline at 6 months follow-up, depression

at 6 months predicted decreased physical health at 12

months, but at no time was physical health a predictor of

depression.

In all of the studies quoted above, the care recipients'

cognitive and functional impairments Ð and hence

responsibilities of the caregiver Ð varied widely. A link

between problem behaviours in care recipients and poor

health status in caregivers has been reported in many

cross-sectional studies, but levels of cognitive impair-

ment, functional disabilities and length of time in the

caregiving role have not shown consistent correlations

with emotional and physical health in dementia or stroke

caregivers (Schulz et al. 1995). Results from longitudinal

studies are also con¯icting. Though tested, no changes in

dementia and stroke caregivers' emotional and/or physical

health have been reported by some researchers (Schulz

et al. 1990, Schulz & Williamson 1991, Wright 1994,

Archbold et al. 1995, Neundorfer et al. 1995), while others

observed improvement or decline depending on the care

recipients' stable or decreasing level of cognitive func-

tioning (Carnwath & Johnson 1987, Deimling 1991).

Length of time used to observe change in caregivers'

emotional and/or physical health ranged from 3 months to

2 years in these reports.

This study is unique in that the course of caregivers'

emotional and physical health at an early point of two

potentially divergent trajectories was explored. In

addition, caregivers' emotional and physical health was

contrasted with ®ndings from matched community

controls in order to examine more clearly the impact of a

spouse's illness. Based on conceptualizations of loss

associated with a spouse's early AD or post-ischaemic

stroke, divergent illness trajectories, and empirical

®ndings by Draper et al. (1992) and Reese et al. (1994),

the following hypotheses were posed:

· At baseline (time 1), depression is higher in AD and

stroke caregivers than community controls; however,

there is no difference in physical health for the three

groups.

· At 6 months (time 2) and 12 months (time 3), depres-

sion increases in AD caregivers and decreases in stroke

caregivers; physical health remains stable over time for

the three groups.

· At times 1, 2 and 3, illness characteristics of AD and

stroke care recipients (i.e. cognitive and functional

impairments) are related to caregivers' depression;

given the early phases of caregiving investigated in

this study, care recipients' illness characteristics have

no relationship to caregivers' physical health.

METHOD

Design and sample

This descriptive comparative study was longitudinal.

Face-to-face interviews were conducted in the couples'

homes or other agreed upon location at baseline (time 1)

and 6 months later (time 2). A follow-up phone interview

was conducted at 1 year (time 3).

A sample size of n� 42 couples (or 84 spouses) was

divided equally between three groups of couples: 14

couples (28 spouses) in the AD group, 14 couples (28

spouses) in the stroke group, and 14 well couples (28

spouses) representing community controls without care-

giving responsibilities.

A convenience sample of AD af¯icted spouses was

recruited from a university medical centre in the south-

eastern region of the United States where subjects had

undergone outpatient diagnostic work-ups and were

classi®ed as early phase probable Alzheimer's disease.

Cases with vascular dementia were excluded. The ®xed

interviews at entry into the study, baseline (time 1) data,

yielded a mean Mini Mental Status Examination

(MMSE) score of 21/30 (range 16 to 26) for AD af¯icted

spouses.

Mean age of AD caregivers was 67 (range 49±82); their

mean length of marriage was 39 years (range 6±57), mean

educational level 1 to 3 years of college (range middle

school to postgraduate), and mean incomes $2548 per

month (range $800 to P$3800). Seven AD caregivers were

male, seven female; two of the AD couples were black, and

all others were white.

Stroke victims were recruited sequentially from a

university medical centre which specialized in acute

stroke care. This medical centre was located in a different

L.K. Wright et al.

554 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(3), 552±563

city and state than the one used for AD subject recruit-

ment, but both centres were in the south-eastern region of

the United States. All subjects meeting study criteria and

willing to participate were entered into the study follow-

ing discharge from the hospital where they had received

treatment for an acute ischaemic stroke. Cases with speech

disabilities were excluded because of the anticipated

confounding effect on caregiving responsibilities. Baseline

(time 1) interviews, conducted approximately 3 months

after the stroke, yielded a mean MMSE score of 23/30

(range 12 to 30) for stroke victims.

Mean age of stroke caregivers was 64 (range 50±85);

their mean length of marriage was 35 years (range 9±52),

mean educational level high school (range elementary

school to undergraduate college completed), and mean

income over $1548 per month (range <$800 to P$3800).

Four stroke caregivers were male, 10 female; six couples in

this group were black and eight were white. Compared to

the AD group, the percentage of black couples was higher

in the stroke group.

`Well' control group spouses were recruited from age

strati®ed lists of various community organizations and

churches. Half of the control group subjects were recruited

within the geographical vicinity from which AD subjects

had been selected and half from the geographical vicinity

of stroke subjects. There were no signi®cant differences

among control group subjects based on recruitment loca-

tion. Both spouses of well (control group) couples were

interviewed, but to preserve independence of sample

selection when comparing them with AD and stroke

caregivers, data from only one spouse per well couple

were used. Well spouses were randomly selected, and in

the same male/female proportion as found in the caregiver

groups (61% female, 39% male). Table 1 lists information

on randomly selected as well as the total sample of well

spouses. Well controls were matched to AD and stroke

caregivers by age and length of marriage. In addition, well

spouses and AD caregivers were matched by education

and income. However, well spouses and stroke caregivers

were not well matched on education (P < 0á01) or income

(P < 0á01).

All subjects in the AD group completed the study, but

sample attrition between time 1 and time 2 was 50%

among stroke caregivers, and 21% among well controls.

There was no further attrition between times 2 and 3. The

researchers' inability to recontact subjects at time 2 was

due to the following: no phone and no response to

repeated written requests for an interview; not being at

home despite a pre-arranged interview time; moving

without leaving a forwarding address; and re-hospitalization

Table 1 Sample characteristics at time 1

AD

caregivers

(n = 14)

Stroke

caregivers

(n = 14)

Well spouses

(n = 14) AD care

recipients

(n = 14)

Stroke care

recipients

(n = 14)Ra (n = 14) Male (n = 14) Female (n = 14)

M (Range) M (Range) M (Range) M (Range) M (Range) M (Range) M (Range)

Age (years) 67á2 (49±82) 63á9 (50±85) 63á9 (49±81) 64á4 (49±81) 64á0 (49±87) 67á9 (50±84) 66á1 (56±78)

Educationb 6á0 (2±8) 3á5*(1±7) 5á1 (2±8) 6á1 (2±8) 5á3 (2±8) 5á4 (1±8) 3á1*(1±8)

Income/$Monthc 5á4 (2±8) 3á0*(1±8) 5á9 (2±8) 5á9 (2±8) 5á9 (2±8) 5á4 (2±8) 3á0*(1±8)

Years married 38á5 (6±57) 34á5 (9±52) 35á4 (1±52) 35á4 (1±52) 35á4 (1±52) 38á5 (6±57) 34á5 (9±52)

MMSE 21á3 (16±26) 22á6 (12±30)

AD symptom/months 33á9 (12±77)

Post-stroke/days 88á4 (58±121)

Gender (n) % (n) % (n) % (n) % (n) % (n) % (n) %

Female (7) 50 (10) 71 (9) 61 (14) 50 (14) 50 (7) 50 (4) 29

Male (7) 50 (4) 29 (5) 39 (14) 50 (14) 50 (7) 50 (10) 71

Ethnic background

White (12) 86 (8) 57 (12) 86 (12) 86 (12) 86 (12) 86 (8) 57

Black (2) 14 (6) 43 (2) 14 (2) 14 (2) 14 (2) 14 (6) 43

a Only one spouse per couple, randomly selected in same male/female proportion as caregivers.b Education based on OARS index: 1 = 0±4 years; 2 = 5±8 years; 3 = high school incomplete; 4 = high school complete; 5 = post school;

6 = 1±3 years college; 7 = 4 years college complete; 8 = postgraduate college.c Income based on the OARS index: 1 = <$800; 2 = $800±1299; 3 = $1300±1799; 4 = $1800±2299; 5 = $2300±2799; 6 = $2800±3299;

7 = $3300±3799; 8 =�$3800.

*P < 0á01.

Sample attrition at time 2 and time 3 did not signi®cantly change demographic characteristics.



of one stroke victim. There were no signi®cant statistical

differences between demographic characteristics of the full

sample and those who remained in the study.

Variables and instrumentation

Caregiver variablesCaregiver variables of interest in this study were depres-

sion, physical health, and background characteristics.

Depression represented reaction to loss and was measured

with the Short Zung Interviewer Assisted Depression

Scale (Tucker et al. 1986, 1987). This scale correlates

signi®cantly with other depression scales and has been

found to be a useful screening test for depression in

elderly patients in whom the diagnosis of depression was

con®rmed with a psychiatric interview (Tucker et al.

1986, 1987). The 10-item scale assesses depressed moods

over the past 2 weeks or longer with response options

ranging from 1� seldom or never to 4�most of the time.

Items are summed, divided by 40 and multiplied by 100 to

create a `Zung Index' (Zung 1973). Scores of <50 are

interpreted as no depression; 50±59 as mild depression,

which corresponds to the concept of dysphoria that is

of special interest in this study; 60±69 as moderate to

marked depression; and scores ³70 as severe depression.

The internal reliability coef®cient, Cronbach's alpha, for

the present sample was 0á79.

Physical health was measured with the short form of the

Multilevel Assessment Inventory (MAI) developed by

Lawton et al. (1982), who reported that the MAI correlates

signi®cantly with other physical health scales. This sum-

mated scale has a range of 27� excellent health to 8�poor

health. Items included: self-rated health; whether health

problems stop desired activities; absence or presence of

heart of circulatory problems; number of doctor visits and

days of hospitalization during the past year; and number

of medications taken per day. Cronbach's alpha for the

present sample was 0á77. All questions were administered

at times 1 and 2. At time 3, only self-rated health was

obtained. Self-rated health is considered a reliable,

racially unbiased indicator of objective health measures

(Liang 1986, Gibson 1991).

Background characteristics included age, education,

income, years married, gender and ethnic background.

These variables were assessed according to the OARS

questionnaire (Fillenbaum 1988). Length of time in the

caregiver role or since the onset of the spouse's illness also

was assessed.

Care recipient variablesCare recipient variables pertaining to illness characteris-

tics were cognitive status (MMSE) and functional impair-

ments related to activities of daily living (ADL) and

instrumental activities of daily living (IADL). The MMSE

is a widely used scale with good psychometric properties

(Folstein et al. 1975). A maximum score of 30 indicates

perfect memory; cut-off points for memory impairment are

24±21 depending on educational level (Anthony et al.

1982). ADL and IADL were based on the Older American

Resources and Services (OARS) questionnaire developed

by Fillenbaum (1988). Answers obtained from each care

recipient were validated by the caregiver. ADL and IADL

are widely used measures in caregiver research because

they provide indications of the ill person's dependency

needs. ADL consists of seven activities including feeding,

dressing, grooming, walking, and bathing; response

options are scaled from 0� totally dependent to 2�without help. Scores are summed yielding a possible

range of 0±14 (Fillenbaum 1988). IADL consists of seven

activities including telephoning, shopping and preparing

a meal; response options are scaled from 0� completely

unable to 2�without help. Scores are summed, yielding a

possible range of 0±14 (Fillenbaum 1988). Internal reli-

ability coef®cients for the present sample were alpha 0á89

for ADL and 0á85 for IADL.

In addition to care recipients' cognitive and functional

status, their physical health was assessed with the MAI

described above. Care recipients' answers were validated

by caregivers. Level of depression in care recipients was

assessed with the Short Zung scale described above. Care

recipients' answers were considered valid and reliable

even for those with a MMSE score of 12. This assumption

is based on previous research where subjects with mild or

moderate cognitive impairment accurately identi®ed and

named feelings (Wright 1993).

Procedures

All interviews were conducted by master's prepared

nurses who had been trained by the senior investigators.

At time 1 and 2, each couple was interviewed together for

demographic, cognitive and functional abilities, and

physical health information. (Interviews assessing depres-

sion, however, were conducted in separate rooms.) All

spouses, including AD af¯icted and stroke victims, signed

an informed consent prior to the ®rst interview. At times 1

and 2, each spouse received $20 ($40 per couple) for

participating in the study. At time 3, only caregivers and

well spouses (both husbands and wives) from the control

group participated. They were interviewed over the tele-

phone.

Statistical analysis

Descriptive statistics (mean, SDSD, percentages) were calcu-

lated as appropriate. The dependent variables depression,

MAI, and describe your health had approximately normal

distributions (skewness 0á734, )0á648, )0á594 and kurtosis

)0á083, )0á588, 0á098 respectively), supporting the use of

L.K. Wright et al.


analysis of variance (ANOVAANOVA) which is considered robust

even with small sample sizes (Munro 1997). To analyse

baseline group differences for depression and physical

health, one factor ANOVAANOVA and post-hoc t-tests with

Bonferroni corrections for multiple comparisons was

used. To analyse change over time for depression and

physical health, ANOVAANOVA with repeated measures and

post-hoc t-tests with Bonferroni corrections for multiple

comparisons was used. Additional descriptive (%) and

non-parametric (Wilcoxon signed rank test) analyses were

performed to examine depression of caregivers who had

been classi®ed as severely, moderately, mildly, or not

depressed. Pearson correlation coef®cients were used to

examine relationships between care recipient characteris-

tics and caregiver health variables.

RESULTS

Differences in depression and physical healthat baseline

Hypothesis 1, predicting baseline depression to be higher

for AD and stroke caregivers than community controls but

no difference in physical health among all three groups,

was supported. Mean scores for depression in AD care-

givers, stroke caregivers and controls were signi®cantly

different (Table 2). Post-hoc comparisons among means

with Bonferroni correction con®rmed the two caregiver

groups to be signi®cantly higher in depression than

controls (P < 0á02). There were no signi®cant differences

in measures of physical health for the summated measure

of physical health (MAI) and for the single item `describe

your health' for AD caregivers, stroke caregivers and

controls. Random selection of controls did not in¯uence

the ®ndings. There were no signi®cant differences

between those selected/not selected, and there were no

signi®cant differences between male and female well

spouses for these variables.

Change over time in depressionand physical health

Hypothesis 2, predicting increased depression at times 2

and 3 for AD caregivers, decreased depression for stroke

caregivers, and physical health to remain stable for all

three groups, was supported for physical health only. As

shown in Table 3, physical health remained stable over

time for all three groups, and there was no signi®cant

main effect. Depression scores of AD caregivers were

signi®cantly higher than for controls at all three times

(P < 0á02), but there was no signi®cant change over time

and no signi®cant interaction effect, indicating that stroke

caregivers did not signi®cantly decline in depression as

hypothesized. The high attrition rate among stroke care-

givers does not seem to have in¯uenced these ®ndings

since there were no signi®cant differences in baseline

levels of depression between drop-outs and subjects who

remained in the study (P < 0á22). Random selection of

controls did not in¯uence the ®ndings. There was no

signi®cant change over time for those selected/not select-

ed, and male and female well spouses did not change

signi®cantly over time in depression and health.

Given the exploratory nature of this study and the fact

that mean depression scores obscure the number of

subjects who can be classi®ed as having severe, moderate,

mild (dysphoria) or no depression, additional analyses

were conducted to examine possible differences between

groups. Table 4 provides a breakdown of the percentage of

AD and stroke caregivers and randomly selected controls

whose depression scores at time, 1, 2 and 3 were classi®ed

according to established criteria of the Zung Index.

Table 5 compares scores from all control group spouses.

As shown in Table 4, severe and moderate depression

was absent among randomly selected controls. For AD and

stroke caregivers, severe depression was reported by a

small percentage of AD caregivers at all three times and by

stroke caregivers at time 3 only. Moderate depression

Table 2 Baseline (time 1) values of depression and physical health for AD and stroke spouse caregivers and well spouses

Group I Group II Group III

AD caregivers Stroke caregivers Well spousesa 1 Factor ANOVAANOVA

(n = 14) (n = 14) (n = 14) F (2,39) P

Short Zung Depression Index M (SDSD) M (SDSD) M (SDSD)

(possible range 25±100) 45á55 (14á75)* 45á54 (13á16)* 33á75 (7á95) 4á289 <0á02

Physical health Ð MAI

(possible range 8±27) 22á36 (3á39) 22á21 (3á33) 22á79 (3á58) 0á105 >0á02

Describe health

(possible range 1±4) 3á14 (0á66) 2á64 (0á84) 3á21 (0á58) 2á744 >0á02

a Only one spouse per couple, randomly selected in same male/female proportion as caregivers. Male and female well spouses did not

differ signi®cantly on variables shown.

*P < 0á02 post-hoc, with Bonferroni correction for multiple comparisons, I, II > III.



showed a steady increase among AD caregivers but a

steady decrease for stroke caregivers even when only those

stroke caregivers who remained in the study are used for

comparison. Over the period of 1 year, the combined

percentage of moderate and severe depression increased

from 21% (n� 3) to 50% (n� 7) among AD caregivers

(P� 0á05). The category mild depression, synonymous

with dysphoria, showed a shift to higher depression levels

among AD but not stroke caregivers.

Table 5, which compares all well husbands and wives

from the control group, shows that two female well

spouses (18%) were mildly depressed at times 1 and 2,

while at time 3, one female (9%) and one male (9%) well

spouse were mildly depressed. Only one female well

Table 3 Changes in depression and physical health for AD and stroke spouse caregivers and well spouses at times 1, 2, and 3

Group I Group II Group III ANOVAANOVA repeated

AD caregivers Stroke caregivers Well spousesa measuresb

(n = 14) (n = 7) (n = 11)

Time 1 Time 2 Time 3 Time 1 Time 2 Time 3 Time 1 Time 2 Time 3

M M M M M M M M M

(SDSD) (SDSD) (SDSD) (SDSD) (SDSD) (SDSD) (SDSD) (SDSD) (SDSD) F(2,29) P

Short Zung 45á55* 48á77* 52á14* 41á07 39á29 41á43 35á00 32á73 34á0 A) 4á697 <0á02

Depression

index

(14á75) (17á81) (18á32) (14á64) (13á21) (14á99) (8á29) (3á62) (6á73) B) 1á144 >0á02

AB) 0á888 >0á02

Physical health 22á36 22á00 ± 23á00 21á86 ± 22á82 22á36 ± A) 0á043 >0á02

(MAI) (3á39) (3á98) (3á65) (5á15) (3á37) (3á85) B) 1á101 >0á02

AB) 0á167 >0á02

Describe health 3á14 3á21 2á93 3á00 2á71 3á14 3á36 3á00 3á09 A) 0á179 >0á02

(0á66) (0á70) (0á92) (0á82) (1á11) (0á69) (0á51) (1á00) (0á70) B) 1á199 >0á02

AB) 1á788 >0á02

a Only one spouse per couple, randomly selected in same male/female proportion as caregivers. Separate analyses of the total sample of

male and female well spouses no signi®cant changes over time for variables shown.b ANOVAANOVA repeated measures: A = group effect; B = time effect; AB = group ´ time.

* P < 0á02 post-hoc, with Bonferroni correction for multiple comparisons, I > III.

Table 4 Percentage of spouses evidencing mild, moderate or severe depression at baseline (T1), 6 months (T2), and 12 Months (T3)

AD caregiver

spouses

Stroke caregiver

spouses

Wella

spouses

T1 T2 T3 [T1] T1 T2 T3 [T1] T1 T2 T3

Level of depression (n = 14) (n = 14) (n = 14) [n = 14] (n = 7) (n = 7) (n = 7) [n = 14] (n = 11) (n = 11) (n = 11)

(Short Zung Index) % % % [%] % % % [%] % % %

Severe depression

(³70)

7 7b 7 [0] 0 0 14 [0] 0 0 0

Moderate depression

(60±69)

14 22c 43 [22] 29 14 0 [0] 0 0 0

Mild depression

(50±59)

22c 29d 7 [22] 0 0 0 [7c] 0 0 0

Not depressed

(<50)

57 42c 43 [56] 71 86 86 [93] 100 100 100

Total 100 100 100 [100] 100 100 100 [100] 100 100 100

[ ] Baseline (T1) sample before drop-outs.a Only one spouse per couple, randomly selected in same male/female proportion as caregivers.b one subject on anti-anxiety medication; c one subject on antidepressant medication; d two subjects on antidepressant medication.

L.K. Wright et al.


spouse (9%) could be classi®ed as moderately depressed

(time 3), and at no time did well spouses evidence severe

depression. The majority were not depressed. As previ-

ously noted, depression did not change signi®cantly over

time for well group spouses, even though a slight

difference in pattern can be noted when comparing all

husbands and wives from the well group instead of

randomly selected spouses used for comparisons with

AD and stroke caregivers.

The pattern observed in the `not depressed' category is

of clinical relevance: over time, fewer AD caregivers were

asymptomatic but more stroke caregivers became asymp-

tomatic. This occurred despite the fact that 29% of AD

caregivers but no stroke caregivers were receiving anti-

depressant medication.

An additional analysis focused on possible racial dif-

ferences in depression because 43% of stroke caregivers in

this study were African American, and previous research

by Haley et al. (1995) and Miller et al. (1995) had docu-

mented racial differences in caregiver depression. (Among

AD caregivers and controls, only two subjects per group

were black; therefore, no additional analyses were

conducted for these sub-groups.) Figure 1 shows levels

of depression for all three groups without racial contrasts

(for subjects who remained in the study). The previously

discussed lower levels of depression for stroke versus AD

caregivers can be seen. Figure 2 shows racial comparisons

for only the stroke group and only for those stroke

caregivers who had remained in the study. A signi®cant

interaction effect (P < 0á05) became evident. Black stroke

caregivers reported higher depression at baseline (time 1)

but lower depression by time 2 and then remained stable.

White stroke caregivers, by contrast, were lower in

depression than black stroke caregivers at baseline but

then showed a steady increase in depression. By time 3,

their level of depression approaches that of AD caregivers.

Whether these observed differences in depression could

be confounded with socio-economic status was examined.

At time 1, education was found to be related to stroke

caregivers' depression (r�)0á54, P < 0á05), but income

did not reach signi®cance. By times 2 and 3, education

and income showed no signi®cant relationship with

depression. (Among AD caregivers, neither education

nor income were related to depression.)

Care recipients' illness characteristics andcaregivers' depression and physical health

Hypothesis 3, predicting signi®cant relationships between

care recipients' illness characteristics and caregivers'

depression but no relationships to caregivers' physical

health, was only partially supported. At time 1, the care

recipients' lower MMSE and IADL scores (indicating a

higher level of functional impairment) were related to

Table 5 Comparing both spouses from the well group at time 1 [T1], total sample and after drop-outs (T1, T2, T3)

[T1]

[n = 14]

T1

n = 11

T2

n = 11

T3

n = 1

%

Male

%

Female

%

Male

%

Female

%

Male

%

Female

%

Male

%

Female

Severe depression (³70) [0] [0] 0 0 0 0 0 0

Moderate depression (60±69) [0] [0] 0 0 0 0 0 9

Mild depression (50±59) [0] [14a] 0 18a 0 18 9 9

Not depressed (<50) [100] [86] 100 82 100 82 91 82

Total 100 100 100 100 100 100 100 100

[ ] Baseline (T1) sample before drop-outs.a One female spouse on antidepressant medication.

Figure 1 Changes in depression between AD and stroke careg-

ivers. d, AD caregivers (n = 14); j, stroke caregivers (n = 7);

m, controls (n = 11).



stroke caregivers' depression (r�)0á63, P < 0á05 and

r�)0á52, P < 0á05 respectively). At time 2, care recipients'

lower ADL and IADL were related to stroke caregivers'

depression (r�)0á86, P < 0á01 and r�)0á90, P < 0á01

respectively). However, at time 3 there were no signi®cant

correlations between illness characteristics of care

recipients and stroke caregivers' depression. Furthermore,

no signi®cant correlations were found between AD care

recipients' illness characteristics and AD caregivers'

depression at times 1, 2 or 3.

Contrary to the hypothesis, some signi®cant relation-

ships between illness characteristics of care recipients and

AD and stroke caregivers' physical health were found. At

time 1, higher ADL and higher IADL levels (indicating less

functional impairment) and less depression in ill spouses

were related to higher levels of stroke caregivers' physical

health (r�)0á52, P < 0á05 and r�)0á53, P < 0á05 and

r�)0á65, P < 0á01 respectively). At time 2, ADL and IADL

levels in ill spouses correlated positively with AD care-

givers' physical health (r�)0á69, P < 0á01 and r�)0á55,

P < 0á05 respectively). There were no signi®cant relation-

ships at time 3.

DISCUSSION

The results of this longitudinal exploratory study begin to

shed light on changes in spouse caregivers' emotional and

physical health along two divergent illness trajectories. It

appears that AD and stroke caregiving have different

consequences, yet there are also similarities.

AD spouse caregivers experienced high levels of depres-

sion even in the early phase of the AD trajectory. This very

likely re¯ects the impact of a devastating diagnosis and

uncertainty about the future. Furthermore, rates of moder-

ate to severe depression among AD caregivers increased

from 21% (n� 3) at time 1 to 50% (n� 7) over the period of 1

year, even though 29% (n� 4) of AD caregivers reported

taking antidepressant medications. These ®ndings support

the initial conceptualization of loss experienced by spouse

caregivers along the progressively worsening AD trajectory.

In this study, AD caregivers experienced higher levels and

rates of depression than stroke caregivers, which is incon-

sistent with reports by Draper et al. (1992) and Reese et al.

(1994), who found no signi®cant differences in depression

between AD and stroke caregivers. However, in the Draper

et al. (1992) study, length of time in the caregiving role

ranged from < 1 to 10 years for dementia caregivers and from

< 1 to >31 years for stroke caregivers. In the Reese et al.

(1994) study, time since the spouses' diagnosis was close to

4 years for both groups of caregivers. Thus, possible early

effects on caregivers' depression were obscured.

Stroke caregivers' depression in this study appears to

follow a different pattern than that observed for AD care-

givers, although comparisons are complicated by the fact

that 50% of stroke caregivers could not be re-evaluated at

times 2 and 3. Statistically, there were no signi®cant

differences in level of depression between drop-outs and

those remaining in the study, but those with mild depres-

sion were lost at a higher rate than not depressed stroke

caregivers. When comparing only those stroke caregivers

who remained in the study, over time, their depression

appeared to abate. Rates of moderate to severe depression

decreased from 29% to 14% over the period of 1 year,

an no stroke caregiver reported taking antidepressant

medications. This seems to support the potential recovery

trajectory following a spouse's stroke and the regaining of

hope for a mutual give and take relationship.

However, Carnwath and Johnson (1987) reported that

the proportion of depressed spousal stroke caregivers

increased over time, rising from approximately 11% at 3

months post-stroke to 18% at 9 months and to 36% at

15 months, a time frame comparable to that of the

present study. On the other hand, ®ndings by Schulz

et al. (1988), are similar to those of the present study.

Beginning with 7 weeks post-stroke, 33% of stroke

caregivers in the Schulz et al. study were found to be

depressed, and although mean levels of depression did

not change signi®cantly over time, there was great

individual variation. Some stroke caregivers with initial

high levels of depression decreased to normal levels

over 6 months; others with initially low levels of

depression increased over time. This shifting of depres-

sion among individual stroke caregivers also can be

noted in the present study (Table 4): at time 3, one

stroke caregiver (14%) reached severe levels of depres-

sion, while others were no longer depressed.

In the Schulz et al. (1988) study, only 14% of stroke

caregivers were non-white subjects, and racial differences

Figure 2 Changes in depression over a period of 1 year for black

and white stroke caregivers. d, black stroke caregivers (n = 3); j,

white stroke caregivers (n = 4).

L.K. Wright et al.


in depression were not examined. Based on ®ndings in

this study, depression in African American stroke care-

givers may assume a different pattern. The intriguing

®ndings shown in Figure 2 need to be viewed as prelim-

inary because of the sample size. Studies with larger

samples where AD and stroke groups are matched by race

and socio-economic status, are needed. However, even

with this exploratory study, distinct differences between

AD and stroke caregivers' depression can be noted when

race is not considered (Figure 1). With racial contrasts,

available only for the stroke group, black stroke caregivers'

depression was higher at time 1, then decreased and

stabilized over time (Figure 2). White stroke caregivers'

depression, by contrast, continued to rise and by time 3

their level of depression was approaching that of AD

caregivers. This would suggest that race and ethnic

background contribute to stroke caregivers' adaptation

over time and may be more important than the care

recipient's illness characteristics.

Lower levels of depression among African American

versus white caregivers have been reported previously for

dementia caregivers (Haley et al. 1995, Miller et al. 1995).

Because this ®nding has implications for service provi-

sions, future studies with larger samples are needed to

permit testing the in¯uence of race and socio-economic

status using multivariate techniques.

In this study, care recipients' early phase cognitive

impairment (MMSE) and functional declines (ADL and

IADL) were not correlated with AD caregivers' depression.

However, signi®cant correlations between stroke care

recipients' impairments and stroke caregivers' depression

were observed (at time 1 for MMSE and IADL and at time 2

for ADL and IADL). At time 1, approximately 3 months

into the stroke trajectory, spouse caregivers were most

likely to be experiencing the full brunt of the care

recipients' impairment. By time 2 (9 months post-stroke),

little additional improvement can be expected for stroke

victims (Hickey 1997). Thus, in situations where the care

recipient did not improve, we can speculate that the

hopelessness of the situation began to be realized.

By time 3 (15 months post-stroke), no relationships

between impairment characteristics and stroke caregivers'

depression were observed. The literature is equivocal in

this area. Findings from this study are consistent with that

of Anderson et al. (1995) who reported no signi®cant

relationship between caregivers' emotional illness and

stroke patients' physical disability 1 year post-stroke.

However, Carnwath and Johnson (1987), for a similar time

frame, reported signi®cant increases in rates of depres-

sion, and that depressed spouses cared for more severely

impaired stroke victims.

These seemingly contradictory observations may be

reconciled by re-de®ning the early stroke caregiving

trajectory and suggesting a branching into three potentially

different outcomes similar to those as suggested by Schulz

and Williamson (1991): (a) continuous improvement of

care recipients and improved caregiver emotional health

over time; (b) some residual impairment in care recipients

to which caregivers adapt; or (c) continuous decline in

care recipients with negative emotional and physical

health consequences for caregivers. Findings from this

study support the view that negative physical health

consequences may manifest at a later point in the care-

giving career, although ethnic background may play an

important role in adaptational response.

A cautionary note is necessary. In addition to the small

sample size of this study, the relatively low internal

reliability coef®cients for depression (alpha 0á79) and

physical health (alpha 0á77) may have obscured more

subtle health changes in the subjects. Alpha tends to the

in¯uenced by the number of items in each scale which

was 10 for the Short Zung Depression Index and 7 for the

MAI. Different measures could be used in future research.

Despite the acknowledged limitations, ®ndings from

this study suggest that interventions with caregivers need

to be targeted according to type and phase of an illness

trajectory. AD caregivers' depression warrants attention

even in the early phase of the spouse's illness. As yet, the

earliest diagnosis of probable Alzheimer's disease does

not take place until moths, sometimes even years, after

symptoms occur, symptoms that typically are denied or

ignored and only identi®ed retrospectively by the patient

and caregiver. Currently, routine genetic testing for

susceptibility genes is not recommended, but with greater

public awareness it may be possible to target `at risk'

individuals. Baseline data early in the AD illness

trajectory could be obtained, and counselling could be

provided to caregivers to ward off depression. Appropriate

psycho-pharmacological interventions need to be

carefully examined given that the caregiver with the

highest depression score in this study was receiving

anti-anxiety, not antidepressant, medication. However,

even with earlier identi®cation, long-term support and

treatment will be important. While initially AD caregivers'

physical health seems to remain stable and appears to be

more robust than emotional health, the cumulative effects

of prolonged depression on physical health have to be

considered. Long-term counselling should provide

anticipatory guidance about what the future holds,

develop the caregivers' ability to handle problem behav-

iours, and connect them to support services such as

respite care (Buckwalter et al. 1995).

Stroke caregivers' depression also warrants attention

in the early phase of the spouses' illness, that is in the

immediate post-stroke period when the caregivers' lives

have been suddenly and dramatically changed. The

intriguing ®ndings about stroke caregivers' race may

indicate a buffering effect inherent in the African

American culture which helps caregivers to accept and

adjust to the spouses' disabilities. During the recovery



phase and especially if the stroke victim does not

recover, all caregivers will need assistance with home

modi®cations to compensate for the spouses' disabili-

ties. When caregivers' emotional health is affected

(irrespective of race), counsellors can address coping

strategies for handling the stroke victims' irritability,

impatience, apathy or denial of de®cits (Williams 1994).

Mobilizing help from other family members or signi®-

cant others and assisting caregivers to connect with a

stroke support group are additional intervention strate-

gies. For both AD and stroke caregivers there is the risk

that with prolonged caregiving responsibilities, their

physical health will deteriorate. Perhaps by providing

early assessments and targeted interventions for their

emotional health, AD and stroke caregivers' physical

health can be maintained. Hopefully, this would

improve their quality of life as well as their stamina

to provide optimal care for an ill family member.

Acknowledgement

This study was supported by the National Alzheimer's

Association, Mary Sue Glover Memorial Pilot Research

Grant.

References

Archbold P.G., Stewart B.J., Miller L.L. et al. (1995) The PREP

system of nursing interventions: a pilot test with families

caring for older members. Research in Nursing and Health

18(1), 3±16.

Anderson C.S., Linto J. & Stewart-Wynne E.G. (1995) A popula-

tion-based assessment of the impact and burden of caregiving

for long-term stroke survivors. Stroke 26(5), 843±849.

Anthony J.C., LaResche L., Niaz U., von-Korff M.R. & Folstein

M.F. (1982) Limits of the `Mini-Mental State' as a screening test

for dementia and delirium among hospital patients. Psycholog-

ical Medicine 12(2), 397±408.

Buckwalter K.C., Weiler K. & Stolley J. (1995) Community

programs. In Geropsychiatric Nursing (Hogstel M.O. ed.),

Mosby, St Louis, Missouri, pp. 341±365.

Carers National Association (CNA) (1997) General election brief-

ing 1997. The Carer (Suppl.), March, CNA, 20/25 Glashouse

Yard, London, EC1A 4JS, England.

Carnwath T.C.M. & Johnson D.A.W. (1987) Psychiatric morbidity

among spouses of patients with stroke. British Medical Journal

294(6569), 409±411.

Deimling G.T. (1991) Respite use and caregiver well-being in

families caring for stable and declining AD patients. Journal of

Gerontological Social Work 18(1±2), 117±134.

Draper B.M., Poulos C.J., Cole A., Poulos R.G. & Ehrlich F. (1992)

A comparison of caregivers for elderly stroke and dementia

victims. Journal of the American Geriatrics Society 40(9),

896±901.

Fillenbaum G.G. (1988) Multidimensional Functional Assessment

of Older Adults. Lawrence Erlbaum, Hillsdale, New Jersey.

Folstein M.F., Folstein S.E. & McHugh P.R. (1975) Mini-Mental

State. Journal of Psychiatric Research 12(3), 189±198.

Gallagher D., Rose J., Rivera P., Lovett S. & Thompson L.W. (1989)

Prevalence of depression in family caregivers. The Gerontolo-

gist 29(4), 449±456.

Gibson R.C. (1991) Race and self-reported health of elderly

persons. Journal of Gerontology 46(5), S235±S242.

Gresham G.E., Duncan P.W., Stason W.B. et al. (1995) Post-Stroke

Rehabilitation: Assessment, Referral, and Patient Management.

Clinical Practice Guideline, No. 16. AHCPR Pub. No. 95-0663.

Department of Health and Human Services, Rockville, Maryland.

Gurland B. (1991) Epidemiology of psychiatric disorders. In

Comprehensive Review of Geriatric Psychiatry (Sadavoy J.,

Lazarus L.W. & Jarvik L.F. eds), American Psychiatric Press,

Washington, District of Columbia, pp. 25±40.

Haley W.E., West C.A.C., Wadley V.G. et al. (1995) Psychological,

social, and health impact of caregiving: a comparison of black

and white dementia family caregivers and noncaregivers.

Psychology and Aging 10(4), 540±552.

Hickey J.V. (1997) The Clinical Practice of Neurological and

Neurosurgical Disease 4th edn. J.B. Lippincott, Philadelphia.

Kiecolt-Glaser J.K., Dura J.R., Speicher C.E., Trask J. & Glaser R.

(1991) Spousal caregivers of dementia victims: longitudinal

changes in immunity and health. Psychosomatic Medicine

53(4), 345±362.

Lawton M.P., Moss M., Fulcomer M. & Kleban M.H. (1982) A

research and service oriented multilevel assessment instru-

ment. Journal of Gerontology 37(1), 91±99.

Liang J. (1986) Self-reported physical health among aged adults.

Journal of Gerontology 41(2), 248±160.

Matson N. (1994) Coping, caring and stress: a study of stroke

carers and carers of older confused people. British Journal of

Clinical Psychology 33(3), 333±344.

Miller B., Campbell R.T., Farran C.J., Kaufman J.E. & Davis L.

(1995) Race, control, mastery, and caregiver distress. Journal of

Gerontology 50B(6), S374±382.

Munro B.H. (1997) Statistical Methods for Health Care Research

3rd edn. J.B. Lippincott, Philadelphia.

National Alliance for Caregiving (NAC) and the American Asso-

ciation of Retired Persons (AARP) (1997) Family Caregiving in

the US Findings from a National Survey. AARP, Washington,

District of Columbia.

Neundorfer M.M. (1991) Coping and health outcomes in spouse

caregivers of persons with dementia. Nursing Research 40(5),

260±265.

Neundorfer M.M., Smyth K.A., Stuckey J.C. & Rechlin L.R. (1995)

Depression among spouse caregivers and the progression of

Alzheimer's disease. Poster presented at the annual meeting of

the Gerontological Society of America, Los Angeles, California,

November.

Pearlin L.I. (1992) The careers of caregivers. The Gerontologist

32(5), 647.

Pruchno R.A., Kleban M.H., Michaels J.E. & Dempsey N.P. (1990)

Mental and physical health of caregiving spouses. Journal of

Gerontology 45(5), P192±199.

Reese D.R., Gross A.M., Smalley D.L. & Messer S.C. (1994)

Caregivers of Alzheimer's disease and stroke patients:

immunological and psychological considerations. The Geron-

tologist 34(4), 534±540.

L.K. Wright et al.


Russo J., Vitaliano P.P., Brewer D.D., Katon W. & Becker J. (1995)

Psychiatric disorders in spouse caregivers of care recipients

with Alzheimer's disease and matched controls: a diathesis-

stress model of psychopathology. Journal of Abnormal

Psychology 104(1), 197±204.

Schulz R., O'Brien A.T., Bookwala J. & Fleissner, K. (1995)

Psychiatric and physical morbidity effects of dementia care-

giving: prevalence, correlates, and causes. The Gerontologist

35(6), 771±791.

Schulz R., Tompkins C.A. & Rau M.T. (1988) A longitudinal study

of the psychosocial impact of stroke on primary support

persons. Psychology and Aging 3(2), 131±141.

Schulz R., Visintainer P. & Williamson G.M. (1990) Psychiatric

and physical morbidity effects of caregiving. Journal of Geron-

tology 45(5), P181±191.

Schulz R. & Williamson G.M. (1991) A 2-year longitudinal study

of depression among Alzheimer's caregivers. Psychology and

Aging 6(4), 569±578.

Silliman R.A., Fletchner R.H., Earp J.L. & Wagne E.H. (1986)

Families of elderly stroke patients. Effects of home care. Journal

American Geriatrics Society 34(9), 643±648.

Stone R., Cafferata G.L. & Sangle, J. (1987) Caregivers of frail

elderly: a national pro®le. The Gerontologist 27(5), 616±626.

Tucker M.A., Ogle S.J., Davinson J.G. & Eilenberg M.D. (1986)

Development of a brief screening test for depression in the

elderly. Journal of Clinical and Experimental Gerontology 8,

173±190.

Tucker M.A., Ogle S.J., Davinson J.G. & Eilenberg M.D. (1987)

Validation of a brief screening test for depression in the elderly.

Age and Ageing 16(3), 139±144.

Wade D.T., Legh-Smith J. & Hewer R.L. (1986) Effects of living

with and looking after survivors of a stroke. British Medical

Journal 293(6544), 418±420.

Williams A. (1994) What bothers caregivers of stroke victims?

Journal of Neuroscience Nursing 26(3), 155±161.

Wright L.K. (1993) Alzheimer's Disease and Marriage. Sage,

Newbury Park, California.

Wright L.K. (1994) AD spousal caregivers longitudinal changes in

health, depression and coping. Journal of Gerontological Nurs-

ing 20(10), 33±45, 48.

Wright L.K., Clipp E.C. & George L.K. (1993) Health consequences

of caregivers stress. Medicine, Exercise, Nutrition, and Health 2,

181±195.

Wright L.K., Hickey J.V., Buckwalter K.C. & Clipp E.C. (1995)

Human development in the context of aging and chronic

illness: the role of attachment in Alzheimer's disease and

stroke. International Journal of Aging and Human Development

41(2), 131±148.

Young R.F. & Kahana, E. (1989) Specifying caregiver outcomes.

gender and relationship aspects of caregiving strain. The

Gerontologist 29(5), 660±666.

Zung W.W.K. (1973) From art to science: the diagnosis and

treatment of depression. Archives of General Psychiatry 29(3),

328±337.



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Emotional and physical health of spouse caregivers of persons with Alzheimer’s disease and stroke