Factors Associated with Depressive Symptoms Among Latino Family Dementia Caregivers

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Factors Associated withDepressive Symptoms AmongLatino Family DementiaCaregiversMolly J. Ranney PhD a & Maria P. Aranda PhD ba School of Social Work, California State University ,Long Beach, USAb School of Social Work, University of SouthernCalifornia , Los Angeles, USAPublished online: 11 Oct 2008.

To cite this article: Molly J. Ranney PhD & Maria P. Aranda PhD (2001) FactorsAssociated with Depressive Symptoms Among Latino Family Dementia Caregivers,Journal of Ethnic And Cultural Diversity in Social Work, 10:1, 1-21, DOI: 10.1300/J051v10n01_01

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Factors Associatedwith Depressive Symptoms

Among Latino FamilyDementia Caregivers

Molly J. RanneyMaría P. Aranda

ABSTRACT. Caregiving to a person affected with an irreversible, late

onset dementia can be an arduous challenge. Utilizing Pearlin and col-

leagues’ (1990) and Lawton and colleagues’ (1989; 1991) stress process

model of caregiving, the factors associated with depressive symptoms

among Latino1family dementia caregivers were examined. Problematic be-

havior of the dementia-affected person was found to be the most important fac-

tor associated with depressive symptoms, followed by poor self-reported

health of the caregiver. Human service providers are advised to include depression

screening tools at the time of assessment of Latino caregivers and to offer behav-

ioral management interventions and self-care strategies. [Article copies available for afee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com> © 2001 by TheHaworth Press, Inc. All rights reserved.]

KEYWORDS. Caregiving stress, Latino, Alzheimer’s disease, depres-sion, health, behavioral problems

INTRODUCTION

Dementia is characterized by a deterioration in intellectual abilities whichtypically involves impairments in memory, judgment, language skills, impulse

Molly J. Ranney, PhD, is Lecturer in the School of Social Work, California StateUniversity, Long Beach. María P. Aranda, PhD, is Assistant Professor in the School ofSocial Work, University of Southern California, Los Angeles.

Journal of Ethnic & Cultural Diversity in Social Work, Vol. 10(1) 2001 2001 by The Haworth Press, Inc. All rights reserved. 1

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control as well as changes in personality and reality testing (National Institute onAging, 1999; Maxmen & Ward, 1995). Several demographic trends are worthnoting: (a) the number of people affected by dementia increases with age, withthe prevalence rate doubling every five years after age 65; (b) Alzheimer’s dis-ease (AD) is the most common cause of dementia among the 65 and older agegroup and is estimated to affect approximately 4 million U.S. Americans; and(c) the number of AD affected persons is expected to increase considerablydue to the continued growth in the numbers of Americans projected to reachold age in the United States (National Institute on Aging, 1999). While thepopulation age 65+ in the U.S. is expected to increase 79% from 1997 to 2030,the Latino older adult population will quadruple to 5 million persons (Ameri-can Association of Retired Persons, 1998; Angel & Hogan, 1994).

Spouses, relatives, and friends comprise the backbone of the informal sys-tem of long-term care for AD-affected persons (National Institute on Aging,1999). While it is widely recognized that caregiving to a person affected with alate onset dementia can be potentially arduous for members of any ethnicgroup, little empirical work is available to inform us on the dynamics ofcaregiving in Latino families. Using the stress process model (Pearlin, 1990;Lawton, Kleban, Moss, Rovine, & Glicksman, 1989; Lawton, Moss, Kleban,Glicksman, & Rovine, 1991), this article examines those factors associatedwith depressive symptoms in Latino caregivers of dementia-affected personsusing data from a demonstration project dedicated to Latino dementia care-givers in Los Angeles County.

LITERATURE REVIEW

Caregiving Stress

Research focused on the stress associated with caregiving has determinedthat dementia caregivers can experience negative health and psychiatric outcomesthemselves when compared to their non-caregiving counterparts (Aneshensel,Pearlin, Mullan, Zarit, & Whitlach, 1995; Schulz, O’Brien, Bookwala, & Fleissner,1995; Schulz & Williamson, 1991; Tennstedt, Cafferata & Sullivan, 1992). Basedon Schulz et al.’s (1995) review of empirical studies, depression is the most fre-quent indicator of caregiver stress among dementia caregivers. However, themajority of these studies have been conducted on White caregiving popula-tions, particularly those who access assistance from community long-termcare agencies. There is evidence that Latinos are less likely to use long-termcare services (see Mui, Choi, & Monk, 1998). This underutilization was initiallyinterpreted as a lack of need for formal support by Latino dementia caregivers andspeculation that Latino caregivers experienced less stress than their White counter-

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parts (Mui et al., 1998; Valle 1998). Refuting these assumptions, recent studies

and related reviews have demonstrated that Latino dementia caregivers have

similar or even greater risk for depressive symptoms (Adam, Kemp, Aranda, &

Takagi, in press; Connell & Gibson, 1997; Friss, Cox & Monk, 1990; Whitlach, &

Yale, 1990; Harwood, Barker, Cantillon, Loewenstein, Ownby, & Duara, 1998;

Mintzer et al., 1992; Polich & Gallagher-Thompson, 1997; Valle, Cook-Gait, &

Tazbaz, 1993; Yañiz, 1990) or personal and role strain (Cox & Monk, 1996)

when compared to other caregiver groups or the general adult population. With

few exceptions (Adam et al., in press; Polich & Gallagher-Thompson, 1997),

these studies have not drawn from the stress process model to guide the exami-

nation of factors associated with depressive symptoms among Latino dementia

caregivers. The stress process model offers a framework in which the stress-in-

ducing relationships among various factors are evaluated in terms of their im-

pact on caregiver stress (Lazarus & Folkman, 1984).Theoretical Framework. Although previous research has focused pre-

dominantly on the White caregiving stress and the coping process, they do

provide a conceptual basis from which to initiate the examination of the

predictors of depressive symptoms among Latino caregivers (Adams et al.,

in press; Aranda & Knight, 1997). Originally presented by Lazarus,

Folkman and their colleagues (Folkman, Lazarus, Pinley & Novacek, 1987;

Holroyd & Lazarus, 1986; Lazarus & Folkman, 1984), the stress process

model has since been applied to caregiver distress by scholars in the area of

dementia caregiving research (Aneshensel et al., 1995; Haley, Levine,

Brown, & Bartolucci, 1987; Haley, Roth, Coleton, Ford, & West, 1996;

Lawton, Kleban, Moss, Rovine, & Glicksman, 1989; Pearlin, Mullan, Semple,

& Skaff, 1990; Lawton, Moss, Kleban, Glicksman, & Rovine, 1991; Yates,

Tennstedt, & Chang, 1999). According to this model, caregiving stressors, un-

less mediated by certain resources, can have a direct impact on the well-be-

ing of the caregiver. Caregiver stress is defined as those “demands and

obstacles that exceed or push to the limit one’s capacities to adapt”

(Aneshensel et al., 1995, p. 34).Drawing from the stress process model of caregiving (Pearlin et al., 1990;

Lawton et al., 1989; 1991), four major domains of study were included in the

current study: (1) the caregiver’s background characteristics; (2) the stressors

or patient’s characteristics; (3) social support as coping resources; and (4) de-

pressive symptoms as the stress outcome. It is important to note that although

these domains represent key aspects of the stress process model, they are not

inclusive of the entire model as delineated in the literature. Due to the unavail-

ability of specific variables in the agency database (e.g., secondary stressors,

coping styles), the authors could not test the full theoretical model. Also, due to

Molly J. Ranney and María P. Aranda 3

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the preliminary nature of the study, only the direct associations between thesevariables and depressive symptoms are considered.

Depressive Symptoms. Chronic stress can produce a negative effect on boththe physical and psychological well-being of the caregiver. Psychological out-comes such as depression have been reported as more likely to be affected bycaregiver stress than are physical health outcomes (Schulz et al., 1995). Anumber of outcomes can be measured which include anxiety, depression, andloss of physical health. In this study, level of depressive symptoms was se-lected as the stress outcome, since depression has been linked to other seriousconcerns such as medical co-morbidity, mortality, and health care costs (Blazer,1989; Von Korff, Ormel, Katon, & Lin, 1992; Wells, Sturm, Sherbourne, &Meredith, 1996; Hankin, Steinwachs, Regier, Burns, Godlberg, & Hoeper,1982). Depression can also compound stress experienced by adversely affect-ing the caregiver’s relationship with significant others, including the demen-tia-affected person (Yates et al., 1999).

In a review of studies on the stress process of Latino dementia care-givers, Aranda and Knight (1997) indicate that Latino caregivers appear tobe at risk for elevated rates of depressive symptomatology. More recentwork has found that Mexican American spousal caregivers report very highrates of clinical depression (about 50% scored in the probable major depres-sion range) in a regional study in Los Angeles, California (Adams et al., inpress). Polich and Gallagher-Thompson (1997) found that of their sampleof female Latina caregivers (62% comprised of daughters), about 31%scored in the mildly depressed range while 17% could be characterized asmoderately to severely depressed. Harwood et al. (1998) also found agreater prevalence of depressive symptoms among Latino (primarily Cu-ban American) caregivers than among their White counterparts. Attentionto these subgroups of depressed caregivers is important given the low utili-zation of mental health specialty services by Latinos (López-Aqueres,Kemp, Staples, & Brummel-Smith, 1984; Vega, Kolody, Aguilar-Gaxiola, &Catalano, 1999).

Caregiver Characteristics. In Schulz and colleague’s (1995) review of theliterature, three caregiver characteristics were found to be consistently associ-ated with a higher level of depressive symptoms: the caregiver’s relationshipto the dementia-affected person (with spouses having higher levels), poorerself-rated health, and lower socioeconomic status. Spousal caregivers, due tothe unique marital relationship with the dementia-affected individual, experi-ence unmet intimacy needs and certain dynamics associated with thecaregiving relationship not experienced by other family and non-kin care-givers (Butler, Lewis, & Sunderland, 1998). For example, spousal caregiversexperience changes in intimacy, financial security, end-of-life issues, and be-


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reavement. Thus, the marriage or partner relationship is especially salient tocaregiver stress outcomes and should not be underestimated.

The caregiver’s overall physical health is of importance in the stress pro-cess given his/her ability to generate the energy and physical resources torespond, adapt and maintain consistent and quality care to the affectedspouse. Previous work has shown a consistent association between self-re-ported health and depression in non-caregiving and caregiving samples(Brodaty & Hazdic-Pavlovic, 1990; Hinrichsen & Niederehe, 1994; Fredman,Daly & Lazur, 1995; Hooker, Monahan, Shifren, & Hutchison, 1992;Schulz et al., 1995; Von Korff et al., 1992; Zarit, 1996;), as well as with apopulation-based study of older Latinos (Black, Markides, & Miller,1998).

Caregivers confront stress within a stratified society and their socioeco-nomic status directly influences the types of stressors they experience, the per-sonal and social resources available to them, and the way stress is expressed(Pearlin, 1990). Lower socioeconomic status has been associated with in-creased depressive symptoms in Latino caregiving samples and noncaregivingsamples (Adams et al., in press; Black, Markides, & Miller, 1998). It is antici-pated that caregivers with limited financial resources may not be able to accesstimely information and interventions needed to navigate the dementia care tra-jectory, and thus, to decrease caregiver stress.

Stressors: Patient Characteristics. Stressors are the burdensome conditions,tasks, and activities of caregiving. Pearlin et al. (1990) divide stressors into pri-mary and secondary types, those directly involved in providing care and thosethat result from providing care, respectively. As aforementioned, this studywas only able to test the primary stressors. Primary stressors stem directlyfrom the needs of the patient. There are two types of primary stressors, the sub-jective and the objective. The subjective type is the caregiver’s internal re-sponses to the hardships of caregiving (e.g., sense of role overload, rolecaptivity, relational deprivation). The objective type reflects the actual hard-ships of caregiving (e.g., managing a dementia patient’s difficult behavior andcognitive impairment, daily dependencies). Behavioral problems exhibited bythe dementia-affected person have been found to be associated with depressivesymptoms among caregivers (Brodaty and Hazdic-Pavlovic, 1990; Hinirichsen &Niederehe, 1994; Hooker et al., 1992; Zarit, 1996), such that the more problem-atic the behavior the more depressive symptoms reported by the caregiver. Ad-ditionally, higher cognitive impairment of the dementia-affected person hasbeen found to be associated with depressive symptoms (Baumgarten et al.,1992).

In their study of Latino and White caregivers, Valle and his associates(1993) found that Latinos reported feeling more distressed by specific


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caregiving tasks (feeding, dressing, toileting) and the patient’s problem behav-iors (hiding things, constantly living the past) than their White counterparts.Cox and Monk (1996) found that Latino caregivers had higher levels of per-sonal and role strain than African American caregivers. It is unclear if distressor strain is more prominent with regard to cognitive or behavioral problems,although Harwood et al. (1998) did find an inverse relationship between lowerpatient cognitive status and higher levels of depressive symptoms.

Coping Resources: Social Support. Coping resources buffer the effects ofstressors and maintain the well-being of the caregiver. The stress processmodel holds that buffering occurs when “the cushioning effect of the mediatorincreases with the severity of the stressor” (Pearlin et al., 1990; p. 589). Twoprincipal stress mediators are social support and coping styles. Social supportconsists of those persons available to help with the physical and emotional careof the dementia-affected person. Coping refers to those behaviors and prac-tices which persons use on their own behalf to mediate stress. Caregivers withmore effective coping abilities and social supports tend to experience fewer ofthe negative effects of stress on their well-being. Thus, this important aspect ofthe model must be carefully considered in order to account for the variability incaregiving outcomes. Unfortunately, due to the high degree of variability inthe measures used across studies, the identification of effective coping re-sources in combating the depression of dementia caregivers has proven to besomewhat equivocal with some studies finding such an effect (Brodaty &Hazdi-Pavlovic, 1990; Schulz & Williamson, 1991; Yates et al., 1999) andothers failing to do so (Morrisey et al., 1990; Parks & Pilsuk, 1991; Semple,1992). Clearly, further research is needed to investigate the direct and indirecteffect of coping resources on the depressive symptoms of caregivers.

Due to the traditional cultural emphasis Latinos have placed upon familism andfilial responsibility (Aranda & Knight, 1997; Connell & Gibson, 1997; Cox &Monk, 1990; Gallagher-Thompson et al., 1997; Prudy & Arguello, 1992), thisline of inquiry is of particular relevance. Latino social networks appear to bemore extensive than that for the White population (Dilworth-Anderson & Bur-ton, 1999), yet it is unknown what role this coping resource has on caregivingoutcomes. It is anticipated that because Latinos rely on a highly complex net-work of kin and non-kin support for in-home care, that the social support aspectof caregiving (and the perception of its viability) is crucial to stress and coping.

METHODOLOGY

Using cross-sectional data obtained from the 1993-1996 El Portal LatinoAlzheimer’s Project, factors associated with depressive symptoms among La-


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tino dementia family caregivers were examined. El Portal, a care managementdemonstration project funded by the federal Health Resources and ServicesAdministration (HRSA), was developed by a coalition of health and social ser-vices agencies led by the Los Angeles Chapter of the Alzheimer’s Association.The demonstration project provides culturally sensitive and linguisticallycompetent educational, medical, social and supportive services for Latinoswith dementia and their caregivers. Services include case management, bilin-gual helpline, adult day care, in-home respite, support groups, legal assistance,transportation, and vendored services (Aranda, Villa, Trejo, Ramírez, &Ranney, in press).

Sample

The nonrandom sample consisted of 97 Latino family dementia caregiverswho were participants in the El Portal Latino Alzheimer’s Project. Participantswere recruited for services as a result of a comprehensive community outreachcampaign that generated self-referrals or referrals from health and human ser-vice providers. The primary purpose of the outreach campaign was to informLatino caregivers about the services that were available from the El PortalProject. Information taken at the time of the initial intake was used as thesource of data. Subjects were selected for the study if they self-identified asLatino or of Latino descent, were primary caregivers to a family member withlate-onset dementia, and had completed all sections of the initial intake inter-view.

Measures

Trained bilingual/bicultural interviewers conducted face to face interviewswith the caregivers. All interviews were conducted in either Spanish or English(based on the caregiver’s preference) and lasted an average of one and one-halfto two hours. The interview instrument was translated into Spanish by a bilin-gual/bicultural translator and then back translation was used by a separate trans-lator to verify its accuracy. The Older Adult Mood and Health Questionnaire(OAMHQ) was the only part of the instrument that did not need to be translatedbecause a Spanish version was already available (Kemp & Adams, 1995).

Depressive Symptoms. Kemp and Adams’s (1995) Older Adult Mood andHealth Questionnaire (OAMHQ) scale was utilized to indicate the level of de-pressive symptoms. This measure was specifically created as a brief screeningtool that takes into account age differences in the self reporting of depressivesymptoms. The scale measures depression based on DSM-III-R (AmericanPsychiatric Association, 1994) criteria which distinguish mood alteration and


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clinically significant depressive symptoms from major depression. In a

cross-ethnic study of dementia caregivers (including Mexican Americans),

Adam and his colleagues (in press) found the OAMHQ to have a high level of

internal consistency (alpha of .93) and test-retest reliability (.87). Kemp and

Adams (1995) also found that scores on the OAMHQ to significantly correlate

with scores on the Geriatric Depression Scale (r = .70, p < .001). Reliability

and validity tests for both Spanish and English versions are equally strong

(Adams et al., in press; Kemp & Adams, 1995).The OAMHQ consists of 22 short statements that are answered in a true and

false format. Half of the statements reflect the person’s dysphoric mood

whereas the other half reflects either behavioral, cognitive, or physiological

symptoms. To establish valid cut off scores, clinical ratings of depression were

made by psychiatrists and compared to scores on the OAMHQ (Kemp & Ad-

ams, 1995). Cut off scores from 0 to 3 indicate no depression, scores from 4 to

10 indicate significant depressive symptoms, and scores from 11 to 22 indicate

probable major depression. Types of questions include: Please tell me “yes” or

“no” if the following statements are true or not true (1) “My daily life is not in-

teresting;” (2) “I gain little pleasure from anything;” and (3) “My outlook is

more gloomy than usual.” In this study, the Cronbach’s alpha for the scale was

.91 for the English version and .86 for the Spanish version.Caregiver Background Characteristics. The caregiver characteristics in-

cluded in the regression model were the caregiver’s relationship to the demen-

tia-affected person, self-reported health and caregiver’s average household

monthly income. The number of background characteristics that could be se-

lected for inclusion in this study was limited by the study’s sample size. Gen-

der and age, which have mixed support in the dementia caregiver literature as

predictors of depression (Schulz et al., 1995), were tested by the use of

bivariate correlational analysis with depressive symptoms. This test was done

to determine if potentially relevant variables could be excluded from this

study. Neither age (r = .02, p = n.s.) nor gender (r = .01, p = n.s.) were found to

significantly correlate with depressive symptoms, and thus, were excluded

from the analyses.Relationship of the caregiver was determined through the use of a sin-

gle-item question, which requested the caregiver to self-report their relation-

ship to the dementia-affected person. Income level was also measured by the

use of a single-item asking the caregiver for a self-report of their average

monthly income. In order to measure the caregiver’s overall health, the care-

giver was asked to rate his or her own health on a five-point scale ranging from

l = excellent to 5 = poor. Within the stress and health literature, the use of a sin-

gle item to measure self-reported health has been found to correlate well with


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other objective health outcomes (Bernard et al., 1997; Mossey & Shapiro,1984).

Stressors. Stressors consisted of the level of cognitive impairment and theproblematic behavior of the dementia-affected person. A modification of theZarit, Orr and Zarit (1985) Memory and Behavior Checklist was used for bothmeasures. While no validity assessments have been conducted, this measurewas developed specifically for understanding the stress experienced by de-mentia caregivers and has been used in dementia caregiver research (Pearlin etal., 1990) with satisfactory results.

To measure memory impairment, eight items were used to assess the levelof difficulty that the dementia-affected person experienced in remembering recentevents, following simple instructions, or recognizing people they know. Types ofquestions specifically included, how difficult is it for the elder to: (1) “know whatday of the week it is,” (2) “remember words;” and (3) “find his/her way aroundthe house.” These items are rated in terms of their level of difficulty utilizing afive-point scale which ranges from 1 = not at all difficult to 5 = can’t do (re-member) it at all. The summated scores had a possible range of 8 to 40, withhigher scores indicating greater difficulty in remembering things. Cronbach’salpha for this scale was .85 for the English version and .83 for the Spanish ver-sion.

The problematic behavior measure inquired as to the extent to which thecaregiver personally dealt with fifteen problematic behaviors of the demen-tia-affected person over a period of one week. The caregivers were asked, “Inthe past week how often have you had to deal with the following behaviors:(1) “repeating of questions or stories?” (2) “bowel or bladder accident;” or(3) “keeping you up at night.” These items are rated on a four-point scalefrom 1 = no days, 2 = 1 to 2 days, 3 = 3 to 5 days and 4 = five or more days.The summated score has a possible range of 15 to 60, with higher scores indi-cating greater frequency of behavior problems. Cronbach’s alpha for this scalewas .80 for both English and Spanish versions.

Coping Resources. Informal support consisted of two items that assessedthe availability of support from both family and friends. The caregivers, re-sponding in a yes or no format, were asked if they had any informal supportavailable from either family or friends in helping them with the care of the pa-tient. Although, there are many valid and reliable measures of coping re-sources that have been used in caregiver research, this was the only availablemeasure that dealt with the availability of informal support used in this study.While this measure has not been previously tested, and it is only composed ofonly two items, it was included because of the importance most practitionersplace on the strong role of informal support (as the most frequently used formof coping resources) among Latino caregivers (Aranda & Knight, 1997).


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ANALYSES

The variables were entered in blocks–selected and ordered according to the

major variables of interest as reviewed in the literature–and guided by the

stress process model posited by Pearlin et al. (1990). Three hypotheses were

tested using hierarchical linear regression: (1) Background characteristics

(self-reported health, income, and relationship to the dementia-affected per-

son) will predict the depressive symptoms of Latino dementia caregivers (i.e.,

poorer health, lower income, and spousal relationship is related to higher de-

pressive symptoms; (2) Primary objective stressors (cognitive impairment and

problematic behavior) will positively predict the depressive symptoms of La-

tino dementia caregivers, controlling for the background characteristics of the

caregiver; and (3) Informal support (a coping resource) will inversely predict

the depressive symptoms of Latino dementia caregivers, controlling for care-

giver’s background characteristics and primary objective stressors.

FINDINGS

Description of the Sample

Descriptive statistics for the sociodemographic characteristics of the Latino

family caregivers are displayed in Table 1. The caregivers were predominately

female (81%) and older, with 51% the sample over 60 years of age (Mean =

60.8 years; S.D. 15.9). Caregivers had a low average household monthly in-

come (Mean = $633; S.D. = $559) with 80% receiving less than $1000.00 a

month. The majority of the sample were either the spouse (42%) of the demen-

tia-affected person or the adult child/child-in-law (50%). Slightly over

one-half of the sample (53.3%) was foreign born, with the majority (36%) of

this group being of Mexican descent. With regard to language, approximately

42% of Latino caregivers spoke mostly Spanish. The educational background

of the caregivers was also relatively low, with 47% having obtained less than a

high school degree. Half of the sample had been providing care to their demen-

tia-affected family member for over three years. In terms of informal support,

less than half (44.7%) reported they had enough support available from either

friends or family in assisting with the care of the patient.

Caregiver and Patient Status

As a group, Latino family dementia caregivers reported experiencing mod-

erate levels of depressive symptoms (Mean = 10.04; S.D. = 5.65), which ac-

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TABLE 1. Description of the El Portal Latino Caregiver

Latino Family Caregivers

(n = 76)Name of Variable f %Female Gender 62 81.0Age (in years)

20-39 5 6.540-59 32 42.160-79 32 42.180-99 7 9.3

Average Household Income (monthly)$0-499 42 54.8$500-999 20 26.0$1000-1499 4 5.5$1500-1999 6 8.2$2000-2499 4 5.5Relationship to Elder

Spouse 32 42.1Child/Child-in-Law 38 50.0Sibling 4 5.3Niece/Nephew 2 2.6

NativityUnited States 35 46.7Mexico 27 36.0Cuba 8 10.5Guatemala 3 4.0El Salvador 2 2.6

Language Most FluentOnly or Mostly Spanish 32 42.1Bilingual (Spanish/English) 17 22.4Only or Mostly English 27 35.5

EducationNo High School Diploma 36 47.4Graduated from High School 38 50.0College Graduate 2 2.6

Months Providing Care0-12 24 31.013-24 14 19.036+ 38 50.0

Informal SupportYes 34 44.7

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cording to the Kemp and Adams (1995) scale, are enough to interfere withdaily functioning (see Table 2). Caregivers also reported having fair to poorhealth (Mean = 3.52; S.D. = 1.09). In terms of patient stressors, the caregiversreported that their dementia-affected family member had moderate levels ofcognitive impairment (Mean = 27.04; S.D. = 7.41). Caregivers also reportedthe problematic behavior of their dementia-affected family member to bewithin the moderate range (Mean = 35.62; S.D. = 9.16).

Multivariate Analysis

A hierarchical regression analysis was used to test the influence of inde-pendent variables on the depressive symptoms of the caregiver. Hierarchicalregression analysis allows for variables to be analyzed according to theoreti-cally-driven relationships posited in the literature. The first block of variablesentered in the analyses consisted of the background caregiver characteristics(self-reported health, average household monthly income, relationship to thedementia-affected person), which tested the first hypothesis. Relationship ofthe caregiver was dummy coded, with “1” equaling spouses and “0” equalingother family members. Next, the primary objective stressors (cognitive statusand problematic behavior of the dementia-affected person) were entered,which tested the second hypothesis. Finally, the coping resource of informalsupport was entered, which tested the third hypothesis. Informal support wasdummy coded, with “1” equaling the presence of support from either family orfriend and “0” equaling no support.

The overall hierarchical regression model tested explained about 25% ofthe variance in the self-reported depressive symptoms of Latino dementiacaregivers (Adjusted R2 = 24.7%, p < .05) (see Table 3). In the first block ofthe analysis, which was significant (R2 change = 9.6%, p < .05), the only back-ground characteristic that had a significant direct effect on depressive symp-toms was the self-reported health of the caregiver (p < .05). Self-reportedhealth was found to have a positive relationship with depressive symptoms,thus, a higher score (i.e., poorer health) was found to be associated with ahigher level of depressive symptoms. These findings do provide partial sup-port for the first hypothesis that poor self-reported health is associated withhigher depressive symptoms.

The second stage of the analyses was also significant (R2 change = 19.6%,p < .01). Problematic behavior was the only stressor found to have a significanteffect on the depressive symptoms of the caregiver (p < .01), such that higherscores of problematic behavior were associated with an increased level of de-pressive symptoms. These findings do provide support for the second hypothe-sis that problematic behavior was positively associated with the depressive


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symptoms of Latino dementia caregivers (controlling for the background char-

acteristics of the caregiver).In the final stage of the analysis, the informal support variable was not sig-

nificantly associated with the depressive symptoms of the caregiver. This find-

ing does not support the third hypothesis which suggested that informal

support will inversely predict the depressive symptoms of the caregiver.

Therefore, the only two factors found to be associated with depressive symp-


TABLE 2. Means and Standard Deviations of Major Variables

Measures PossibleRange

Mean StandardDeviation

Caregiver

Depressive Symptoms 0-22 10.04 5.65

Self-Reported Health 1-5 3.52 1.09

Patient

Cognitive Functioning 8-40 27.04 7.41

Problematic Behavior 15-60 35.62 9.16

TABLE 3. Standardized Regression Coefficients for Measures of Latino De-pressive Symptoms (n = 76)

Factor Standardized Betas

Background Characteristics

Household Monthly Income .13

Relationship to Elder .16

Self-Reported Health .26*

R2 Change = .096

Stressors

Cognitive Functioning 2.04

Problematic Behavior .46**

R2 Change = .196

Coping Resources

Informal Support 2.14

R2 Change = .018

F Statistic for Model = 4.94**

Total R2 = .310

Adjusted R2 = .247

*p < .05, **p < .01

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toms among Latino dementia caregivers, in order of importance, were theproblematic behavior of the dementia-affected person and the self-reportedhealth status of the caregiver. The final model explained 25% of the variance indepressive symptoms.

DISCUSSION

Latino dementia caregivers scored in the moderate range on the OAMHQ, in-dicating the presence of clinically significant symptoms that interfere with dailyfunctioning. This is consistent with previous exploratory studies on the subjectwhich have also found Latino dementia caregivers to score in the depressivesymptom range on various depression measures (Adams et al., in press); Polich &Gallagher, 1997; Valle et al., 1993; Cox & Monk, 1990; Mintzer et al., 1992;Yañiz, 1990). It is important to note that the use of a self-report depression mea-sure with Latinos has been under debate, with some arguing that inflated scoresare due to cultural bias (Aneshensel et al., 1983; Vega et al., 1986). Clearly, ad-ditional validation of both self-report and diagnostic interview scales is neededfor this population. Qualitative work by Calderon and Tennstedt (1998) suggeststhat Latino and other minority groups may perceive and express caregiver stressand burden differently than the White population, and thus, current scales mayobscure the phenomenological experience of caregiving in these populations.Longitudinal data are also needed in order to examine the nature and progressionof mood changes in Latino caregivers.

Problematic behavior was found to be the most important predictor of de-pressive symptoms for Latino dementia family caregivers, which is consis-tent with the previous studies of White caregivers (Baumgarten et al., 1992;Brodaty & Hazdi-Pavloviv, 1990; Hinrichsen & Niederehe, 1994; Semple,1992). The likelihood of experiencing depressive symptoms in response to apatient’s problematic behavior is understandable, since it is often a formida-ble aspect of dementia caregiving. Also, the mere presence of the problem-atic behavior can be a painful reminder of the change in the personality of thepatient (Pearlin et al., 1990), as well as a source of stigma and shame (Aran-da, 1999). Behavior management education and intervention strategies aresorely needed for this population. Such intervention strategies have been usedsuccessfully with predominantly White groups (Cohen-Mansfield, 2000;Kennet, Burgio, & Schulz, 2000; Ostwald, Hepburn, Caron, Burns, &Mantell, 1999) and should be evaluated in terms of their applicability to La-tino dementia caregivers. Cognitive impairment has not had the strong sup-port in previous studies that problematic behavior has had as a predictor ofdepressive symptoms (Schulz et al., 1995). Therefore, its lack of significance


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in this study is not completely surprising. However, it is important to note

that the small sample size of this study could have influenced the results. Ad-

ditional research is needed to explore the relationship between cognitive

stressors and depressive symptoms.The relationship between self-reported health and caregiver depressive

symptoms is consistent with studies of non-Latino caregivers in which poorer

caregiver self-reported health is found to be predictive of higher levels of de-

pressive symptoms among White dementia caregivers (Brodaty &

Hazdic-Pavlovic, 1990; Hinirichsen & Niederehe, 1994; Hooker et al., 1992;

Zarit, 1996). Polich and Gallagher’s (1997) study of Latino dementia caregivers

similarly found the caregiver’s health to be related to depressive symptoms. The

nature of the relationship between depressive symptoms and physical illness is

less clear since depressive symptoms can either precipitate or result from

physical illness.This study failed to find either the caregiver’s income or their relationship

to the dementia-affected person to be associated with depressive symptoms;

however, this may also be an artifact of the sample size and/or the low varia-

tion in income. Further research is also needed concerning the relationship be-

tween depressive symptoms and other caregiver background characteristics

such as gender and nativity or country of birth.The availability of informal support was not found to be inversely asso-

ciated with the depressive symptoms of the caregivers. This may have been

a result of the study’s reliance on a single-item measure of support which

may have obscured the multifaceted measurement of social support. In any

case, it is also important to note that less than 50% of the Latino caregivers

reported that they had informal support available to them. Future work

should utilize more sensitive measures of social support that examine sev-

eral areas: the availability, need, and use of social supports across several

areas of assistance (Barrera, 1981). Coping resources used by Latino de-

mentia caregivers might differ from those of other ethnic populations. For

example, traditionally the church and other indigenous mutual aid groups

have played a strong role within the Latino culture and scales should reflect

such forms of support. The use of a larger Latino caregiver sample as well

as the use of more scientifically rigorous and comprehensive measures to

evaluate the availability and nature of social support would facilitate the

testing and exploration of the stress process model. This information would

facilitate the identification of effective coping resources and facilitate the

development of culturally valid measures of social support in Latino care-

giver research.


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LIMITATIONS

Several limitations of the study are worth noting. The study employed aconvenience, non-random sample, which could have resulted in a selectionbias, and thus influenced the results. The small sample size, which limited thenumber of variables that could be included in the regression analyses, also lim-its the generalizability of the findings and weakened the statistical power of theanalysis. Certain variables pertinent to Pearlin et al.’s (1990) model were notincluded in the original study and thus could not be examined. The effects ofthese omissions are not known. As mentioned above, the use of a two-itemcoping resources scale, which only assessed the presence of informal support,did not allow for a more comprehensive testing of this complex construct. Fur-thermore, since the initial intake did not include objective diagnostic verifica-tion, there was no way of confirming that the patient’s symptoms weredementia-related at the time of intake. Although, subsequent referrals for diag-nostic verification by a health care provider have correlated highly with thecaregivers’ report of symptoms, level of impairment, etc., (Rosa Ramírez, per-sonal communication, September 2, 1999). Finally, although the majoritywere of Mexican American descent, the study combined several subgroups ofLatinos. Therefore, the findings may not be generalizable to Latinos fromother subgroups. Despite these limitations, the findings offer direction for fu-ture areas of inquiry, especially in light of the paucity of research on the Latinocaregiving experience.

IMPLICATIONS

The results of this study suggest that a depression screening tool should be in-cluded as part of the psychosocial assessment of Latino dementia caregivers.This would offer intake workers an evaluation tool for identifying at-risk care-givers and ensure that these caregivers receive intervention services as early aspossible. These findings also suggest that programs such as El Portal, which pro-vide care management and vendored health and psychosocial services, are nec-essary for identifying sources of stress and applying culturally competentinterventions over the course of the family’s adaptation to the dementing illness.

Problematic behavior and poor caregiver self-reported health were found tobe associated with higher levels of depressive symptoms. Interventions tai-lored towards managing problem or disruptive behaviors have been docu-mented for non-Latino populations in both community (see review by Kennet,Burgio, & Schulz, 2000; Ostwald et al., 1999) and nursing home settings (Co-hen-Mansfield, 2000). The development of interventions that are sensitive to


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the Latino culture and empirically-based have only recently been addressed byscholars such as Gallagher-Thompson and her colleagues (2000) and Valle(1998). The consensus to date is that no “cookie-cutter” approach to interven-tions is possible given the vast heterogeneity within the Latino community andthe lack of any one caregiver or patient profile.

In terms of physical health, self-care strategies that promote stress reduction,better nutrition, physical exercise, and proactive communication with one’shealth care providers, may prove fruitful for Latino caregivers of any age. Often-times the caregiver forgoes his/her own self-care routines in the midst of caringfor the family member, thus increasing the risk of poor health-related outcomes.Cognitive behavioral strategies that assist the caregiver in reframing the care ex-perience and ferreting out automatic, defeatist thoughts can increase the per-son’s self-efficacy and more positive psychological outcomes.

Future research is greatly needed to investigate all aspects of the stress pro-cess among Latino dementia caregivers. Research on the Latino caregiving ex-perience and appropriate interventions is still in the exploratory stage. As such,many questions remain unanswered. For example, the use of coping styles, ap-praisal processes, and coping resources such as religion and spirituality have notbeen examined in the stress and process model of adaptation in relation to Latinodementia caregivers. Second, strategies that go beyond the family dyad and ef-fect changes in socioenvironmental systems (i.e., primary health care, social ser-vices, immigration, long-term care, and so forth) need to be examined. Lastly,given recent epidemiological work suggesting that U.S.-born Latinos may be athigher risk for depressive symptoms than their foreign-born counterparts (VegaKolody, Aguilar-Gaxiola, Alderete, Catalano & Caraveio-Anduaga, 1998), itmay be valuable to examine the role of immigrant status and acculturation on thepsychological and physical well-being of caregiving families.

ENDNOTE

1. For the purpose of this article, the term, “Latino,” is used to classify a diversegroup of people representing culture-of-origin orientations from over 20 differentSpanish-speaking countries from Latin America (Mexico, Cuba, Puerto Rico, Centraland South America, and other countries in the West Indies; Bean & Tienda, 1987).

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Documents

Factors Associated with Depressive Symptoms Among Latino Family Dementia Caregivers