Ageing International

, Volume 35, Issue 2, pp 109–127 | Cite as

Psychosocial Factors Among Chinese American Women Dementia Caregivers and their Association with Salivary Cortisol: Results of an Exploratory Study

  • Jason M. HollandEmail author
  • Larry W. Thompson
  • Marian Tzuang
  • Dolores Gallagher-ThompsonEmail author


Little is known about Chinese American dementia caregivers’ psychological and physical response to caregiving. In the present study, descriptive information is presented for a sample of 47 Chinese American dementia caregivers on a variety of psychosocial measures, including measures of depressive symptoms, overall perceived stress, stress specific to caregiving, coping, positive aspects of caregiving, caregiving self-efficacy, and belief in Asian values. Additionally, the association between these psychosocial factors and diurnal cortisol patterns is examined. Generally speaking, these caregivers were found to report significant levels of distress (e.g., depressive symptoms) but also showed indications of resiliency, as suggested by their high levels of self-efficacy, positive caregiving experiences, and problem solving. Stronger beliefs in Asian values were associated with more normal cortisol patterns, less depressive symptoms, and greater self-efficacy, highlighting the salience of culture in shaping the caregiving experience of Chinese Americans.


Cortisol Health Caregiver stress Chinese-Americans Cultural values 


  1. Aranda, M. P., & Knight, B. (1997). The influence of ethnicity and culture on the caregiving and coping process: a socio-cultural review and analysis. The Gerontologist, 37, 342–354.Google Scholar
  2. Au, A., Lai, M., Lau, K., Pan, P., Lam, L., Thompson, L., & Gallagher-Thompson, D. (2009). Social support and well-being in dementia family caregivers: The mediating role of self-efficacy. Aging & Mental Health, 13, 761–768.Google Scholar
  3. Bond, M. H. (1996). The handbook of Chinese psychology. New York, NY: Oxford Univ. Press.Google Scholar
  4. Chou, K.-R., LaMontagne, L. L., & Hepworth, J. T. (1999). Burden experienced by caregivers of relatives with dementia in Taiwan. Nursing Research, 48(4), 206–214.CrossRefGoogle Scholar
  5. Cohen, S., & Williamson, G. (1988). Perceived stress in a probability sample of the United States, in social psychology of health. In S. Spacapan & S. Oskamp (Eds.), Claremont symposium on applied social psychology. Newbury Park: Sage.Google Scholar
  6. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396.CrossRefGoogle Scholar
  7. Cole, S. R. (1999). Assessment of differential item functioning in the Perceived Stress Scale-10. Journal of Epidemiology and Community Health, 53, 319–320.CrossRefGoogle Scholar
  8. Davis, L. L., Weaver, M., Zamrini, E., Stevens, A., Duck-Hee, K., & Parker, C. R. (2004). Biopsychological markers of distress in informal caregivers. Biological Research for Nursing, 6, 90–99.CrossRefGoogle Scholar
  9. de Vugt, M. E., Nicolson, N. A., Aalten, P., & Lousberg, R. (2005). Behavioral problems in dementia patients and salivary cortisol patterns in caregivers. The Journal of Neuropsychiatry and Clinical Neurosciences, 17(2), 201–207.Google Scholar
  10. Folstein, M. F., Folstein, S. E., & Mchugh, P. R. (1975). Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.CrossRefGoogle Scholar
  11. Foo, K. H., & Kazantzis, N. (2007). Integrating homework assignments based on culture: working with Chinese patients. Cognitive and Behavioral Practice, 14, 333–340.CrossRefGoogle Scholar
  12. Gallagher, D., Rose, J., Rivera, P., & Lovett, S. (1989). Prevalence of depression in family caregivers. The Gerontologist, 29(4), 449–456.Google Scholar
  13. Gallagher-Thompson, D., Shurgot, G. R., Rider, K., McKibbin, C., Gray, H. L., & Sephton, S. E. (2006). Ethnicity, stress, and cortisol function in Caucasian and Hispanic women: a preliminary study of family dementia caregivers and non-caregivers. The American Journal of Geriatric Psychiatry, 14, 334–342.CrossRefGoogle Scholar
  14. Gallagher-Thompson, D., Gray, H., Tang, P., Pu, C. Y., Leung, L. Y., Wang, P.-C., et al. (2007). Impact of in-home intervention versus telephone support in reducing depression and stress of Chinese caregivers: results of a pilot study. The American Journal of Geriatric Psychiatry, 15(5), 425–434.CrossRefGoogle Scholar
  15. Gallagher-Thompson, D., Gray, H., Dupart, T., Jimenez, D., & Thompson, L. W. (2008). Effectiveness of cognitive-behavioral small group intervention for reduction of depression and stress in Non Hispanic White and Hispanic/Latino women dementia family caregivers: outcomes and mediators of change. Journal of Rational-Emotive and Cognitive-Behavior Therapy, 26, 286–303.CrossRefGoogle Scholar
  16. Gallagher-Thompson, D., Wang, P.-C., Liu, W., Cheung, V., Peng, R., China, D., et al. (2010). Effectiveness of a psychoeducational skill training DVD program to reduce stress in Chinese American dementia caregivers: results of a preliminary study. Aging & Mental Health, 14, 263–273.CrossRefGoogle Scholar
  17. Goldman, N., Glei, D. A., Seplaki, C., Liu, I.-W., & Weinstein, M. (2005). Perceived stress and physiological dysregulation in older adults. Stress, 8(2), 95–105.CrossRefGoogle Scholar
  18. Guo, Z., Levy, B. R., Hinton, W. L., Weitzman, P. F., & Levkoff, S. (2000). The power of labels: recruiting dementia affected Chinese American elders and their caregivers. Journal of Mental Health and Aging, 6, 103–112.Google Scholar
  19. Gupta, R., & Yick, A. (2001). Validation of CES-D Scale for older Chinese immigrants. Journal of Mental Health and Aging, 7, 257–272.Google Scholar
  20. Hertzog, C., Van Alstine, J., Usala, P., & Hultsch, D. (1990). Measurement properties of the Center for Epidemiological Studies Depression Scale (CES-D) in older populations. Psychological Assessment, 2, 64–72.CrossRefGoogle Scholar
  21. Hinton, L., Guo, Z., Hillygus, J., & Levkoff, S. (2000). Working with culture: a qualitative analysis of barriers to the recruitment of Chinese American family caregivers for dementia research. Journal of Cross-Cultural Gerontology, 15, 119–137.CrossRefGoogle Scholar
  22. Irwin, M., Hauger, R., Patterson, T. L., Semple, S., Ziegler, M., & Grant, I. (1997). Alzheimer caregiver stress: basal natural killer cell activity, pituitary-adrenal cortical function, and sympathetic tone. Annals of Behavioral Medicine, 19, 83–90.CrossRefGoogle Scholar
  23. Iwamasa, G. Y., & Sorocco, K. H. (2007). The psychology of Asian American older adults. In F. T. L. Leung, A. G. Inman, A. Ebreo, H. H. Yang, L. Kinoshita, & M. Fu (Eds.), Handbook of Asian American psychology (2nd ed., pp. 213–226). Thousand Oaks: Sage.Google Scholar
  24. Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffee, M. W. (1963). Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914–919.Google Scholar
  25. Kee, C. H.-Y. (2004). Cultural features as advantageous to therapy: a Singaporean perspective. Journal of Systemic Therapies, 23, 67–79.CrossRefGoogle Scholar
  26. Knight, B. G., & Sayegh, P. (2010). Cultural values and caregiving: the updated sociocultural stress and coping model. Journal of Gerontology: Psychological Sciences, 65B, 5–13.CrossRefGoogle Scholar
  27. Kraemer, H. C., Giese-Davis, J., Yutsis, M., O’Hara, R., Neri, E., Gallagher-Thompson, D., et al. (2006). Design decisions to optimize reliability of daytime cortisol slopes in an older population. The American Journal of Geriatric Psychiatry, 14, 325–333.CrossRefGoogle Scholar
  28. Lai, D. W. L. (2007). Cultural predictors of caregiving burden of Chinese-Canadian family caregivers. Canadian Journal on Aging, 26, 133–148.CrossRefGoogle Scholar
  29. Lawton, M. P., & Brody, E. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist, 9, 179–186.Google Scholar
  30. Levkoff, S., Lui, B., Fung, S., Hinton, L., & Chang, K. (1998). The evolution of a culturally distinct support group for Chinese caregivers of dementia-impaired elders: trial and error. Alzheimer’s Reports, 1, 77–82.Google Scholar
  31. Li, H. (2004). Barriers to and unmet needs for supportive services: experiences of Asian-American caregivers. Journal of Cross-Cultural Gerontology, 19, 241–260.CrossRefGoogle Scholar
  32. Lovallo, W. R. (2005). Stress & health: Biological and psychological interactions. Thousand Oaks: Sage.Google Scholar
  33. Mahoney, D. F., Cloutterbuck, J., Neary, S., & Zhan, L. (2005). African American, Chinese, and Latino caregivers’ impressions of the onset and diagnosis of dementia: cross-cultural similarities and differences. The Gerontologist, 45(6), 783–792.Google Scholar
  34. McCallum, T. J., Sorocco, K. H., & Fritsch, T. (2006). Mental health and diurnal salivary cortisol patterns among African American and European American female dementia family caregivers. The American Journal of Geriatric Psychiatry, 14(8), 684–693.CrossRefGoogle Scholar
  35. Miller, G., Chen, E., & Zhou, E. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological Bulletin, 133, 25–45.CrossRefGoogle Scholar
  36. Mills, P. J., Ziegler, M. G., Patterson, T., Dimsdale, J. E., Hauger, R., Irwin, M., et al. (1997). Plasma catecholamine and lymphocyte beta 2-adrenergic receptor alterations in elderly Alzheimer caregivers under stress. Psychosomatic Medicine, 59(3), 251–256.Google Scholar
  37. Moskowitz, J. T., & Epel, E. S. (2006). Benefit finding and diurnal cortisol slope in maternal caregivers: a moderating role for positive emotion. The Journal of Positive Psychology, 1(2), 83–91.CrossRefGoogle Scholar
  38. Newmark, P. (1991). About translation. Clevedon: Multilingual Matters, Ltd.Google Scholar
  39. Ory, M., Hoffman, R. R., Yee, J. L., Tennstedt, S., & Schulz, R. (1999). Prevalence and impact of caregiving: a detailed comparison between dementia and non-dementia caregivers. The Gerontologist, 39, 177–185.Google Scholar
  40. Owens, R. (Ed.). (1996). The translator’s handbook (3rd ed.). London: Aslib Publishing Co.Google Scholar
  41. Patterson, T. L., & Grant, I. (2003). Interventions for caregiving in dementia: physical outcomes. Current Opinion in Psychiatry, 16, 629–633.CrossRefGoogle Scholar
  42. Patterson, T. L., Semple, S. J., Shaw, W. S., Yu, E., He, Y., Zhang, M. Y., et al. (1998). The cultural context of caregiving: a comparison of Alzheimer’s caregivers in Shanghai, China and San Diego, California. Psychological Medicine, 28, 1071–1084.CrossRefGoogle Scholar
  43. Pinquart, M., & Sörensen, S. (2005). Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: a meta-analysis. The Gerontologist, 45(1), 90–106.Google Scholar
  44. Pinquart, M., & Sörensen, S. (2007). Correlates of physical health of informal caregivers: a meta-analysis. Journal of Gerontology: Psychological Sciences, 62B(2), 126–137.Google Scholar
  45. Ponterotto, J. G., Baluch, S., & Carielli, D. (1998). The Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA): critique and research recommendations. Measurement and Evaluation in Counseling and Development, 31, 109–124.Google Scholar
  46. Rabinowitz, Y. G., Mausbach, B. T., Coon, D. W., Depp, C., Thompson, L. W., & Gallagher-Thompson, D. (2006). The moderating effect of self-efficacy on intervention response in women family caregivers of older adults with dementia. American Journal of Geriatric Psychiatry, 14, 642–649.CrossRefGoogle Scholar
  47. Radloff, L. S. (1977). The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychological Measures, 1, 385–401.CrossRefGoogle Scholar
  48. Sapolsky, R. M., Romero, L. M., & Munck, A. U. (2000). How do glucocorticoids influence stress responses? Integrating permissive, suppressive, stimulatory, and preparative actions. Endocrine Reviews, 21(1), 55–89.CrossRefGoogle Scholar
  49. Schulz, R., & Martire, L. (2004). Family caregiving of persons with dementia: prevalence, health effects, and support strategies. The American Journal of Geriatric Psychiatry, 12, 240–249.Google Scholar
  50. Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis. New York: Oxford University Press.CrossRefGoogle Scholar
  51. Steffen, A. M., McKibbin, C., Zeiss, A. M., Gallagher-Thompson, D., & Bandura, A. (2002). The revised scale for caregiving self-efficacy: reliability and validity studies. Journal of Gerontology: Series B, Psychological Sciences, 57, P74–P86.Google Scholar
  52. Suinn, R. M., Ahuna, C., & Khoo, G. (1992). The Suinn-Lew Asian Self-Identity Acculturation Scale: concurrent and factorial validation. Educational and Psychological Measurement, 52, 1041–1046.CrossRefGoogle Scholar
  53. Tarlow, B., Wisniewski, S., Belle, S., Rubert, M., Ory, M., & Gallagher-Thompson, D. (2004). Positive aspects of caregiving, contributions of the REACH project to the development of a new measure for Alzheimer’s caregiving. Research on Aging, 26, 429–453.CrossRefGoogle Scholar
  54. Teri, L., Truax, P., Logsdon, R., Uomoto, J., Zarit, S., & Vitaliano, P. (1992). Assessment of behavioral problems in dementia: the Revised Memory and Behavior Problems Checklist (RMBPC). Psychology and Aging, 7, 622–631.CrossRefGoogle Scholar
  55. U.S. Census Bureau. (2008). An older and more diverse nation by midcentury. Retrieved October 29, 2009, from
  56. Valle, R. (1998). Caregiving across cultures. Washington, DC: Routledge/Taylor & Francis.Google Scholar
  57. Vedhara, K., Cox, N. K. M., Wilcock, G. K., Perks, P., Hunt, M., Anderson, S., et al. (1999). Chronic stress in elderly carers of dementia patients and antibody response to influenza vaccination. Lancet, 353, 627–631.CrossRefGoogle Scholar
  58. Vitaliano, P., Russo, J., Carr, J., Maiuro, R., & Becker, J. (1985). The ways of coping checklist: revision and psychometric properties. Multivariate Behavioral Research, 20, 3–26.CrossRefGoogle Scholar
  59. Vitaliano, P. P., Zhang, J., & Scanlan, J. M. (2003). Is caregiving hazardous to one’s physical health? A meta-analysis. Psychological Bulletin, 129, 946–972.CrossRefGoogle Scholar
  60. Wahbeh, H., Kishiyama, S. S., Zajdel, D., & Oken, B. S. (2008). Salivary cortisol awakening response in mild Alzheimer’s disease, caregivers, and noncaregivers. Alzheimer’s Disease & Associated Disorders, 22(2), 181–183.CrossRefGoogle Scholar
  61. Wang, D., Laidlaw, K., Power, M. J., & Shen, J. (2010). Older people’s belief of filial piety in China: expectation and non-expectation. Clinical Gerontologist, 33, 21–38.CrossRefGoogle Scholar
  62. Weinstein, M., Goldman, N., Hedley, A., Yu-Hsuan, L., & Seeman, T. (2003). Social linkages to biological markers of health among the elderly. Journal of Biosocial Science, 35, 433–453.CrossRefGoogle Scholar
  63. Wong, D. F. K., Tsui, H. K. P., Pearson, V., Chen, E. Y. H., & Chiu, S. N. (2004). Family burdens, Chinese health beliefs, and the mental health of Chinese caregivers in Hong Kong. Transcultural Psychiatry, 41, 497–513.CrossRefGoogle Scholar
  64. Yeo, G., & Gallagher-Thompson, D. (Eds.). (2006). Ethnicity and the Dementias (2nd ed.). NY: Routledge.Google Scholar
  65. Zhan, H. J. (2006). Joy and sorrow: explaining Chinese caregivers’ reward and stress. Journal of Aging Studies, 20, 27–38.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Center for Health Care Evaluation (152-MPD), VA Palo Alto Health Care SystemStanford University School of MedicineMenlo ParkUSA
  2. 2.Department of Psychiatry & Behavioral SciencesStanford University School of MedicinePalo AltoUSA

Personalised recommendations