Journal of General Internal Medicine

, Volume 18, Issue 12, pp 1006–1014 | Cite as

Patient and caregiver characteristics associated with depression in caregivers of patients with dementia

  • Kenneth E. CovinskyEmail author
  • Robert Newcomer
  • Patrick Fox
  • Joan Wood
  • Laura Sands
  • Kyle Dane
  • Kristine Yaffe
Original Articles


OBJECTIVE: Many patients with dementia who live at home would require nursing home care if they did not have the assistance of family caregivers. However, caregiving sometimes has adverse health consequences for caregivers, including very high rates of depression. The goal of this study was to determine the patient and caregiver characteristics associated with depression among caregivers of patients with dementia.

DESIGN: Cross-sectional study.

PARTICIPANTS AND SETTING: Five thousand six hundred and twenty-seven patients with moderate to advanced dementia and their primary caregivers upon enrollment in the Medicare Alzheimer’s Disease Demonstration (MADDE) at 8 locations in the United States.

MEASUREMENTS: Caregiver depression was defined as 6 or more symptoms on the 15-item Geriatric Depression Scale. Patient characteristics measured included ethnicity and other demographic characteristics, income, activities of daily living (ADL) function, Mini-Mental Status Exam (MMSE) score, and behavioral problems. Caregiver characteristics measured included demographic characteristics, relationship to the patient, hours spent caregiving, and ADL and Instrumental Activities of Daily Living (IADL) function. We used x2 and t tests to measure the bivariate relationships between patient and caregiver predictors and caregiver depression. We used logistic regression to determine the independent predictors of caregiver depression.

RESULTS: Thirty-two percent of caregivers reported 6 or more symptoms of depression and were classified as depressed. Independent patient predictors of caregiver depression included younger age (odds ratio [OR], 1.91; 95% confidence interval [CI], 1.33 to 2.76 in patients less than 65 years compared to patients over 85 years), white (OR, 1.53; 95% CI, 1.18 to 1.99) and Hispanic ethnicity (OR, 2.50; 95% CI, 1.69 to 3.70) compared to black ethnicity, education (OR, 1.16; 95% CI, 1.01 to 1.33 for those with less than a high school education), ADL dependence (OR, 1.55; 95% CI, 1.26 to 1.90 for patients dependent in 2 or more ADL compared to patients dependent in no ADL), and behavioral disturbance, particularly angry or aggressive behavior (OR, 1.47; 95% CI, 1.27 to 1.69 for patients with angry or aggressive behavior). Independent caregiver predictors of depression included low income (OR, 1.45; 95% CI, 1.18 to 1.77 for less than $10,000/per year, compared to >$20,000 per year), the relationship to the patient (OR, 2.73; 95% CI, 1.31 to 5.72 for wife, compared to son of male patient), hours spent caregiving (OR, 1.89; 95% CI, 1.51 to 2.38 for 40 to 79 hours/week compared to less than 40 hours/week), and functional dependence (OR, 2.53; 95% CI, 2.13 to 3.01 for ADL dependent compared to IADL independent).

CONCLUSION: Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.

Key words

caregivers depression Alzheimer’s disease dementia race/ethnicity 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Arno PS, Levine C, Memmott MM. The economic value of informal caregiving. Health Aff (Millwood). 1999;18:182–8.CrossRefGoogle Scholar
  2. 2.
    Covinsky KE, Eng C, Lui LY, et al. Reduced employment in caregivers of frail elders: impact of ethnicity, patient clinical characteristics, and caregiver characteristics. J Gerontol A Biol Sci Med Sci. 2001;56:M707–13.PubMedGoogle Scholar
  3. 3.
    Manton KG, Corder LS, Stallard E. Estimates of change in chronic disability and institutional incidence and prevalence rates in the US elderly population from the 1982, 1984, and 1989 National Long Term Care Survey. J Gerontol. 1993;48:S153–66.PubMedGoogle Scholar
  4. 4.
    Fried LP, Guralnik JM. Disability in older adults: evidence regarding significance, etiology, and risk. J Am Geriatr Soc. 1997;45:92–100.PubMedGoogle Scholar
  5. 5.
    Levine C. Home sweet hospital: the nature and limits of private responsibilities for home health care. J Aging Health. 1999;11:341–59.PubMedCrossRefGoogle Scholar
  6. 6.
    Levine C. The loneliness of the long-term care giver. Caring. 1999;18:54–7.PubMedGoogle Scholar
  7. 7.
    Bourgeois MS, Schulz R, Burgio L. Interventions for caregivers of patients with Alzheimer’s disease: a review and analysis of content, process, and outcomes. Int J Aging Hum Dev. 1996;43:35–92.PubMedGoogle Scholar
  8. 8.
    Donaldson C, Tarrier N, Burns A. The impact of the symptoms of dementia on caregivers. Br J Psychiatry. 1997;170:62–8.PubMedGoogle Scholar
  9. 9.
    Drinka TJ, Smith JC, Drinka PJ. Correlates of depression and burden for informal caregivers of patients in a geriatrics referral clinic. J Am Geriatr Soc. 1987;35:522–5.PubMedGoogle Scholar
  10. 10.
    Dunkin JJ, Anderson-Hanley C. Dementia caregiver burden: a review of the literature and guidelines for assessment and intervention. Neurology. 1998;51(1 suppl 1):S53–60; discussion S65–7.PubMedGoogle Scholar
  11. 11.
    Harwood DG, Barker WW, Cantillon M, Loewenstein DA, Ownby R, Duara R. Depressive symptomatology in first-degree family care-givers of Alzheimer disease patients: a cross-ethnic comparison. Alzheimer Dis Assoc Disord. 1998;12:340–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Haley WE, West CA, Wadley VG, et al. Psychological, social, and health impact of caregiving: a comparison of black and white dementia family caregivers and noncaregivers. Psychol Aging. 1995;10:540–52.PubMedCrossRefGoogle Scholar
  13. 13.
    Janevic MR, Connell CM. Racial, ethnic, and cultural differences in the dementia caregiving experience: recent findings. Gerontologist. 2001;41:334–47.PubMedGoogle Scholar
  14. 14.
    Ory MG, Hoffman RR III, Yee JL, Tennstedt S, Schulz R. Prevalence and impact of caregiving: a detailed comparison between dementia and nondementia caregivers. Gerontologist. 1999;39:177–85.PubMedCrossRefGoogle Scholar
  15. 15.
    Perel VD. Psychosocial impact of Alzheimer disease. JAMA. 1998;279:1038–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Rankin ED, Haut MW, Keefover RW. Clinical assessment of family caregivers in dementia. Gerontologist. 1992;32:813–21.PubMedGoogle Scholar
  17. 17.
    Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA. 1999;282:2215–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Schulz R, O’Brien AT, Bookwala J, Fleissner K. Psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates, and causes. Gerontologist. 1995;35:771–91.PubMedGoogle Scholar
  19. 19.
    Schulz R, Williamson GM. A 2-year longitudinal study of depression among Alzheimer’s caregivers. Psychol Aging. 1991;6:569–78.PubMedCrossRefGoogle Scholar
  20. 20.
    Covinsky KE, Fortinsky RH, Palmer RM, Kresevic DM, Landefeld CS. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med. 1997;126:417–25.PubMedGoogle Scholar
  21. 21.
    Covinsky KE, Kahana E, Chin MH, Palmer RM, Fortinsky RH, Landefeld CS. Depressive symptoms and 3-year mortality in older hospitalized medical patients. Ann Intern Med. 1999;130:563–9.PubMedGoogle Scholar
  22. 22.
    Clyburn LD, Stones MJ, Hadjistavropoulos T, Tuokko H. Predicting caregiver burden and depression in Alzheimer’s disease. J Gerontol B Psychol Sci Soc Sci. 2000;55:S2–13.PubMedGoogle Scholar
  23. 23.
    Livingston G, Manela M, Katona C. Depression and other psychiatric morbidity in carers of elderly people living at home. BMJ. 1996;312:153–6.PubMedGoogle Scholar
  24. 24.
    Yaffe K, Fox P, Newcomer R, et al. Patient and caregiver characteristics and nursing home placement in patients with dementia. JAMA. 2002;287:2090–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Fox P, Newcomer R, Yordi C, Arnsberger P. Lessons learned from the Medicare Alzheimer’s Disease Demonstration. Alzheimer Dis Assoc Disord. 2000;14:87–93.PubMedCrossRefGoogle Scholar
  26. 26.
    Newcomer R, Spitalny M, Fox P, Yordi C. Effects of the Medicare Alzheimer Disease Demonstration on the use of community-based services. Health Serv Res. 1999;34:645–67.PubMedGoogle Scholar
  27. 27.
    Newcomer R, Yordi C, DuNah R, Fox P, Wilkinson A. Effects of the Medicare Alzheimer’s Disease Demonstration on caregiver burden and depression. Health Serv Res. 1999;34:669–89.PubMedGoogle Scholar
  28. 28.
    Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98.PubMedCrossRefGoogle Scholar
  29. 29.
    Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.PubMedGoogle Scholar
  30. 30.
    Lawton MP, Moss M, Fulcomer M, Kleban MH. A research and service oriented multilevel assessment instrument. J Gerontol. 1982;37:91–9.PubMedGoogle Scholar
  31. 31.
    Sheikh J, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;6:165–73.Google Scholar
  32. 32.
    Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. 1982;17:37–49.PubMedCrossRefGoogle Scholar
  33. 33.
    Gerety MB, Williams JW Jr, Mulrow CD, et al. Performance of case-finding tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores. J Am Geriatr Soc. 1994;42:1103–9.PubMedGoogle Scholar
  34. 34.
    Burke WJ, Roccaforte WH, Wengel SP. The short form of the Geriatric Depression Scale: a comparison with the 30-item form. J Geriatr Psychiatry Neurol. 1991;4:173–8.PubMedCrossRefGoogle Scholar
  35. 35.
    Whooley MA, Browner WS. Association between depressive symptoms and mortality in older women. Study of Osteoporotic Fractures Research Group. Arch Intern Med. 1998;158:2129–35.PubMedCrossRefGoogle Scholar
  36. 36.
    Gonzales E. Resourcefullness, appraisals, and coping effects of family caregivers. Issues Ment Health Nurs. 1997;18:209–27.CrossRefGoogle Scholar
  37. 37.
    Cox C, Monk A. Strain among caregivers: comparing the experiences of African American and white caregivers seeking Alzheimer’s assistance. Int J Aging Human Dev. 1996;43:93–105.Google Scholar
  38. 38.
    Kessler R, McGonagle K, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry. 1994;51:8–19.PubMedGoogle Scholar
  39. 39.
    Aranda MP, Knight BG. The influence of ethnicity and culture on the caregiver stress and coping process: a sociocultural review and analysis. Gerontologist. 1997;37:342–54.PubMedGoogle Scholar
  40. 40.
    Hinton WL, Levkoff S. Constructing Alzheimer’s: narratives of lost identities, confusion and loneliness in old age. Cult Med Psychiatry. 1999;23:453–75.PubMedCrossRefGoogle Scholar
  41. 41.
    Ortiz A, Simmons J, Hinton WL. Locations of remorse and homelands of resilience: notes on grief and sense of loss of place of Latino and Irish-American caregivers of demented elders. Cult Med Psychiatry. 1999;23:477–500.PubMedCrossRefGoogle Scholar
  42. 42.
    Williamson GM, Schulz R. Relationship orientation, quality of prior relationship, and distress among caregivers of Alzheimer’s patients. Psychol Aging. 1990;5:502–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Karlawish JH, Casarett D, Klocinski J, Clark CM. The relationship between caregivers’ global ratings of Alzheimer’s disease patients’ quality of life, disease severity, and the caregiving experience. J Am Geriatr Soc. 2001;49:1066–70.PubMedCrossRefGoogle Scholar
  44. 44.
    Mace N, Rabins P. The 36-Hour Day. 3rd edn. Baltimore: Johns Hopkins University Press; 1999.Google Scholar
  45. 45.
    Mittelman MS, Ferris SH, Shulman E, et al. A comprehensive support program: effect on depression in spouse-caregivers of AD patients. Gerontologist. 1995;35:792–802.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Kenneth E. Covinsky
    • 1
    Email author
  • Robert Newcomer
    • 2
  • Patrick Fox
    • 2
  • Joan Wood
    • 1
  • Laura Sands
    • 1
  • Kyle Dane
    • 1
  • Kristine Yaffe
    • 3
  1. 1.Received from the Department of MedicineUniversity of California, San Francisco and the San Francisco VA Medical CenterSan Francisco
  2. 2.Institute for Health and AgingUniversity of California, San Francisco and the San Francisco VA Medical CenterSan Francisco
  3. 3.the Departments of Psychiatry, Neurology, and Epidemiology and BiostatisticsUniversity of California, San Francisco and the San Francisco VA Medical CenterSan Francisco

Personalised recommendations