|Year : 2015 | Volume
| Issue : 6 | Page : 239-247
Caregiver Burden for Patients with Dementia with or Without Hiring Foreign Health Aides: A Cross-Sectional Study in a Northern Taiwan Memory Clinic
Nian-Sheng Tzeng1, Chiung-Wen Chang2, Ju-Yueh Hsu1, Yu-Ching Chou3, Hsin-An Chang1, Yu-Chen Kao4
1 Department of Psychiatry, Tri Service General Hospital, School of Medicine, National Defense Medical Center; Student Counseling Center, National Defense Medical Center, Taipei, Taiwan
2 Department of Psychiatry, Tri Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
3 School of Public Health, National Defense Medical Center, Taipei, Taiwan
4 Department of Psychiatry, Tri Service General Hospital, School of Medicine, National Defense Medical Center; Department of Psychiatry, Tri Service General Hospital, Song-Shan Branch, National Defense Medical Center, Taipei, Taiwan
|Date of Submission||12-Aug-2015|
|Date of Acceptance||26-Oct-2015|
|Date of Web Publication||31-Dec-2015|
325, Sec. 2, Cheng Gung Road, Nei Hu District 114, Taipei
Source of Support: None, Conflict of Interest: None
Background: The aim of the present study was to determine the prevalence, profile, and severity of dementia and the relative impact of these factors on caregiver burden in a selected population of persons with dementia and their caregivers. Methods: A convenience sample of 100 outpatients and their family caregivers dyads who presented to a memory clinic in one medical center during one consecutive year were recruited. The diagnosis and severity of dementia were determined according to the Diagnostic and Statistical Manual of Mental Disorders, Version IV, Text Revision. The clinical dementia rating scale, mini-mental status examination, and Clinical Global Impression of severity were also administered. The caregiver strain index was used to assess caregiver burden. Results: Caregiver burden is related to the severity of dementia, impairment of cognitive function, and severity of neuropsychiatric symptoms. The caregivers who were younger, nonspousal family members, had a poor relationship with the dementia patient, and psychosomatic symptoms after caring for the patient, or provided longer hours of care-giving, experienced greater strains. Hiring foreign helpers was not associated with a lower caregiver burden. Conclusions: Greater caregiver burden is associated with several factors related to persons with dementia and their caregivers. A possible over-burden on caregivers should be of concern in Taiwan. Hiring foreign helpers was not associated with a lower caregiver burden.
Keywords: Dementia, caregiver burden, foreign health aides
|How to cite this article:|
Tzeng NS, Chang CW, Hsu JY, Chou YC, Chang HA, Kao YC. Caregiver Burden for Patients with Dementia with or Without Hiring Foreign Health Aides: A Cross-Sectional Study in a Northern Taiwan Memory Clinic. J Med Sci 2015;35:239-47
|How to cite this URL:|
Tzeng NS, Chang CW, Hsu JY, Chou YC, Chang HA, Kao YC. Caregiver Burden for Patients with Dementia with or Without Hiring Foreign Health Aides: A Cross-Sectional Study in a Northern Taiwan Memory Clinic. J Med Sci [serial online] 2015 [cited 2022 Jan 16];35:239-47. Available from: https://www.jmedscindmc.com/text.asp?2015/35/6/239/172999
| Introduction|| |
There are 35.6 million people who have dementia and 7.7 million new cases every year worldwide.  Between 2011 and 2012, 130,000 people or 4.97% of those aged 65 and over in Taiwan had dementia.  In Taiwan, about 80% of the dementia patients are cared by their family members, a situation similar to that in Western countries.  Since family caregivers play an essential role in the care of these patients, the stress from care-giving often threatens the caregivers' mental and physical health or even their quality of life. ,, Caregiver strains have been defined as a multidimensional response to physical, psychological, emotional, social, and financial stressors associated with the care-giving experiences. ,,
Caregiver burdens or strains are often heavy and usually affect the health of both caregivers and care-recipients.  Several tools have been developed to assess caregiver burdens in terms of physical burden, psychological/emotion burden, social burden, economic burden and development restraint burden, , and even mental health problems.  Previous studies have suggested that disease-related factors, caregivers' sociodemographic factors, and care-giving-related factors are three important contributors to caregiver burdens. ,
Since 1992, foreign workers have started immigrating to Taiwan, among these workers, up to 167,980 foreigners, in 2008, became foreign nurse aides and caregivers,  some of them work in long-term care facilities, , and some of them work at their employers' home as foreign home care helpers for the dementia patients. ,,,, The influence of whether hiring foreign helpers on the caregiver burden would also be investigated.
| Materials and Methods|| |
All participants, patients with dementia, and their caregivers provide their written informed consents to participate in the study, and the next of kin or legally authorized representative consented on the behalf of participants with dementia.
Subjects and clinical assessments
Using convenience sampling, we recruited 100 dyads of patients with dementia and their caregivers who together visited the outpatient memory clinic in a medical center during 1 year. Individuals living in institutions or in-patients with severe physical disease were not eligible for inclusion. One senior board-certified psychiatrist with a subspecialty in geriatric psychiatry confirmed and assessed the diagnosis, type, and severity of each patient with dementia according to the Diagnostic and Statistical Manual of Mental Disorders, Version IV, Text Revision. Two certified psychiatric social workers interviewed the caregivers, with semi-structured questionnaires for collection of the demographic data, relationship between the family caregivers and the dementia patients, and self-report psychological and somatic symptoms, such as depression, anxiety, headaches, or digestive problems of the caregivers.
Data about dementia patients included their demographics, diagnosis, clinical dementia rating scale (CDR), mini-mental status examination (MMSE), and Clinical Global Impression of Severity (CGI-S) as determined by the psychiatrist. Caregiver data were collected during face-to-face interviews in the outpatient clinic, by the two experienced psychiatric social workers who then completed the caregiver strain index (CSI).
The CDR consists of six domains such as memory, orientation, judgment/problem solving, community affairs, home hobbies, and personal care. CDR scores range from 0 to 3, 0 means healthy, 0.5 questionable or very mild impairment, 1 mild impairment, 2 moderate impairment, and 3 severe impairment. This scale is commonly used to stage dementia of Alzheimer's type, ,, vascular or other types of dementia, and cognitive impairments. ,,
Dementia patients are frequently associated with behavioral and psychological disturbances or neuropsychiatric symptoms.  The CGI rating scale is commonly used to measure symptom severity, treatment response, and the efficacy of treatments. , The CGI-S scale is a 7-point scale that requires the clinician to rate the severity of the patient's illness at the time of assessment relative to the clinician's experience with patients who have the same diagnosis. Considering total clinical experience, a patient is assessed by the rater on the severity of mental illness at the time of rating as 1 normal not at all ill, 2 suspect mentally ill, 3 mildly ill, 4 moderately ill, 5 markedly ill, 6 severely ill, or 7 extremely ill. This scale has been used with different diagnoses including schizophrenia, , bipolar disorder,  panic disorder and depression,  and dementia. 
The MMSE is a brief 30-point questionnaire that is used to screen for cognitive impairment.  It samples functions including arithmetic, memory, and orientation. In our study, we used two cut-off points to divide patients' MMSE scores into 3 groups. Group 1 as MMSE scores <10 meant severe impairment. Group 2 as MMSE scores from 10 to 24 meant mild to moderate impairment. Group 3 as MMSE scores >24 meant normal. The MMSE has also been used to estimate the severity of cognitive impairment  and to follow the course of cognitive changes in an individual over time, , thus making it an effective way to document an individual's response to treatment. ,
The CSI is a tool that can be used to identify quickly families with potential concerns about care-giving. It was developed by Robinson in 1983 to screen for strain in caregivers of patients with chronic illnesses. , The CSI is a 13-question tool that measures strain related to the provision of care. CSI scores range from 0 to 13 with a cut-off point of 7; scores under 7 mean a low burden and those above 7 mean a high burden. CSI covers physical, social, financial, and emotional domains. The internal consistency of the CSI, as assessed by Cronbach's α, was 0.86.  This index has been used to evaluate caregiver burden for major mental or physical illnesses, such as schizophrenia or bipolar disorder,  spinal cord injuries,  dementia, ,,,, Parkinson's disease, , and older patients with cancers. 
All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the Institutional and/or National Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable Ethical Standards. (TSGHIRB-1-102-05-102).
Demographic data are presented as frequencies, percentages, means, and standard deviations (SD). Correlations between caregiver burden and variables including patient and caregiver demographic factors, disease-related factors, and care-giving-related factors were assessed with Pearson's correlation coefficient and Spearman's correlation coefficient according to the characteristics of the data. All statistical tests were two-tailed, and values of P < 0.05 were considered statistically significant. Data were analyzed with IBM SPSS statistics version 22 (IBM; SPSS; Statistics 22).
| Results|| |
Dementia patients and disease-related characteristics
The ages of dementia patients ranged from 59 to 99 (mean = 79.9) and 56% were female. The mean age at diagnosis was 76.73 and the average disease course was 2.7 years. With regard to type of dementia, 64% were diagnosed as Alzheimer's dementia, 27% as vascular dementia, 7% as mixed dementia, and 2% as other. About 90.1% of the dementia patients had other physical problems. About 69% had significantly impaired memory function. In terms of behavioral and psychological disturbances, 37% had nighttime wandering and about 26% had agitated behavior and depressed mood. For cognitive enhancement pharmacotherapy, 72% received none, 7% donepezil, 12% rivastigmine, and 9% memantine.
CDR scores ranged from 0.5 (very mild) to 3 (severe) and were divided into 4 groups such as group 1 (very mild, CDR score = 0.5) accounted for 1%, group 2 (mild, CDR score = 1) 43%, group 3 (moderate, CDR score = 2) 37%, and group 4 (severe, CDR score = 3) 19%. MMSE scores ranged from 0 to 29 and were divided into 3 groups such as group 1 (MMSE score <10) accounted for 29%, group 2 (MMSE score = 10 and <24) 64%, and group 3 (MMSE score was ≥24) 7%. CSI-S scores ranged from 2 to 4 and were divided into three groups such as group 1 (CGI-S score = 2) made up 24%, group 2 (CGI-S score = 3) 56%, and group 3 (CGI-S score = 4) 20% [Table 1].
Caregiver and caring-related characteristics
The caregivers ranged in age from 18 to 86 (mean = 57.38) and 60% were female. With regard to marital status, 16% were single, 82% married, and 2% widowed. Of the dementia patients, 31% were cared for by spouses, and 69% were cared for by nonspousal family members, including children and their spouses (66%) and grandsons or granddaughters (3%). In terms of resident status, 74% lived together with the dementia patient. Twenty-eight percent were unemployed, 8% worked part time jobs, 33% had full-time jobs, and 31% were retired. For level of education, 3% were illiterate, 9% were elementary school graduates, 12% junior high school, 25% senior high school, 47% college, and 4% graduate school and above.
Most of the caregivers received help from others-74% from other family members and 32% from foreign domestic helpers. On average, caregivers spent 8.85 h/day and 2.87 years in care-giving. In caring for dementia patients, 77% developed psychological and somatic symptoms such as depression, anxiety, headaches, or digestive problems. Of the self-reported health condition of caregivers, 11% considered themselves very good, 22% good, 35% normal, 30% poor, and 2% very poor. Thirty-two percent of caregivers reported that their relationship with the dementia patient now at that time was very good, 30% good, 26% normal, 10% poor, and 2% very poor [Table 2].
Caregiver burden and its association with dementia
CSI scores ranged from 0 to 13, the mean was 8.85 (SD = 3.675), and 73% were in the high burden (>7) group [Table 3].
The 3 highest scores were "some behavior is upsetting" (0.85 0.359), "there have been emotional adjustments" (0.83 0.378) and "there have been changes in personal plans" (0.83 0.378). The 3 lowest scores were "I feel completely overwhelmed" (0.39 0.490), "care-giving is a financial strain" (0.46 0.501) and "there have been work adjustments" (0.52 0.502).
Correlations among predictors and caregiver burden
There were small to moderate positive relationships between CDR, CGI-S, number of hours in care-giving, current relationship with the dementia patient, psychosomatic symptoms after caring, and caregiver burden. The CSI was correlated with the severity of dementia (CDR, r = 0.507, P < 0.01), impairment of cognitive function (MMSE, r = −0.506, P < 0.01), and severity of neuropsychiatric symptoms (CGI-S, r = 0.225, P < 0.05). The more severe the stage of impairment of cognitive function or progress of neuropsychiatric symptoms in persons with dementia the greater burden caregivers experienced. Caregivers who were younger (r = −0.271, P < 0.01), nonspouses (r = 0.313, P < 0.01) had a poor relationship with the dementia patient (r = 0.240, P < 0.05) had psychosomatic symptoms after caring (r = 0.374, P < 0.01) or provided longer hours of care-giving (r = 0.235, P < 0.05) experienced greater burdens [Table 4].
|Table 4: Correlations for the impact of caregiver demographics, disease and care-giving-related factors on caregiver burden |
Click here to view
Of the total of 100 caregivers, 32 hired foreign domestic helpers for assistance in caring for the dementia patients. There is no significant difference between the groups with or without hiring a foreign health aide in the MMSE scores, CDR, and CGI-S of the patients with dementia. However, 51 of those still had a high caregiver burdens (CSI score >7). Twenty-two of the 32 caregivers who had not hired any foreign helpers showed high caregiver burdens. There was no significant difference between the burdens of caregivers who hired foreign helpers and those who did not; however, the caregiver time spending to the dementia patients was significantly different between the two groups [Table 5].
|Table 5: Comparison of cognitive functions, severity and caregiver burden between groups hiring a foreign aid or not |
Click here to view
| Discussion|| |
The CGI-S, CDR, and MMSE of the patient were associated with the CSI of the caregiver. The higher the stage of dementia or severity of the neuropsychiatric symptoms or the lower the cognitive function of the patient the greater the burden on the caregiver. These findings are similar to those in previous studies. ,, We used CGI-S to rate patients' severity of neuropsychiatric symptoms, and most in this selected outpatient population were in the mild to moderately severe range. In previous studies that used the Neuropsychiatric Inventory (NPI) or other scales, similar findings suggested that the more severe the neuropsychiatric symptoms the greater the caregiver burden. ,, Even though we used a simple tool to rate the severity of neuropsychiatric symptoms, the findings were similar. This suggests that for clinicians, the CGI-S might be a good tool to evaluate both the symptom severity and the caregiver burden.
Previous studies have suggested that caregivers' gender, age, education, and living together with dementia patients were significantly related to caregiver burden. Caregivers with lower educational levels were at a disadvantage in accessing resources, had less ability to cope with stress and formulate strategies, tended to get depressed, and had higher case loading than those with higher levels of educational. In our study, however, caregivers' education level had no significant relationship with caregiver burden. In our study, when caregivers were younger, their burdens were greater. This finding was consistent with previous studies. Because 84% of caregivers were married (82% married, 2% widowed) and 69% were nonspouses (children and/or their spouses, grandsons or granddaughters), these caregivers not only cared for the dementia patient but also cared for their own children or worked. The caregivers played multiple roles at the same time, and overloading happened easily.
In general, closer kinship ties (spouse, child, and siblings) were an early factor found to influence caregiver burden. ,, In this study, those with a poor relationship with dementia patients experienced higher strains. Zarit et al. originally noted that wives experienced a greater caregiver burden, compared to other family members.  More recently, Chumbler et al. found no significant difference in caregiver burden between caregivers who were adult children or spouses.  Tang et al. found that about 52% of the caregivers in China were spouses.  Compared to Taiwan, Fuh found that most caregivers were adult children or daughters-in-law. ,
In the Western literature, major caregivers were spouses, , but in the Asia-Pacific area, they were more often children. The profile of caregivers in our sample was comparable to that described in other Asia-Pacific studies. ,, In our study, many caregivers were adult male children, as well as female spouses, daughters, and daughters-in-law. The result was different from that in non-Asian countries. This may be related to oriental cultural values. "Xiao" or filial piety is considered a key virtue in Chinese culture and means to be good to or to take care of one's parents. ,, In our society, the percentage of elders living with the spouse or children was higher than that in Western countries as most family members believe that they have a responsibility to take care of elders because of Xiao. Having a good relationship between a patient and caregiver was related to greater caregiver burden. This paradoxical finding may partially explain the double-edged effects of ties between family members, either the caregivers or the recipients.
The average hours of care were 25-50 h/week in previous studies. ,, In our study, the average was 8.85 h/day or 61.95 h/week. Longer hours in caring resulted in a greater caregiver burden. In our study, psychosomatic symptoms after caring were positively correlated with caregiver burden. This suggests that when caring hour were longer, the caregiver burden increased, and psychosomatic symptoms also increased. In this study, 59.4% of the caregivers reported depression and anxiety and 59.4% sleeping disturbances, consistent with past studies. It is important to evaluate regularly the caregiver burden to decrease the risk of overload.
Tsao and Chiu reported that the assistance that foreign domestic helpers could provide reduced the psychological or physical burden on primary family caregivers for physically challenged elderly persons; however, these studies had smaller sample sizes (n = 13 and 17 respectively) and mixed disabilities. , In our study, there were no significant differences in caregiver burden between groups with or without foreign domestic helpers. These findings were not compatible with the anticipation that hiring foreign domestic helpers could reduce the caregiver burden. From the 2008 Report of Taiwan's Council of Labor Affairs, the main purpose (92.1%) in hiring foreign domestic helpers was to provide appropriate care to ill family members, share psychological stress (63.5%), and allow family to go to work (54.1%). In previous studies, 62% of the employers and families spend about 5 h/day taking turns with their foreign domestic helpers in caring for patients, instead of giving all the care work to the foreign domestic helpers. , In our study, the caregivers' time spending to the dementia patients in the group hiring foreign helpers is shorter than the group not hiring foreign helpers, as 6.77 5.57 < 9.83 6.25 h a day (P = 0.002). However, the CSI scores are not significantly different between two groups. This hints that the caregivers who hire foreign helpers might have other stressors related to patient-caring, even though they have spared some time from caring the dementia patients. For example, the money expenditures on hiring foreign aides would be economic burden for them. The basic salary of one foreign health helper would cost a family additional 17,000 New Taiwan dollars (around USD 550 dollars) a month, not including the health insurance and other fees. 
Subjects were recruited from only one memory clinic in a medical center hospital in Northern Taiwan. The sample size was rather small, and the study utilized a cross-sectional design, and may describe only these patients and their caregivers and not all of Taiwan.
Considering the limitations of real-life clinical situations, we used the CGI instead of the NPI or other tools to evaluate the severity of neuropsychiatric symptoms and the behavioral and psychological symptoms of dementia, but the results were still consistent with those of studies using the NPI or other tools, in that caregiver burden was associated with symptom severity. ,
The complex issues in caregiver-related factors should be included as predictors; these include caregiver overload, caregiver role captivity, and caregiver's experience with care-giving. More qualitative research is recommended to assess the true predictive value of the factors we investigated.
| Conclusions|| |
Greater caregiver burdens were related to moderate or severe dementia and the time spent in caring for the patients. The caregivers, who were younger, nonspousal family members, had a poor relationship with the dementia patient, had psychosomatic symptoms after caring, and provided longer hours of care-giving, experienced greater burdens. Hiring foreign helpers was not associated with a lower caregiver burden. The majority of the caregivers are offspring and, in this study, male offspring were over-represented. The great burden on caregivers should be of concern in Taiwan.
The authors would like to thank all the clinical workers in the dementia clinic in Tri-Service General Hospital for their assistance in this study. We also thank Professor San-Yuan Huang and Ms. Wei-Shan Chiang for their help in the paper work and the process of research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Dementia Cases Set to Triple by 2050 But Still Largely Ignored. Available from: http://www.who.int/mediacentre/news/releases/2012/dementia_20120411/en/index.html. [Last accessed on 2015 Aug 1].
Taiwan Alzheimer`s Disease Association. 2015-2056 Expected Dementia Popultion Report in Taiwan. Available from: http://www.tada2002.org.tw/tada_know_02.html#01. [Last accessed on 2015 Aug 1].
Liu HC, Lin KN, Tsou HK, Lee KM, Yan SH, Wang SJ, et al
. Impact of demented patients on their family members and care-givers in Taiwan. Neuroepidemiology 1991;10:143-9.
Kuo LM, Huang HL, Hsu WC, Shyu YI. Health-related quality of life and self-efficacy of managing behavior problems for family caregivers of vascular dementia and Alzheimer's disease patients. Dement Geriatr Cogn Disord 2014;38:310-20.
Chou KR, LaMontagne LL, Hepworth JT. Burden experienced by caregivers of relatives with dementia in Taiwan. Nurs Res 1999;48:206-14.
Etters L, Goodall D, Harrison BE. Caregiver burden among dementia patient caregivers: A review of the literature. J Am Acad Nurse Pract 2008;20:423-8.
Liu Y, Insel KC, Reed PG, Crist JD. Family caregiving of older Chinese people with dementia: Testing a model. Nurs Res 2012;61:39-50.
Gaugler JE, Kane RL, Kane RA, Newcomer R. Unmet care needs and key outcomes in dementia. J Am Geriatr Soc 2005;53:2098-105.
Beeri MS, Werner P, Davidson M, Noy S. The cost of behavioral and psychological symptoms of dementia (BPSD) in community dwelling Alzheimer's disease patients. Int J Geriatr Psychiatry 2002;17:403-8.
Iecovich E. Caregiving burden, community services, and quality of life of primary caregivers of frail elderly persons. J Appl Gerontol 2008;27:309-30.
Schulz R, Martire LM. Family caregiving of persons with dementia: Prevalence, health effects, and support strategies. Am J Geriatr Psychiatry 2004;12:240-9.
Kim H, Chang M, Rose K, Kim S. Predictors of caregiver burden in caregivers of individuals with dementia. J Adv Nurs 2012;68:846-55.
Council of Labor Affairs. Council of Labor Affairs. The Report of Foreign Work Application and Administration. Taipei: Council of Labor Affairs; 2008.
Huang FF, Yang HH. The effects of nationality differences and work stressors on work adjustment for foreign nurse aides. BMC Health Serv Res 2011;11:192.
Sung HC, Chang SM, Tsai CS. Working in long-term care settings for older people with dementia: Nurses' aides. J Clin Nurs 2005;14:587-93.
Tsao YS. A Study of Hiring Foreign Care Helpers for Primary Family Caregivers of the Elders and its Influence on Care Relationship. Unpublished Master Thesis. Taipei, Taiwan (in Traditional Chinese with English Abstract): National Taiwan University; 2002.
Chiu YW. A Study on the Participation of a Foreign Carer in Family Care for Disabled Elders. Unpublished Ph.D Thesis. Taichung, Taiwan, (in Traditional Chinese with English Abstract): Tunghai University; 2009.
Ministry of Labor. Statistic Digest of Labor Trends. Available from: http://www.statdb.mol.gov.tw/html/trend/1011/htm/51202.pdf. [Last accessed on 2015 Aug 1].
Cheng SJ. Migrant women domestic workers in Hong Kong, Singapore and Taiwan: A comparative analysis. Asian Pac Migr J 1996;5:139-52.
Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry 1982;140:566-72.
Rubin EH, Morris JC, Grant EA, Vendegna T. Very mild senile dementia of the Alzheimer type. I. Clinical assessment. Arch Neurol 1989;46:379-82.
Davis PB, Morris JC, Grant E. Brief screening tests versus clinical staging in senile dementia of the Alzheimer type. J Am Geriatr Soc 1990;38:129-35.
Gupta M, Dasgupta A, Khwaja GA, Chowdhury D, Patidar Y, Batra A. Behavioural and psychological symptoms in poststroke vascular cognitive impairment. Behav Neurol 2014;2014:430128.
Taemeeyapradit U, Udomittipong D, Tepparak N. Characteristics of behavioral and psychological symptoms of dementia, severity and levels of distress on caregivers. J Med Assoc Thai 2014;97:423-30.
Nakamura K, Kasai M, Ouchi Y, Nakatsuka M, Tanaka N, Kato Y, et al
. Apathy is more severe in vascular than amnestic mild cognitive impairment in a community: The Kurihara Project. Psychiatry Clin Neurosci 2013;67:517-25.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition: DSM-IV-TR. Arlington, VA, USA: American Psychiatric Publication; 2000.
Guy W. ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: U.S. Dept. of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs; 1976.
Rush JA. Psychiatric Measures. Washington, DC: Ameican Psychiatric Association; 2000.
Donlon PT, Swaback DO, Osborne ML. Pimozide versus fluphenazine in ambulatory schizophrenics: A 12-month comparison study. Dis Nerv Syst 1977;38:119-23.
Kopala LC, Good KP, Honer WG. Extrapyramidal signs and clinical symptoms in first-episode schizophrenia: Response to low-dose risperidone. J Clin Psychopharmacol 1997;17:308-13.
Spearing MK, Post RM, Leverich GS, Brandt D, Nolen W. Modification of the Clinical Global Impressions (CGI) Scale for use in bipolar illness (BP): The CGI-BP. Psychiatry Res 1997;73:159-71.
Leon AC, Shear MK, Klerman GL, Portera L, Rosenbaum JF, Goldenberg I. A comparison of symptom determinants of patient and clinician global ratings in patients with panic disorder and depression. J Clin Psychopharmacol 1993;13:327-31.
Dahlke F, Lohaus A, Gutzmann H. Reliability and clinical concepts underlying global judgments in dementia: Implications for clinical research. Psychopharmacol Bull 1992;28:425-32.
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.
Dick JP, Guiloff RJ, Stewart A, Blackstock J, Bielawska C, Paul EA, et al
. Mini-mental state examination in neurological patients. J Neurol Neurosurg Psychiatry 1984;47:496-9.
Zun L, Howes DS. The mental status evaluation. Application in the emergency department. Am J Emerg Med 1988;6:165-72.
Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 2003;41:678-84.
Eagger SA, Levy R, Sahakian BJ. Tacrine in Alzheimer's disease. Lancet 1991;337:989-92.
Gauthier S, Leuzy A, Racine E, Rosa-Neto P. Diagnosis and management of Alzheimer's disease: Past, present and future ethical issues. Prog Neurobiol 2013;110:102-13.
Robinson BC. Validation of a Caregiver Strain Index. J Gerontol 1983;38:344-8.
Sullivan MT. Caregiver Strain Index (CSI). In: Assessment Tools- Try This® Tools and Resources for Achieving the Best Practices in the Care of Older Adults. Hartford Institute of Geriatric Nursing Website; 2002.
Rodrigo C, Fernando T, Rajapakse S, De Silva V, Hanwella R. Caregiver strain and symptoms of depression among principal caregivers of patients with schizophrenia and bipolar affective disorder in Sri Lanka. Int J Ment Health Syst 2013;7:2.
Middleton JW, Simpson GK, De Wolf A, Quirk R, Descallar J, Cameron ID. Psychological distress, quality of life, and burden in caregivers during community reintegration after spinal cord injury. Arch Phys Med Rehabil 2014;95:1312-9.
Bradshaw LE, Goldberg SE, Schneider JM, Harwood RH. Carers for older people with co-morbid cognitive impairment in general hospital: Characteristics and psychological well-being. Int J Geriatr Psychiatry 2013;28:681-90.
Diwan S, Hougham GW, Sachs GA. Strain experienced by caregivers of dementia patients receiving palliative care: Findings from the Palliative Excellence in Alzheimer Care Efforts (PEACE) Program. J Palliat Med 2004;7:797-807.
Hoskins S, Coleman M, McNeely D. Stress in carers of individuals with dementia and Community Mental Health Teams: An uncontrolled evaluation study. J Adv Nurs 2005;50:325-33.
Simpson R, Wakefield P, Spiers N, Jagger C, Lindesay J. Carer-held records for dementia: A controlled trial. Int Psychogeriatr 2006;18:259-68.
Yarmo-Roberts D, Freak-Poli RL, Cooper B, Noonan T, Stolewinder J, Reid CM. The heart of the matter: Health status of aged care clients receiving home- and community-based care. J Aging Res 2010;2010:275303.
Santos-García D, de la Fuente-Fernández R. Factors contributing to caregivers' stress and burden in Parkinson's disease. Acta Neurol Scand 2015;131:203-10.
van der Marck MA, Bloem BR, Borm GF, Overeem S, Munneke M, Guttman M. Effectiveness of multidisciplinary care for Parkinson's disease: A randomized, controlled trial. Mov Disord 2013;28:605-11.
Hsu T, Loscalzo M, Ramani R, Forman S, Popplewell L, Clark K, et al
. Factors associated with high burden in caregivers of older adults with cancer. Cancer 2014;120:2927-35.
Hughes TB, Black BS, Albert M, Gitlin LN, Johnson DM, Lyketsos CG, et al
. Correlates of objective and subjective measures of caregiver burden among dementia caregivers: Influence of unmet patient and caregiver dementia-related care needs. 2014;26:1875-83.
Mioshi E, Foxe D, Leslie F, Savage S, Hsieh S, Miller L, et al
. The impact of dementia severity on caregiver burden in frontotemporal dementia and Alzheimer disease. Alzheimer Dis Assoc Disord 2013;27:68-73.
Fauth EB, Gibbons A. Which behavioral and psychological symptoms of dementia are the most problematic? Variability by prevalence, intensity, distress ratings, and associations with caregiver depressive symptoms. Int J Geriatr Psychiatry 2014;29:263-71.
Kaufer DI, Cummings JL, Christine D, Bray T, Castellon S, Masterman D, et al
. Assessing the impact of neuropsychiatric symptoms in Alzheimer's disease: The Neuropsychiatric Inventory Caregiver Distress Scale. J Am Geriatr Soc 1998;46:210-5.
Fuh JL, Liu CK, Mega MS, Wang SJ, Cummings JL. Behavioral disorders and caregivers' reaction in Taiwanese patients with Alzheimer's disease. Int Psychogeriatr 2001;13:121-8.
Brody EM, Litvin SJ, Hoffman C, Kleban MH. Marital status of caregiving daughters and co-residence with dependent parents. Gerontologist 1995;35:75-85.
Lévesque L, Ducharme F, Lachance L. Is there a difference between family caregiving of institutionalized elders with or without dementia? West J Nurs Res 1999;21:472-91413.
Zarit SH, Reever KE, Bach-Peterson J. Relatives of the impaired elderly: Correlates of feelings of burden. Gerontologist 1980;20:649-55.
Chumbler NR, Grimm JW, Cody M, Beck C. Gender, kinship and caregiver burden: The case of community-dwelling memory impaired seniors. Int J Geriatr Psychiatry 2003;18:722-32.
Tang B, Harary E, Kurzman R, Mould-Quevedo JF, Pan S, Yang J, et al
. Clinical characterization and the caregiver burden of dementia in China. Value Health Reg Issues 2013;2:118-26.
Hung SS, Liao YC, Wang WF. The factors associated with burden of caring patients with dementia: A memory clinic based study. Taiwan J Psychiatry (Taipei) 2012;26:96-104.
Fuh JL. Dementia in Taiwan: Current status. Taiwan Geriatr Gerontol (Tradit Chin) 2008;3:169-81.
Wimo A, von Strauss E, Nordberg G, Sassi F, Johansson L. Time spent on informal and formal care giving for persons with dementia in Sweden. Health Policy 2002;61:255-68.
Baumgarten M, Battista RN, Infante-Rivard C, Hanley JA, Becker R, Gauthier S. The psychological and physical health of family members caring for an elderly person with dementia. J Clin Epidemiol 1992;45:61-70.
Neubauer S, Holle R, Menn P, Grossfeld-Schmitz M, Graesel E. Measurement of informal care time in a study of patients with dementia. Int Psychogeriatr 2008;20:1160-76.
Tew CW, Tan LF, Luo N, Ng WY, Yap P. Why family caregivers choose to institutionalize a loved one with dementia: A Singapore perspective. Dement Geriatr Cogn Disord 2010;30:509-16.
Cheng ST, Lam LC, Kwok T, Ng NS, Fung AW. The social networks of Hong Kong Chinese family caregivers of Alzheimer's disease: Correlates with positive gains and burden. Gerontologist 2013;53:998-1008.
Sun F, Ong R, Burnette D. The influence of ethnicity and culture on dementia caregiving: A review of empirical studies on Chinese Americans. Am J Alzheimers Dis Other Demen 2012;27:13-22.
Asai MO, Kameoka VA. The influence of Sekentei on family caregiving and underutilization of social services among Japanese caregivers. Soc Work 2005;50:111-8.
Kim Y. Korean american family postcaregivers on dementia caregiving: A phenomenological inquiry. J Gerontol Soc Work 2009;52:600-17.
Ministry of Labor. Questions and Answers about the Foreign Domestic Workers Salary Issues. Available from: http://www.mol.gov.tw/announcement/2101/23601/. [Last accessed on 2015 Aug 1].
Fuh JL, Wang SJ, Liu HC, Wang HC. The caregiving burden scale among Chinese caregivers of Alzheimer patients. Dement Geriatr Cogn Disord 1999;10:186-91.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|This article has been cited by|
||Association Between Antibiotic Treatment of Chlamydia pneumoniae and Reduced Risk of Alzheimer Dementia: A Nationwide Cohort Study in Taiwan
| ||Hsun Ou,Wu-Chien Chien,Chi-Hsiang Chung,Hsin-An Chang,Yu-Chen Kao,Pei-Chuan Wu,Nian-Sheng Tzeng |
| ||Frontiers in Aging Neuroscience. 2021; 13 |
|[Pubmed] | [DOI]|
||Are Anticholinergic Medications Associated With Increased Risk of Dementia and Behavioral and Psychological Symptoms of Dementia? A Nationwide 15-Year Follow-Up Cohort Study in Taiwan
| ||Yia-Ping Liu,Wu-Chien Chien,Chi-Hsiang Chung,Hsin-An Chang,Yu-Chen Kao,Nian-Sheng Tzeng |
| ||Frontiers in Pharmacology. 2020; 11 |
|[Pubmed] | [DOI]|
||The Needs and Utilization of Long-Term Care Service Resources by Dementia Family Caregivers and the Affecting Factors
| ||Chia-Hui Chang,Yung Ming,Tsung-Hung Chang,Yea-Yin Yen,Shou-Jen Lan |
| ||International Journal of Environmental Research and Public Health. 2020; 17(16): 6009 |
|[Pubmed] | [DOI]|
||Association between the Use of Dipeptidyl Peptidase 4 Inhibitors and the Risk of Dementia among Patients with Type 2 Diabetes in Taiwan
| ||Kuan-Chan Chen,Chi-Hsiang Chung,Chieh-Hua Lu,Nian-Sheng Tzeng,Chien-Hsing Lee,Sheng-Chiang Su,Feng-Chih Kuo,Jhih-Syuan Liu,Chang-Hsun Hsieh,Wu-Chien Chien |
| ||Journal of Clinical Medicine. 2020; 9(3): 660 |
|[Pubmed] | [DOI]|
||Positive aspect of caregiving among primary informal dementia caregivers in Singapore
| ||Fiona Devi,Qi Yuan,Peizhi Wang,Gregory Tee Hng Tan,Richard Roshan Goveas,Li Ling Ng,Siow Ann Chong,Mythily Subramaniam,Hemachandra Reddy |
| ||PLOS ONE. 2020; 15(8): e0237677 |
|[Pubmed] | [DOI]|
New Users of Herbal Medicine Containing Aristolochic Acids and the Risk of Dementia in the Elderly: A Nationwide, Population-Based Study in Taiwan
| ||Yueh-Er Chiou,Wu-Chien Chien,Chi-Hsiang Chung,Hsin-An Chang,Yu-Chen Kao,Pei-Kwei Tsay,Nian-Sheng Tzeng |
| ||Neuropsychiatric Disease and Treatment. 2020; Volume 16: 1493 |
|[Pubmed] | [DOI]|
||Association between amphetamine-related disorders and dementia-a nationwide cohort study in Taiwan
| ||Nian-Sheng Tzeng,Wu-Chien Chien,Chi-Hsiang Chung,Hsin-An Chang,Yu-Chen Kao,Yia-Ping Liu |
| ||Annals of Clinical and Translational Neurology. 2020; |
|[Pubmed] | [DOI]|
||Increased risk of dementia in patients with genital warts: A nationwide cohort study in Taiwan
| ||Chia-Hua Lin,Wu-Chien Chien,Chi-Hsiang Chung,Chien-Ping Chiang,Wei-Ming Wang,Hsin-An Chang,Yu-Chen Kao,Nian-Sheng Tzeng |
| ||The Journal of Dermatology. 2020; |
|[Pubmed] | [DOI]|
||Risk of Dementia in Adults With ADHD: A Nationwide, Population-Based Cohort Study in Taiwan
| ||Nian-Sheng Tzeng,Chi-Hsiang Chung,Fu-Huang Lin,Chin-Bin Yeh,San-Yuan Huang,Ru-Band Lu,Hsin-An Chang,Yu-Chen Kao,Hui-Wen Yeh,Wei-Shan Chiang,Yu-Ching Chou,Chang-Huei Tsao,Yung-Fu Wu,Wu-Chien Chien |
| ||Journal of Attention Disorders. 2019; 23(9): 995 |
|[Pubmed] | [DOI]|
||Mediating effects of burden on quality of life for caregivers of first-time stroke patients discharged from the hospital within one year
| ||Yu-Hsia Tsai,Meei-Fang Lou,Tsui-Hsia Feng,Tsung-Lan Chu,Ying-Jen Chen,Hsueh-Erh Liu |
| ||BMC Neurology. 2018; 18(1) |
|[Pubmed] | [DOI]|
||Electroconvulsive Therapy and Risk of Dementia—A Nationwide Cohort Study in Taiwan
| ||Ching-Wen Chu,Wu-Chien Chien,Chi-Hsiang Chung,Pei-Chun Chao,Hsin-An Chang,Yu-Chen Kao,Yu-Ching Chou,Nian-Sheng Tzeng |
| ||Frontiers in Psychiatry. 2018; 9 |
|[Pubmed] | [DOI]|
||Cognitive enhancers associated with decreased risk of injury in patients with dementia: a nationwide cohort study in Taiwan
| ||Pei-Chun Chao,Wu-Chien Chien,Chi-Hsiang Chung,Ching-Wen Chu,Chin-Bin Yeh,San-Yuan Huang,Ru-Band Lu,Hsin-An Chang,Yu-Chen Kao,Hui-Wen Yeh,Wei-Shan Chiang,Yu-Ching Chou,Nian-Sheng Tzeng |
| ||Journal of Investigative Medicine. 2018; 66(3): 684 |
|[Pubmed] | [DOI]|
||Risk of dementia after charcoal-burning suicide attempts: a nationwide cohort study in Taiwan
| ||Shan-Yueh Chang,Wu-Chien Chien,Chi-Hsiang Chung,Hsin-An Chang,Yu-Chen Kao,Hui-Wen Yeh,Yu-Ching Chou,Chung-Kan Peng,Chih-Hao Shen,Nian-Sheng Tzeng |
| ||Journal of Investigative Medicine. 2018; 66(7): 1070 |
|[Pubmed] | [DOI]|
||Anti-herpetic Medications and Reduced Risk of Dementia in Patients with Herpes Simplex Virus Infections—a Nationwide, Population-Based Cohort Study in Taiwan
| ||Nian-Sheng Tzeng,Chi-Hsiang Chung,Fu-Huang Lin,Chien-Ping Chiang,Chin-Bin Yeh,San-Yuan Huang,Ru-Band Lu,Hsin-An Chang,Yu-Chen Kao,Hui-Wen Yeh,Wei-Shan Chiang,Yu-Ching Chou,Chang-Huei Tsao,Yung-Fu Wu,Wu-Chien Chien |
| ||Neurotherapeutics. 2018; |
|[Pubmed] | [DOI]|
||Fibromyalgia and Risk of Dementia—A Nationwide, Population-Based, Cohort Study
| ||Nian-Sheng Tzeng,Chi-Hsiang Chung,Feng-Cheng Liu,Yu-Hsiang Chiu,Hsin-An Chang,Chin-Bin Yeh,San-Yuan Huang,Ru-Band Lu,Hui-Wen Yeh,Yu-Chen Kao,Wei-Shan Chiang,Chang-Hui Tsao,Yung-Fu Wu,Yu-Ching Chou,Fu-Huang Lin,Wu-Chien Chien |
| ||The American Journal of the Medical Sciences. 2018; 355(2): 153 |
|[Pubmed] | [DOI]|
||Magnesium oxide use and reduced risk of dementia: a retrospective, nationwide cohort study in Taiwan
| ||Nian-Sheng Tzeng,Chi-Hsiang Chung,Fu-Huang Lin,Ching-Feng Huang,Chin-Bin Yeh,San-Yuan Huang,Ru-Band Lu,Hsin-An Chang,Yu-Chen Kao,Hui-Wen Yeh,Wei-Shan Chiang,Yu-Ching Chou,Chang-Huei Tsao,Yung-Fu Wu,Wu-Chien Chien |
| ||Current Medical Research and Opinion. 2017; : 1 |
|[Pubmed] | [DOI]|
||Risky wandering behaviors of persons with dementia predict family caregivers’ health outcomes
| ||Li-Min Peng,Yi-Chen Chiu,Jersey Liang,Ting Huan Chang |
| ||Aging & Mental Health. 2017; : 1 |
|[Pubmed] | [DOI]|
||Balancing competing needs mediates the association of caregiving demand with caregiver role strain and depressive symptoms of dementia caregivers: A cross-sectional study
| ||Hsin-Yun Liu,Ching-Tzu Yang,Yu-Nu Wang,Wen-Chuin Hsu,Tzu-Hsin Huang,Yueh-E Lin,Chin-Yi Liu,Yea-Ing L. Shyu |
| ||Journal of Advanced Nursing. 2017; |
|[Pubmed] | [DOI]|