NUR 7643 Module 6 Dementia Caregiver Case: Caregiver Strain, REACH II and Counseling That Delays Placement Example

Eleven Years of Caring: Treating Depression and Strain in a 76-Year-Old Wife Whose Husband Has Alzheimer Disease

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7643: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Populations Part B

Mentor Name

Month Day, Year

Eleven Years of Caring: Treating Depression and Strain in a 76-Year-Old Wife Whose Husband Has Alzheimer Disease

The Patient Is the Caregiver

Rosa, an invented patient, is 76 and lives in Elizabeth with her husband, Ernesto, who was diagnosed with Alzheimer disease eleven years ago. He now needs help dressing and bathing, wanders at night, sometimes does not recognize her and becomes upset in the late afternoon. Their two children live in Texas and Florida and call weekly. Rosa does all his care. She came to her primary care visit for her blood pressure, which is now poorly controlled, and broke down in tears when asked how she was managing.

She sleeps about four hours a night because Ernesto wakes and tries to leave the house. She has lost ten pounds, has stopped going to Mass, feels hopeless and guilty that she sometimes loses her temper with him, and says she feels like a prisoner in her own home. She has missed two of her own medical appointments because no one could stay with him. She denies thoughts of suicide but says she sometimes wishes it could all be over. She speaks Spanish at home and is more comfortable with it in the visit.

Her own background shapes the picture. She came from Puerto Rico at nineteen, worked in a garment factory and then as a school cafeteria aide, and raised her children while Ernesto drove a delivery truck. She believes that caring for her husband is her duty and that asking for help would shame the family. Her children have offered to pay for help before, and she refused. The paper treats these beliefs with respect while helping her see that accepting support can be part of keeping her promise to him.

Assessment

Rosa's PHQ-9, given in Spanish, is 17, consistent with moderately severe depression. Her interview confirms a major depressive episode: two months and more of sadness, no interest in Mass or friends, broken sleep, lost weight, guilt and a sense that nothing will change. Her wish that it could be over is explored: she means an end to the exhaustion, not to her life, and she has no plan. Her blood pressure, weight loss and missed appointments are part of the picture. Elder mistreatment is also considered, gently, since exhausted caregivers sometimes lose control; she describes raising her voice but never hitting or neglecting Ernesto, and his care at home appears safe.

Why the Caregiver's Health Matters

Schulz and Beach (1999) followed 392 older spouses who were caregivers and 427 who were not, aged 66 to 96, for an average of four and a half years. After adjusting for age, illness and other factors, spouses who said caregiving strained them mentally or emotionally died at a rate 1.63 times that of spouses who gave no care, over roughly four and a half years, while caregivers who did not feel strained had no clear increase. The study showed that strain, not caregiving alone, carried the risk. For Rosa, her poorly controlled blood pressure, weight loss and missed appointments are treated as part of this danger, not side issues.

A Structured Caregiver Program

Belle et al. (2006) tested the REACH II program with 642 caregivers of people with Alzheimer disease or related dementias in five U.S. cities, including 212 Hispanic or Latino, 219 white and 211 Black or African American caregivers. The program offered twelve home and telephone sessions over six months covering the caregiver's mood, strain, own health, support network and the loved one's difficult behaviors, tailored to each caregiver's risks. Quality of life rose further with the program among Hispanic and white caregivers and among Black caregivers who were spouses, and clinical depression was lower, 12.6 percent compared with 22.7 percent.

Rosa is enrolled in a similar program delivered in Spanish through a local agency on aging. Sessions teach her ways to respond to Ernesto's late-day agitation and night wandering, how to make the house safer, including door alarms, how to manage her own stress and how to ask for help.

Counseling for the Family

Mittelman et al. (2006) randomly assigned 406 spouse caregivers of people with Alzheimer disease to an enhanced counseling and support program or usual care. The program offered six sessions of individual and family counseling, ongoing support group participation and telephone counseling whenever needed. Those whose spouses received the program had a 28.3 percent lower rate of nursing home placement, with a predicted delay of 557 days, and much of this effect came from better social support, better responses to behavior problems and fewer depressive symptoms in the caregiver.

For Rosa, two family sessions are held by video with her children, who agree to split the cost of an aide on Monday, Wednesday and Friday mornings and to call on set days. Her son plans to visit for a week each season. A Spanish-language caregiver support group meets at her parish.

Treating Her Depression

A low starting dose of sertraline is added because her score sits in the moderately severe band and she prefers medicine alongside the program. Sodium is checked at four weeks. Her blood pressure medicine is adjusted. Ernesto's own night waking is addressed with his clinician, since better sleep for him means better sleep for her, and an adult day program is arranged to give her time for her own appointments.

Planning Ahead

Rosa and her children begin discussing what will happen if she can no longer care for Ernesto at home. This is framed not as giving up but as planning, and the counseling trial's finding that support delays placement is shared as hope that home care can continue longer with help. A plan is made for emergencies, naming who will care for Ernesto if Rosa is ill.

Conclusion

Rosa has major depression after eleven years of caring alone for her husband with Alzheimer disease, with sleep loss, weight loss and neglected health that a large study links to higher mortality in strained caregivers. A Spanish-language program modeled on REACH II, family counseling drawn from a trial that delayed placement, respite, a home aide, sertraline and attention to her blood pressure form her plan. Her PHQ-9, sleep, weight and blood pressure will be reviewed monthly, and her children share the work.

References

Belle, S. H., Burgio, L., Burns, R., Coon, D., Czaja, S. J., Gallagher-Thompson, D., Gitlin, L. N., Klinger, J., Koepke, K. M., Lee, C. C., Martindale-Adams, J., Nichols, L., Schulz, R., Stahl, S., Stevens, A., Winter, L., & Zhang, S. (2006). Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: A randomized, controlled trial. Annals of Internal Medicine, 145(10), 727-738. https://doi.org/10.7326/0003-4819-145-10-200611210-00005

Mittelman, M. S., Haley, W. E., Clay, O. J., & Roth, D. L. (2006). Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology, 67(9), 1592-1599. https://doi.org/10.1212/01.wnl.0000242727.81172.91

Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality: The Caregiver Health Effects Study. JAMA, 282(23), 2215-2219. https://doi.org/10.1001/jama.282.23.2215