Journal of Gerontological Nursing

Effects of the Quality of Dyadic Relationships on the Psychological Well-Being of Elderly Care-Recipients

Barbara L Nunley, RN, CS, MS; Lynne A Hall, RN, DrPH; Graham D Rowles, PHD

Abstract

ABSTRACT

The purpose of this study was to examine the association of the quality of caregiver relationships with the psychological well-being of elderly care- recipients. Sociodemographic variables and characteristics of the care- recipient situation (e.g., self-rated physical health, amount of instrumental support needed) were explored as potential predictors of the psychological well-being of elderly individuals. A secondary analysis of data collected during inhome interviews with 37 community-dwelling older adults revealed no significant correlations between the quality of the primary intimate relationship and any dimension of psychological well-being. However, better self-rated health was associated with fewer depressive symptoms, higher morale, greater life satisfaction, and better quality of life. The more instrumental support needed by an individual, the greater their depressive symptoms and the lower their morale. The findings also revealed that the older the individual was, the greater the depressive symptoms were and the lower life satisfaction became. Self- rated physical health predicted each dimension of psychological well-being. The findings suggest that age, the amount of instrumental support needed, and perceptions of physical health are important indicators of the psychological well-being of elderly care- recipients.

Abstract

ABSTRACT

The purpose of this study was to examine the association of the quality of caregiver relationships with the psychological well-being of elderly care- recipients. Sociodemographic variables and characteristics of the care- recipient situation (e.g., self-rated physical health, amount of instrumental support needed) were explored as potential predictors of the psychological well-being of elderly individuals. A secondary analysis of data collected during inhome interviews with 37 community-dwelling older adults revealed no significant correlations between the quality of the primary intimate relationship and any dimension of psychological well-being. However, better self-rated health was associated with fewer depressive symptoms, higher morale, greater life satisfaction, and better quality of life. The more instrumental support needed by an individual, the greater their depressive symptoms and the lower their morale. The findings also revealed that the older the individual was, the greater the depressive symptoms were and the lower life satisfaction became. Self- rated physical health predicted each dimension of psychological well-being. The findings suggest that age, the amount of instrumental support needed, and perceptions of physical health are important indicators of the psychological well-being of elderly care- recipients.

During the past decade, there has been an abundance of literature on informal caregivers - a portion of which focuses on characteristics of dyadic caregiving relationships. This literature suggests the degree of involvement in caregiving is determined by the quality of the relationship between the caregiver and the care-recipient (Morris, Morris, & Britton, 1988; Pallet, 1990; Pruchno, Michaels, & Potashnik, 1990), and dyadic interactions influence the level of commitment to caregiving. Caregivers who are emotionally invested in the relationship with the carerecipient report lower levels of depression and caregiver burden than those who are less emotionally invested (Pruchno & Resch, 1989). Motenko (1989) reported that wife caregivers' well-being was enhanced by continuing expression of marital affection. Kramer (1993) found that the quality of the relationship prior to the onset of Alzheimer's disease was an important predictor of depression, quality of life, and caregiving satisfaction among wife caregivers. Mui (1995) found that the quality of the relationship with the parent was one of the most important predictors of emotional strain for daughters caring for frail elderly parents. Spaid and Barusch (1994) discovered that closeness between the caregiver and care-recipient explained 45% of the variance in predicting burden among 131 older spouse caregivers. Wright (1993) explored the impact of Alzheimer's disease on the marital relationship and found that caregiver spouses remain committed to marriage as an institution by clinging to the image of the afflicted spouse as a valued person.

While the effects of the quality of dyadic relationships on the psychological well-being of the caregiver have been documented, a gap remains in the literature regarding the effect of such relationships on the psychological well-being of the care-recipient. This study investigated the effects of the quality of the relationships with the primary caregivers on the psychological well-being of elderly care-recipients and sought to contribute additional insight into factors affecting the psychological well-being of elderly care-recipients.

Psychological well-being was defined as involving the dimensions of depressive symptomatology, morale, life satisfaction, and quality of life. The study tested the hypothesis that elderly individuals reporting a positive intimate relationship with their caregiver would have fewer depressive symptoms, higher morale, and greater life satisfaction and quality of life than those with less positive relationships. A secondary purpose of this study was to explore sociodemographic variables and characteristics of the care-recipient situation that might be of additional explanatory value in understanding psychological well-being of elderly individuals.

Table

TABLE 1SOCIODEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE OF ELDERLY CARE-RECIPIENTS (N = 37)

TABLE 1

SOCIODEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE OF ELDERLY CARE-RECIPIENTS (N = 37)

RELATED LITERATURE

Strong attachment to a special person has been correlated with dimensions of psychological well-being among older adults (Ducharme & Rowat, 1992; Rickelman, Gallman, & Parra, 1994; Roos & Havens, 1991). In a study of 100 older men, Rickelman et al. (1994) found that a strong level of attachment to a significant other, primarily a spouse, was positively correlated with quality of life for 67% of respondents. Ducharme and Rowat (1992) found a positive relationship between well-being and conjugal support for both men and women. Roos and Havens (1991) studied the determinants of successful aging in a 12-year longitudinal study of a cohort of representative elderly individuals, 65 to 84 years of age. Successful aging was defined as:

* Living to an advanced age.

* Retaining the ability to function independently.

* Remaining mentally alert.

Individuals who expressed more satisfaction with their lives were those whose spouses remained alive at the end of the study period. Factors associated with psychological well-being in elderly individuals vary across studies and provide inconsistent findings. In a number of studies, self-rated physical health of elderly individuals has been strongly associated with their psychological wellbeing (Heidrich, 1993; Heidrich & D'Amico, 1993; Rickelman et al., 1994; Roos & Havens, 1991). Another factor showing an associawith psychological well-being is amount of instrumental support (Heidrich, 1993; Heidrich & D'Amico, 1993). In a study of 41 men with some form of arthritis, Bradbury and Catanzaro (1989) found that physical impairments imposed by the disease negatively affected participants' perceptions of quality of life. In contrast, Levin (1994) found that physical disabilities in a sample of 98 participants, mostly women between the ages of 60 and 90, had no relationship to quality of life. Marital status, gender, race, education, age, and income also have shown inconsistent associations with psychological wellbeing (Arling, 1987; Heidrich, 1993; Heidrich & D'Amico, 1993; Rickelman et al, 1994).

METHOD

Sample

Data for this study were crosssectional and collected during inhome interviews with 37 community-dwelling elderly individuals. The sample was recruited from a research volunteer pool of a Center on Aging affiliated with a University Medical Center (McCurren, Hall, & Rowles, 1993). The Center is an academic, research, and service unit of the University. Inclusion criteria were:

* Seventy-five years of age or older.

* Scoring in the "intact intellectual functioning" range of the Short Portable Mental Status Questionnaire (Pfeiffer, 1975).

* Indicating a primary caregiver provides instrumental assistance to the elderly care-recipient.

The 37 care-recipients in the sample had a mean age of 79.1 years (SD - 4.8; range 73 to 94). Sixty-four percent had more than a high school education and 77% had an income in excess of $15,000. The majority of the sample were White (92%), and slightly more than half (51%) were women. Sociodemographic characteristics of the study sample are shown in Table 1.

Measures

Physical health. Self-rated physical health was measured by a single item. The participants rated their health as very good (4), good (3), fair (2), or poor (1). Subjective ratings of health have been used in numerous studies and are regarded as a valid proxy for objective health (Chipperfield, 1993).

Instrumental support needed. An Instrumental Support Activities Checklist (Hall & Rowles, 1987) measured the instrumental support needed. This 20-item checklist (Table 2) measured the amount of instrumental assistance needed with tasks such as washing laundry, preparing meals, and light housekeeping chores (yes = 1, no = 0). This 20-item measure was adapted from items included in previous indices of instrumental support in elderly individuals (Kivett, 1985; Mutran, 1985; Stoller & Earl, 1983).

Autonomy and reUtedness inventory (ARI). The quality of elderly care-recipient and caregiver relationships was measured with the ARI (Schaefer & Edgerton, 1982). The ARI measures both the positive and negative dimensions of primary intimate relationships between two people. Subscales include:

* Autonomy.

* Relatedness.

* Acceptance.

* Support.

* Listening.

* Control.

* Detachment/rejection.

* Hostile control.

The care-recipients were asked to describe their perception of the caregivers' behavior toward them on 32 items. These items were rated on a 5p oint Likert scale ranging from not at all like (1) to very much like (5). Total cumulative scores range from 0 to 128 with higher scores indicating a more positive rating of the relationship. Cronbach's alpha for the total scores of previous studies ranged between .90 and .94 (Hall, Gurley, Sachs, & Kryscio, 1991; Hall & Kiernan, 1992). The construct validity of this instrument for measuring dyadic relationship quality was supported by correlations of the subscales with Spanier 's (1976) Dyadic Adjustment Scale among a sample of married women (Hall & Kiernan, 1992). The Cronbach's alpha for the sample of the present study was .87.

Psychological well-being. Psychological well-being was defined as including dimensions of depressive symptomatology, morale, life satisfaction, and quality of life. The following scales were used to measure the dimensions of psychological well-being.

* Center for Epidemiologic StudiesDepression scale (CES-D). The CESD (Radloff, 1977), a 20-item selfreport scale, was used to measure depressive symptomatology. Participants rated how frequently each symptom occurred during the past week on a scale ranging from rarely or none of the time (0) to most or all of the time (3). Cumulative scores range from 0 to 60 with a score of 16 or greater indicating high depressive symptoms. The CES-D has been used with elderly individuals (Heidrich, 1993; Heidrich & D'Amico, 1993) because it focuses on affective rather than somatic symptoms (Heidrich & D'Amico, 1993). Cronbach's alphas in previous studies ranged between .88 to .90 (Heidrich & D'Amico, 1993; Williamson & Schultz, 1993). In this sample the Cronbach's alpha was .72.

* Philadelphia Geriatric Center Morale scale (PGC). The 17-item PGC scale (Lawton, 1975) was used to measure the morale of the carerecipients. Morale was assessed in terms of three dimensions: agitation, attitudes toward aging, and lonely dissatisfaction. Higher scores indicate lower morale. Good internal consistency of the PGC was demonstrated with a Cronbach's alpha of .83 in appraising the well-being of 1 82 community-dwelling older adults (Ruffing-Rahal, 1991). In the present study, Cronbach's alpha was .80.

Table

TABLE 2INSTRUMENTAL SUPPORT ACTIVITIES CHECKLIST

TABLE 2

INSTRUMENTAL SUPPORT ACTIVITIES CHECKLIST

Life satisfaction and quality of life. These two dimensions of psychological well-being were measured using Cantril (1965) ladder scales. To measure life satisfaction, the respondents were shown a picture of a ladder with nine rungs, with the top rung labeled very satisfied (9) and the bottom rung labeled not at all satisfied (0). The quality of life ladder was labeled with the best possible life at the top rung (9), and the worst possib e life (0) at the bottom rung.

Procedure

Elderly participants who met the inclusion criteria were interviewed in their homes by trained interviewers. After giving informed consent, physical and psychological wellbeing assessments were then completed. The relationships among the quality of the primary intimate relationship of the care-recipient and caregiver dyad, the sociodemographic variables, and the characteristics of the care-recipient situation with the psychological well-being of the care-recipient were assessed with correlations, ?2, and t tests, as appropriate. Using multiple regression with backward elimination, the best predictive models for depressive symptoms, morale, life satisfaction, and quality of life were identified.

RESULTS

Descriptive Analyses

Eleven percent of elderly carerecipients reported their health as very good, 38% as good, 40% as fair, and 1 1 % as poor. Elderly individuals needed instrumental support with a mean number of activities of 6.3 (SD = 4.6; range 1 to 18). The mean CESD score was 10.7 (SD = 6.7; range 1 to 30); 22% of elderly individuals scored in the high range (CES-D > 16). Of 19 women in the sample, only 1 (3%) had high depressive symptoms. Of the 18 men, 7 (39%) had high depressive symptoms. Poor self-rated physical health was associated with high depressive symptoms (xp 2 = 10.8, df = 3, p = .01). Of the sociodemographic characteristics, only gender (xp 2 = 6.2, df = 1, p = .01) was significantly associated with high depressive symptoms.

Table

TABLE 3INTERCORRELATIONS OF DEPENDENT VARIABLES, SELF-RATED PHYSICAL HEALTH, AND INSTRUMENTAL SUPPORT NEEDED WITH THE QUALITY OF PRIMARY INTIMATE RELATIONSHIPS AS MEASURED BY THE AUTONOMY AND RELATEDNESS INVENTORY (N = 37)

TABLE 3

INTERCORRELATIONS OF DEPENDENT VARIABLES, SELF-RATED PHYSICAL HEALTH, AND INSTRUMENTAL SUPPORT NEEDED WITH THE QUALITY OF PRIMARY INTIMATE RELATIONSHIPS AS MEASURED BY THE AUTONOMY AND RELATEDNESS INVENTORY (N = 37)

Independent-samples t tests were conducted to assess potential differences in the major study variables by gender. The mean scores for men and women did not differ for the quality of the primary intimate relationship, depressive symptoms, morale, life satisfaction, quality of life, self-rated physical health, or instrumental support needed.

Correlational Analyses

The intercorrelations among the dependent variables and the quality of the primary intimate relationship, self-rated health, and instrumental support needed are shown in Table 3. Not surprisingly, higher depressive symptoms were associated with lower morale, life satisfaction, and quality of life. Lower morale also was associated with lower life satisfaction and lower quality of life. Higher quality of life was correlated with greater life satisfaction. There were no significant correlations between the quality of the primary intimate relationship and any dimension of psychological wellbeing, nor were there any significant gender correlations between the quality of the primary intimate relationship and any dimension of psychological well-being. However, some of the ARI subscales were correlated with the dependent variables, self-rated health, and instrumental support needed:

Table

TABLE 4MULTIPLE REGRESSION ESTIMATES FOR THE BEST PREDICTIVE MODELS OF DEPRESSIVE SYMPTOMS, MORALE, LIFE SATISFACTION, AND QUALITY OF LIFE (N = 37)

TABLE 4

MULTIPLE REGRESSION ESTIMATES FOR THE BEST PREDICTIVE MODELS OF DEPRESSIVE SYMPTOMS, MORALE, LIFE SATISFACTION, AND QUALITY OF LIFE (N = 37)

* Support and life satisfaction (.52, p = .001).

* Acceptance and self-rated health (.34, p = .04).

* Autonomy and instrumental support needed (-.36, p = .03).

Thus, the more support given by the caregiver, the greater the life satisfaction of the care-recipient. In addition, the better the self-rated health of the care-recipient, the more accepting the care-recipient, and the more instrumental support needed by the care-recipient the less autonomy perceived in the relationship with the caregiver.

Better self-rated health was associated with a lower level of depressive symptomatology, higher morale, and greater life satisfaction and quality of life. The greater the need for instrumental support, the higher the level of depressive symptomatology and the lower the life satisfaction. The only significant associations with age, marital status, gender, race, income, level of education, and any dimension of psychological well-being were between age and the CES-D (.42, p = .01) and between age and life satisfaction (-A3, p = .01). This indicates that the older the individual, the higher the level of depressive symptoms and the lower the life satisfaction.

Regression Analyses

The results of backward elimination to identify the best predictive models for depressive symptoms, morale, life satisfaction, and quality of life are shown in Table 4. Predictors included in each initial model were:

* The quality of the primary intimate relationship.

* Gender.

* Income.

* Self-rated physical health.

* Amount of instrumental support needed.

These variables were allowed to eliminate one at a time at/) > .05. The quality of the primary intimate relationship, gender, and income did not predict any dimension of psychological well-being. In contrast, self-rated physical health was associated with each dimension of psychological well-being. The amount of instrumental support needed was associated only with depressive symptoms. Selfrated physical health and the amount of instrumental support needed accounted for 45% of the variance in depressive symptoms. Self-rated physical health accounted for 39% of the variance in morale, 15% in life satisfaction, and 24% in quality of life.

DISCUSSION

The quality of the primary intimate relationship was not associated with depressive symptoms, morale, life satisfaction, or quality of life. Therefore, the hypothesis was not supported in this sample of elderly individuals. This finding is not consistent with previous research (Ducharme & Rowat, 1992; Rickelman et al., 1994; Roos & Havens, 1991). One can only conjecture that this finding is a result of sample characteristics and the small sample size rather than the conceptualization of the relationship between the quality of the primary intimate relationship and psychological well-being. Ac-cording to Brubaker, Gorman, and Hiestand (1990), the relationship between the care-recipient and caregiver is influenced by both personal and situational characteristics of the carerecipient. Such attributes of the carerecipient contribute to their wellbeing and may promote a positive relationship between the care-recipient and the caregiver. As indicated by the mean score of the. ARI, a positive relationship did exist overall within the dyads.

Another finding of the present study, which is quite different from previous research, was that men (39%) reported higher depressive symptoms than women (3%). Historically, women have reported higher levels of depressive symptoms than men (Kennedy et al, 1989; Murreil, Himmelfarb, & Wright, 1983). An explanation for this finding may be found in a study by Berkman et al. (1986). Berkman et al. investigated the relationship of physical health and functioning to depressive symptoms in 2,806 noninstitutionalized elderly. Men experienced a steady increase in depressive symptoms with age, whereas women reached a peak at 75 to 79 years of age. In addition, women had higher rates of depressive symptoms than men until the age of 85 when men began to have the higher scores. These findings indicate an increasing prevalence of depressive symptoms among men and a decreasing prevalence among women with advanced old age. In adults 80 years old or older, Mirowsky and Ross (1992) found that depression reaches a higher level at this age than at any other age because of physical dysfunction and low personal control. In addition, Arling (1987) found that noninstitutionalized elderly individuals of more advanced age had more life strain. In contrast, Heidrich (1993) found that depressive symptoms were not related to age. Consequently, the finding in the present study that men had a higher prevalence of depressive symptoms than women may be a result of the age of the sample which ranged from 73 to 94 years with a mean age of 79.1 years. However, further exploration of this phenomenon is needed.

The finding that self-rated physical health of older adults was a predictor of psychological well-being has been consistently documented in the literature (Heidrich, 1993; Heidrich & D'Amico, 1993; Rickelman et al., 1994). The greater the amount of instrumental support needed, the greater the depressive symptoms. This finding is congruent with those of Heidrich and D'Amico (1993), significantly relating depression to difficulty with activities of daily living.

The results of this study add to the few studies providing insight into factors affecting the psychological wellbeing of elderly care-recipients. The findings extend the knowledge that self-rated health is a strong predictor of psychological well-being in older adults. Further support also is given to the developing body of research linking age and the amount of instrumental support needed with depressive symptomatology. The findings of this study reveal a new dimension in the quality of the dyadic relationship between the care-recipient and the caregiver. Because of the multidimensionality of the care-recipient and caregiver relationship, attention needs to be directed toward identifying the dimensions enhancing the quality of relationships, improving psychological well-being, and sustaining the caregiving experience. This study contributes to developing this knowledge, because findings indicating the type of support given by the caregiver (e.g., "being there" and willing to help the care-recipient when needed, providing comfort when things go wrong, making things easier for the care-recipient) results in enhanced care-recipient satisfaction with their life situation.

Limitations

There are several limitations to this study. An existing data set was used for secondary analyses, which limited the study variables to those in the data set. This limited the ability to obtain information on other relevant variables, such as the medical diagnoses of the care-recipients, that could have influenced the findings in relation to depression. The small convenience sample was not representative of the general population of elder care-recipients. Sixtyfour percent of the sample had more than a high school education, and 77% had an income in excess of $15,000. Finally, the cross-sectional nature of the data does not permit the determination of causal relationships. Despite these limitations, some tentative clinical implications for advanced practice gerontological nurses working in the community can be suggested.

IMPLICATIONS FOR PRACTICE

Nursing interventions should be aimed at maintaining and promoting psychological well-being in the carerecipient and caregiver dyad through health-promotion and health-maintenance activities. These interventions should begin by including an assessment and evaluation of the quality of the dyadic relationship along with a multidimensional assessment. The instruments used in this study could be part of such an assessment.

To assess the quality of the dyadic relationship, the ARI (Schaefer & Edgerton, 1982) could be administered to each member of the dyad. Using this instrument, the carerecipient and caregiver would rate their perception of the relationship on the dimensions of Autonomy, Relatedness, Acceptance, Support, Listening, Control, Detachment and Rejection, and Hostile Control. Incongruences between the carerecipient's and the caregiver's perception of the relationship potentially could lead to various problems in the caregiving experience. By recognizing these incongruencies and consulting with the dyad, the nurse could assist the members in working toward more realistic goals and role responsibilities in the caregiving relationship (Cicirelli, 1990).

Other areas for nurses to assess when interfacing with caregiver dyads in the community are selfrated physical health, and the need for instrumental support. A subjective health rating scale and the Instrumental Support Activities Checklist (Hall & Rowles, 1987) could be administered (Table 2). Because poor self-rated physical health and high need for instrumental support are associated with depressive symptoms in the older population (Berkman et al., 1986; Heidrich & D'Amico, 1993; Murrell et al., 1983), nurses need to monitor these factors and initiate interventions to prevent a decline in psychological well-being. Finally, the CESD (Radloff, 1977) should be administered as part of the multidimensional assessment. The CES-D has been used extensively with elderly individuals and provides a basis for further diagnostic assessment for depression if warranted (Radloff & Teri, 1986).

Following assessment of the dyad, the nursing plan of care should involve both members in its development and implementation. Dyad members should be encouraged to discuss their needs and concerns. Teaching healthy coping strategies and ways to improve performance of instrumental activities may be beneficial in preventing depressive symptomatology (Berkman et al., 1986) and increasing life satisfaction (Levin, 1994). Measures to enhance the selfesteem of the care-recipient and caregiver also may be helpful. The nurse can promote and facilitate the use of secondary networks (formal and informal groups) which would provide additional support for the dyad.

CONCLUSION

The results of this research indicate that age, amount of instrumental support needed, perceptions of health, and type of support provided by the caregiver are important correlates of the psychological well-being of elderly care-recipients. However, further research is needed to verify these findings and to explore the quality of the primary intimate relationship within a larger and more diverse sample. In addition, evaluative research is needed to validate which nursing interventions are most effective in maintaining and promoting psychological well-being of the dyad. By directing research toward a better understanding of elderly care-recipients' psychological well-being, the clinician can assess and identify critical predictors impacting their psychological wellbeing. The identification of these predictors will ultimately result in discovering better ways to enhance and strengthen older adults' health and well-being.

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TABLE 1

SOCIODEMOGRAPHIC CHARACTERISTICS OF THE SAMPLE OF ELDERLY CARE-RECIPIENTS (N = 37)

TABLE 2

INSTRUMENTAL SUPPORT ACTIVITIES CHECKLIST

TABLE 3

INTERCORRELATIONS OF DEPENDENT VARIABLES, SELF-RATED PHYSICAL HEALTH, AND INSTRUMENTAL SUPPORT NEEDED WITH THE QUALITY OF PRIMARY INTIMATE RELATIONSHIPS AS MEASURED BY THE AUTONOMY AND RELATEDNESS INVENTORY (N = 37)

TABLE 4

MULTIPLE REGRESSION ESTIMATES FOR THE BEST PREDICTIVE MODELS OF DEPRESSIVE SYMPTOMS, MORALE, LIFE SATISFACTION, AND QUALITY OF LIFE (N = 37)

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