Family carers of frail older adults: An often forgotten potential client group

As the population of Australia and the rest of the world ages and the attention of health care providers turns to the needs of frail older adults, the family carers of those frail older adults are often overlooked. The time frame for caring for a frail spouse or parent can last for many years and sometimes a couple of decades or more. While some find caring for a family member with chronic illness and disability rewarding, many find it quite stressful. That stress leads to high levels of symptoms of depression, anxiety and high levels of anger including elevated prevalence of clinical depression and anxiety compared with matched non-carers. Physical health can be affected as well, with carers found to have depressed immune system functioning and at risk for a variety of stress-related diseases. Carers who are stressed by caring have higher levels of mortality as well. In general, distress is higher in carers for persons with dementia than for persons with physical impairments who are cognitively intact (Knight & Losada, 2011).

Psychologists can play a role in helping to reduce these high levels of stress. There are a number of evidence-based approaches to working with family carers (Coon et al., 2012). They fall into three broad types: psychoeducational skill-building interventions, psychotherapy and multicomponent interventions. For the psychoeducational approaches, behaviour management and progressively lowered stress threshold approaches focus on teaching the carer skills to manage the person with dementia more effectively. Behaviour management teaches the carer how to use behaviour therapy approaches to shape problem behaviours of the elderly while progressively lowered stress threshold approaches focus on finding ways to reduce environmental stressors for the patient and so reduce the likelihood of problem behaviours. Psychoeducational interventions for depression and anger focus on the family carer. These approaches teach skills drawn from cognitive behaviour therapy (CBT) principles to manage the carer’s own distress.

Most of the evidence-based psychotherapy interventions draw on CBT theory and skills along with knowledge of the family-caring experience to help carers manage their depression or anxiety. Coon et al. (2012) note that the range of techniques used draw from the gamut of CBT and that those delivering the services tend to be more highly trained than many of those doing the psychoeducational approaches, who have ranged from peer counsellors to highly educated professionals.

Multicomponent interventions incorporate more than one type of psychological approach. One of the best known is from the Mittelman group at New York University and involves a combination of two individual and four family sessions to start followed by availability of sessions to address crises and changes over the course of the following year (Mittelman, Epstein, & Pierzchala, 2003).

It is notable that most of the interventions studied to date focus on the primary family carer as an individual when caring is by its nature a family system event. While evidence from randomised control trials is generally lacking for family-level interventions, the conceptual appeal is obvious. The Qualls group at the University of Colorado in Colorado Springs has worked with families through the 'cycle of caring' experiences. The book Caregiver Family Therapy (Qualls & Williams, 2013) is recommended as an excellent source for understanding the family issues around caring, regardless of whether one is working with family sessions or only with a primarycarer.

Cultural issues also have strong influences on family caring, and not always in the directions that one might expect. In research over the past 20 years, my students, colleagues, and I compared carers across several cultural and national groups (Knight & Sayegh, 2010). In our work and in that of others, there appears to be a common core stress and coping model that links the frail elder’s impairment (behaviour problems in dementia or functional disability in physical frailty) to the carer’s perception of burden to poor mental and physical health outcomes. Differences across cultures were linked more to different use of coping strategies and differences in social support rather than to cultural values and perception of burden. To our surprise, the greater focus on familism values in other cultures were linked to higher levels of burden and worse outcomes.

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