Preliminary Evidence for Effectiveness of Resourcefulness Training in Women Dementia Caregivers

Special Article – Family Caregivers

J Fam Med. 2016; 3(5): 1069.

Preliminary Evidence for Effectiveness of Resourcefulness Training in Women Dementia Caregivers

Zauszniewski JA1*, Lekhak N2, Burant CJ3, Variath M4 and Morris DL5

1Kate Hanna Harvey Professor of Community Health Nursing, Frances Payne Bolton (FPB) School of Nursing, Case Western Reserve University (CWRU), Cleveland, OH, USA

2Sarah Cole Hirsh Legacy Fellow, PhD nursing student, FPB School of Nursing, CWRU, Cleveland, OH, USA

3Assistant Professor, FPB School of Nursing, CWRU, Cleveland, OH, USA

4PhD Nursing Student, FPB School of Nursing, CWRU, Cleveland, OH, USA

5Florence Cellar Associate Professor of Gerontological Nursing, FPB School of Nursing, CWRU, Cleveland, OH, USA

*Corresponding author: Zauszniewski JA, Frances Payne Bolton School of Nursing, Case Western Reserve University, 2120 Cornell Road, Cleveland, OH 44106- 4904, USA

Received: June 20, 2016; Accepted: July 13, 2016; Published: July 15, 2016


Nearly 10 million women in the U.S. are caregivers for an elder with dementia, which often produces overwhelming stress and adversely affects their health. Resourcefulness training (RT) may promote the caregiver’s optimal health and continue in their caregiving role. This pilot trial of 138 women dementia caregivers examined the effectiveness of RT on perceived stress, depressive cognitions, and negative emotions over time. Caregivers were first randomized to RT or no RT and then further randomized into random versus choice conditions followed by assignment to the journal or recorder methods, thus creating eight groups. We examined differences on perceived stress, depressive cognitions, and negative emotions between groups: 1) RT versus no-RT, 2) choice versus random condition; and 3) journaling versus recording. Significant time by group interactions were found on stress (F=4.36, p<.05), depressive cognitions (F=10.93, p<.001), and negative emotions (F=20.48, p<.001) in the RT versus no RT group. No differences were found between the random versus choice conditions or the journaling versus recording methods for practicing the RT skills. The results provide evidence for the effectiveness of RT for decreasing stress, depressive cognitions, and negative emotions in women caregivers of elders with dementia. The findings also suggest the need for further examination of the effects of allowing caregivers to choose a method for practicing RT in larger samples if caregivers of elders with dementia.

Keywords: Dementia caregivers; Caregiver stress; Intervention; Resourcefulness


RT: Resourcefulness Training; NAC: The National Alliance for Caregiving; QOL: Quality of Life; REACH: Resources for Enhancing Alzheimer’s Caregiver Health; PSS: Perceived Stress Scale; DCS: Depressive Cognition Scale; ESC: Emotional Symptom Checklist; RMANOVA: Repeated Measures Analysis of Variance; RCTs: Randomized Controlled Trials


Every minute in the United States (US) a new case of Alzheimer’s disease or other dementia goes undetected, changing the affected elder’s family forever [1]. Typically, the closest and most accessible family member [2] assumes responsibility for the care of the elder. Dementia is the most under recognized health crisis of the 21st century with over 46 million people worldwide living with dementia, a number expected to reach 131.5 million by 2050 [3]. In the US, family members provide more than 18 billion hours of informal, unpaid care for over 5.4 million elders with dementia, costing more than $221 billion each year [1]. The annual cost associated with health care, long-term care, and hospice for persons with dementia is estimated to be $214 billion, making dementia one of the most costly chronic illnesses [4].

The National Alliance for Caregiving & the AARP Public Policy Institute reported that more than 50% of dementia caregivers perform activities of daily living, administer medications, and manage finances and communications, and other activities of the elders [5]. Compared to other caregivers, dementia caregivers report greater physical strain (28% vs 17%) due to the duration and complexity of dementia caregiving [5]. Approximately two thirds of dementia caregivers are women [1] who are known to experience overwhelming stress and adverse effects on their health and wellbeing [6-8]. Thus, there is a substantial need to provide women dementia caregivers with interventions to sustain their health. This study tested the effects of a resourcefulness training intervention on the psychological health of women dementia caregivers.

Caregiver Stress

Family caregivers of elders with dementia endure daily stress for long periods of time [9] related to uncertainty of how disease will progress in care-recipients [10], and the physical, mental, behavioral and memory problems associated with dementia [11]. Dementia caregivers are particularly vulnerable to stress because they not only provide direct care for the elders, but also manage behavioral and memory problems, and are the elder’s advocate for healthcare and household decisions. The increasing demand for caregiving time, loss of freedom to work and to socialize [11,12] can result in feelings of resentment, family conflict, and physical, emotional and financial strain [12], increasing caregivers’ stress level [6]. Chronic stress increases cortisol and inflammatory markers in the body [9], making caregivers vulnerable to poor health, depression, and low quality of life [13].

Caregiver Depressive Symptoms

The tremendous burden experienced by dementia caregivers makes them vulnerable to psychological health problems often expressed in thoughts and feelings, which reflect depressive symptoms [14-15]. Thus, dementia caregivers are at greater risk for developing depressive illness [6,14]. Factors associated with dementia caregiver depression include female gender, high caregiving workload, and behavioral and memory problems in the elder [15]. Research suggests that dementia caregivers are prone to negative, dysfunctional or maladaptive cognitions [16-17]. Further, dementia caregivers often express negative emotions associated with caregiving such as anger and anxiety. In fact, dementia caregivers have more fluctuations in negative affect than other caregivers [18]. Fluctuations in affect expressed in negative emotions have been linked with closeness to the elder, dependency needs of the elder, older age, lower socioeconomic status, and lack of sleep [18-19]. Thus, the psychological impact of dementia caregiving is profound and has been associated with poorer health and quality of life [12,18]. Therefore, the need for intervention research focused on promoting positive psychological health outcomes is evident.

Dementia Caregiver Invention Research

Systematic reviews describe interventions for dementia caregivers, including those focused on reducing stress and promoting/ preserving health [20-26]. Multi-site projects such as the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) [27-29], had a primary aim to develop and test methods for helping family caregivers manage daily activities and stress associated with dementia caregiving. REACH projects tested educational support groups [30], behavioral care [31], and skills training programs [32], familybased interventions [33], environmental modifications [34-35], and computer-based information and communication services [33,36]. Each REACH study has been a well-designed, randomized, controlled clinical trial with caregivers randomly assigned to treatments [28- 29]. All of the interventions were found to be superior to control conditions for women versus men, and for caregivers with lower versus higher education. Positive outcomes include fewer depressive and anxiety symptoms, better adaptation, fewer problem behaviors, greater satisfaction, improved affect, and better sense of well-being [30-36].

Although many positive findings have emerged from the REACH trials, interventions tested did not include teaching resourcefulness skills. Systematic reviews of other intervention studies of dementia caregivers have described beneficial effects on caregiver health of such skills as cognitive reframing, problem solving, self-management, and help-seeking [22, 37-39], all of which are incorporated within resourcefulness training [40-41]. Consistent with the personal (selfhelp) and social (help-seeking) skills taught during resourcefulness training (RT), researchers have identified the need for interventions to assist dementia caregivers to seek out and mobilize social resources while enhancing personal coping effectiveness [42-43]. RT has been found effective in reducing stress, depressive cognitions, and negative emotions, and improving overall health in older adults [44-46] and caregiver populations [47-49], including dementia caregivers [50-51].

Therefore, the study reported here addressed the following aims: 1) To compare the effects of RT (which includes journaling or recording as practice / reinforcement methods) with comparison groups (journaling or recording without learning resourcefulness skills); 2) To determine whether choosing between the two practice methods yields greater effects than random assignment; and 3) to establish whether there is a difference in effectiveness between the journal and the records for practicing resourcefulness skills.



This study was a modified partially randomized preference trial [52] that involved the use of randomization and the element of preference (i.e. choice between journaling and digital recording), resulting in the formation of eight groups (Figure 1). The study design involved two levels of randomization that initially resulted in four groups (indicated by solid arrows in Figure 1), which were then further randomized to use journal or recorder methods (random condition), or to choice condition where they chose between the journal and recorder. Groups designated as “no RT” were not taught resourcefulness skills. Effects on stress, depressive cognitions, and negative emotions examined at baseline (T1) and at 2 (T2), 6 (T3) weeks post-intervention.