Background: To inform public health suicide prevention and mental health promotion campaigns, this study will carry out gender-specific analyses to ascertain the determinants of suicidal ideation or death thoughts in a large representative sample of community dwelling older adults.

Methods: Data used in this study were from the ESA survey (Enquête sur la Santé des Aînés – Survey on the Health of the Elderly) on a large representative sample of community dwelling older adults (n = 2,494). Multivariate logistic regression analysis was used to study the association between suicidal ideation, mental health service, and antidepressant use and a number of clinical and socio-demographic factors.

Results: The prevalence of suicidal ideation reached 6.3%. The findings of this study show that the presence of suicidal ideation in females is associated with younger age, single or widowed status, the reporting of daily life stressors, and chronic conditions as well as the presence of major or minor depression in the past year. In males, suicidal ideation is associated with older age, single or widowed status, and depression. Furthermore, suicidal ideation is significantly associated with antidepressant use in females but not males and this after controlling for a number of clinical factors.

Conclusion: Although no gender differences are observed between suicidal ideation and mental health service use, females with suicidal ideation are more likely to be dispensed antidepressants than males with suicidal ideation. Future research should focus on gender-specific determinants of antidepressant and mental health service use associated with suicidal ideation.

Background: Caregiving for people with Alzheimer's disease (AD) is highly stressful and has significant negative consequences, such as anxiety and depression. Previous research offers conflicting findings as to whether coping strategies are associated with greater psychological distress or not. We conducted this study with a view to obtaining new data regarding the association of coping strategies and psychological distress in AD caregivers.

Methods: Eighty people with AD and their primary caregivers living in the community were recruited from local health services. Purposive recruitment was carried out to ensure that the sample was representative of people living with dementia in terms of dementia severity, gender, and care setting. We used the State-Trait Anxiety Inventory to measure anxiety, the Beck Depression Inventory to measure depression, and the Coping Strategies Inventory to measure coping strategies.

Results: Most caregivers reported higher anxiety and depression levels. Use of disengagement coping strategies (Wald = 3.35, p = 0.01) and higher caregiver burden (Wald = 4.83, p = 0.02) predicted anxiety on logistic regression. In turn, use of disengagement coping strategies (Wald = 12.48, p = 0.001) and higher caregiver burden (Wald = 6.91, p = 0.009) predicted depression on logistic regression.

Conclusion: These results may be useful for designing treatment interventions that aim to modify the use of coping strategies and thus reduces caregiver anxiety and depression.

Background: Early definitions of mild cognitive impairment (MCI) excluded the presence of functional impairment, with preservation of a person's ability to perform activities of daily living (ADL) as a diagnostic criterion. However, recent studies have reported varying degrees of functional impairment associated with MCI. Hence, we aimed to test the potential functional impairment associated with MCI and its predictors.

Methods: Sixty-nine healthy elderly subjects, 115 amnestic single-domain MCI subjects (a-MCI), and 111 amnestic multi-domain MCI subjects (md-MCI) were assessed using a battery of neuropsychological tests including measures of attention, memory, working memory, executive functions, language, and depression. Additionally, functional ability was assessed by both qualitative (WHO-DAS II) and quantitative (CHART) instruments. Cognitive and functional performance was compared between groups, and regression analyses were performed to identify predictors of functional ability.

Results: The md-MCI group was more impaired than the a-MCI group, and both were more impaired than healthy subjects in all cognitive measures, in total CHART score, CHART cognitive and mobility subscores, and WHO-DAS II communication and participation subscales. For the rest of the functional measures, the md-MCI group was more impaired than healthy controls. Prediction of functional ability by cognitive measures was limited to md-MCI subjects and was higher for the CHART than for the WHO-DAS II. The WHO-DAS II was largely influenced by depressive symptoms.

Conclusions: Functional impairment is a defining feature of MCI and is partially dependent on the degree of cognitive impairment. Quantitative measures of functional ability seem more sensitive to functional impairment in MCI than qualitative measures, which seem to be more related to depression.

Background: The ability to manage everyday technology (ET), such as computers and microwave ovens, is increasingly required in the performance of everyday activities and participation in society. This study aimed to identify aspects that influence the ability to manage ET among older adults with and without cognitive impairment.

Methods: Older adults with mild Alzheimer's disease and mild cognitive impairment and without known cognitive impairment were assessed as they managed their ET at home. Data were collected using the Management of Everyday Technology Assessment (META). Rasch-based measures of the person's ability to manage ET were analyzed. These measures were used as dependent variables in backward procedure ANOVA analyses. Different predefined aspects that could influence the ability to manage ET were used as independent variables.

Results: Three aspects had a significant effect upon the ability to manage ET. These were: (1) variability in intrapersonal capacities (such as “the capacity to pay attention and focus”, (2) environmental characteristics (such as “the impact of the design”) and (3) diagnostic group.

Conclusions: Variability in intrapersonal capacities seems to be of more importance than the actual level of intrapersonal capacity in relation to the ability to manage ET for this sample. This implies that investigations of ability to manage ET should also include intraperson variability. Additionally, adaptations in environmental characteristics could simplify the management of ET to support older adults as technology users.

Background: Sense of competence in dementia care staff (SCIDS) may be associated with more positive attitudes to dementia among care staff and better outcomes for those being cared for. There is a need for a reliable and valid measure of sense of competence specific to dementia care staff. This study describes the development and evaluation of a measure to assess “sense of competence” in dementia care staff and reports on its psychometric properties.

Methods: The systematic measure development process involved care staff and experts. For item selection and assessment of psychometric properties, a pilot study (N = 37) and a large-scale study (N = 211) with a test–retest reliability (N = 58) sub-study were undertaken.

Results: The final measure consists of 17 items across four subscales with acceptable to good internal consistency and moderate to substantial test–retest reliability. As predicted, the measure was positively associated with work experience, job satisfaction, and person-centered approaches to dementia care, giving a first indication for its validity.

Conclusions: The SCIDS scale provides a useful and user-friendly means of measuring sense of competence in care staff. It has been developed using a robust process and has adequate psychometric properties. Further exploration of the construct and the scale's validity is warranted. It may be useful to assess the impact of training and perceived abilities and skills in dementia care.

Background: Increasing out-of-pocket health expenditure among older people worsens the inequitable access to essential health services in low and middle-income countries (LMIC). We investigated various socioeconomic and health factors associated with out-of-pocket and catastrophic health expenditures among rural older people in India.

Methods: We recruited 1,000 participants aged above 65 years from Kaniyambadi block, Vellore, India. We assessed their out-of-pocket health expenditure, health service utilization, socioeconomic profiles, disability, cognition, and health status by standard instruments. We employed appropriate multivariate statistics evaluating these determinants.

Results: Male gender, poor sanitation, diabetes, tuberculosis, malaria, respiratory ailments, gastrointestinal diseases, dementia, depression, and disability were associated with higher out-of-pocket expenditures. Illiteracy, tuberculosis, diabetes, and dementia increased the risk for catastrophic health expenditures, while pension schemes protected against it. Income inequalities were associated with inequities on education, disease prevalence, and access to safe water, sanitation, and nutrition.

Conclusions: Interactions between determinants of out-of-pocket health expenditure, economic inequality, and inequities on essential health care delivery to older people are complex. We highlight the need for equitable health services and policies, focusing on both medical and social determinants.

Background: The ways in which aging affects social economic decision-making is a central issue in the psychology of aging. To examine age-related differences in social economic decision-making as a function of empathy, 80 healthy volunteers participated in the Repeated Fixed Opponent Ultimatum Game (UG-R). Previous economic decision-making research has shown that in younger adults empathy is associated with prosocial behavior. The effects of empathy on older adult social economic decision-making are not well understood.

Methods: On each of 20 consecutive trials in the UG-R, one player (“Proposer”) splits $10 with another player (“Responder”) who chooses either to accept (whereby both receive the proposed division) or reject (whereby neither receives anything). Trait cognitive and emotional empathy were measured using the Interpersonal Reactivity Index.

Results: UG-R data were examined as a function of age and cognitive empathy. For “unfair” offers (i.e. offers less than $5), older Responders with high cognitive empathy showed less prosocial behavior and obtained greater payoffs than younger Responders with high cognitive empathy.

Conclusions: High levels of cognitive empathy may differentially affect economic decision-making behavior in younger and older adults. For older adults, high cognitive empathy may play a role in obtaining high financial payoffs while for younger adults it may instead be involved in facilitating social relationships.

Background: Depression in informal caregivers of persons with dementia is a major, costly and growing problem. However, it is not yet clear which caregivers are at increased risk of developing depression. With this knowledge preventive strategies could focus on these groups to maximize health gain and minimize effort.

Methods: The onset of clinically relevant depression was measured with the Center for Epidemiologic Studies - Depression Scale in 725 caregivers who were not depressed at baseline and who were providing care for a relative with dementia. Caregivers were followed over 18 months. The indices calculated to identify the most important risk indicators were: odds ratio, attributable fraction, exposure rate and number needing to be treated.

Results: The following significant indicators of depression onset were identified: increased initial depressive symptoms, poor self-rated health status and white or Hispanic race/ethnicity. The incidence of depression would decrease by 72.3% (attributive fraction) if these risk indicators together are targeted by a completely effective intervention. Race/ethnicity was not a significant predictor if caregivers of patients who died or were institutionalized were left out of the analyses.

Conclusion: Detection of only a few characteristics makes it possible to identify high-risk groups in an efficient way. Focusing on these easy-to-assess characteristics might contribute to a cost-effective prevention of depression in caregivers.

Background: Out-of-home mobility refers to the realization of trips outside the home, by foot or by other means of transportation. Although out-of-home mobility is important for the well-being of older people with cognitive impairment, its importance for their caregivers is not clear. This study aims to clarify the relationship between caregiving burden and out-of-home mobility of care-recipients using Global Positioning Systems (GPS) technology.

Methods: Seventy-six dyads (care-recipients and caregivers) were recruited from a psychogeriatric center, where they underwent cognitive assessment, followed by psychosocial interviews at home. Care-recipients received GPS tracking kits to carry for a period of four weeks, whenever they left home. Mobility data and diagnostic and psychosocial data were examined in relation to caregiver burden.

Results: The strongest predictors of burden were care-recipients’ lower cognitive status and more time spent walking out-of-home. An interaction was found between cognitive status and time spent walking in relation to caregiver burden. The relationship between walking and burden was stronger among caregivers of care-recipients with dementia than caregivers of care-recipients with no cognitive impairment or mild cognitive impairment. Care-recipients’ behavioral and emotional states were also positively related to caregiver burden.

Conclusions: The findings stress the importance of maintaining older persons’ out-of-home mobility during cognitive decline.

Background: Anxiety and depression are prevalent in patients with chronic obstructive pulmonary disease (COPD). This study evaluates the sensitivity and specificity of two self-administered anxiety rating scales in older people with COPD. The Geriatric Anxiety Inventory (GAI) and the Hospital Anxiety and Depression Scale (HADS) are established useful screening tools but they have not been previously validated in this population.

Methods: Older people with COPD completed the GAI and the HADS along with a structured diagnostic psychiatric interview, the Mini International Neuropsychiatric Interview (MINI). The outcomes of both rating scales were compared against the diagnosis of anxiety disorders based on the MINI. Receiver operating characteristic (ROC) curves were used to identify the optimal diagnostic cut points for each scale.

Results: Fourteen (25.5%) of the 55 participants, were diagnosed with an anxiety disorder. Mean GAI and HADS-anxiety subscale scores were significantly higher in subjects with an anxiety disorder than those without the diagnosis (p = 0.002 and 0.005 respectively). Both scales demonstrated moderate diagnostic value (area under the ROC curve was 0.83 for GAI and 0.79 for HADS). Optimal cut points were ≥3 (GAI) and ≥4 (HADS-anxiety subscale). At these cut-points, the GAI had a sensitivity of 85.7%, specificity of 78.0% and the HADS had a sensitivity of 78.6%, specificity 70.7%.

Conclusion: Our results support the use of the GAI and HADS as screening instruments for anxiety disorders in older people with COPD. The optimal cut points in this population were lower than previously recommended for both rating scales. The results of this study should be replicated before these cut points can be recommended for general use in older people with COPD.

Background: The influences of demographics, culture, language, and environmental changes on Mini-Mental State Examination (MMSE) scores are considerable.

Methods: Using a sample of 7452 healthy, community-dwelling elderly Koreans, aged 55 to 94 years, who participated in the four ongoing geriatric cohorts in Korea, we investigated demographic influences on MMSE scores and derived normative data for this population. Geropsychiatrists strictly excluded subjects with cognitive disorders according to the protocol of the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet (CERAD-K) Clinical Assessment Battery (CERAD-K-C).

Results: Education (standardized β = 0.463), age (standardized β = −0.303), and gender (standardized β = −0.057) had significant effects on MMSE scores (p < 0.001). The score of MMSE increase 0.379 point per 1-year education, decrease 0.188 per 1-year older, and decrease 0.491 in women compared to men. Education explained 30.4% of the scores’ total variance, which was much larger than the variances explained by age (8.4%) or gender (0.3%). Accordingly, we present normative data for the MMSE stratified by education (0, 1–3, 4–6, 7–9, 10–12, and ≥ 13 years), age (60–69, 70–79, and 80–89 years), and gender.

Conclusions: We provide contemporary education-, age-, and gender-stratified norms for the MMSE, derived from a large, community-dwelling elderly Korean population sample, which could be useful in evaluating individual MMSE scores.

Background: Whereas the State-Trait Anxiety Inventory (STAI-Y) is probably the most widely used self-reported measure of anxiety, the lack of current norms among elderly people appears to be problematic in both a clinical and research context. The objective of the present study was to provide normative data for the STAI-Y trait scale from a large elderly cohort and to identify the main sociodemographic and health-related determinants of trait anxiety.

Methods: The STAI-Y trait scale was completed by 7,538 community-dwelling participants aged 65 years and over from the “Three City” epidemiological study. Trained nurses and psychologists collected information during a face-to-face interview including sociodemographic characteristics and clinical variables.

Results: The scale was found to have good internal consistency (Cronbach's α = 0.89). Norms were stratified for gender and educational level differentiating persons with and without depressive symptoms. Multivariate linear regression found the STAI-Y trait score to be significantly associated with female gender, psychotropic medication use, higher depressive symptoms, higher cognitive complaints, and with an interaction between subjective health and marital status. Age was not associated with the total score.

Conclusion: This study provides norms for the STAI-Y trait scale in the general elderly population which are of potential use in both a clinical and research context. The present results confirm the importance of several factors previously associated with higher trait anxiety in the elderly. However, more research is needed to better understand the clinical specificities of anxiety in the elderly and the improvement of assessment.

Background: Official health organizations have established the dose of physical activity needed for preserving both physical and psychological health in old age. The objective of this study was to explore whether adherence to the recommended criterion of physical activity accounted for better psychological functioning in older adults in Israel.

Methods: A random sample of 1,663 (799 men) Israelis reported their physical activity routine, and based on official guidelines were divided into sufficiently active, insufficiently active, and inactive groups. The General Health Questionnaire (GHQ) was used for assessing mental health and the Mini-Mental State Examination (MMSE) for assessing cognitive functioning.

Results: Factor analysis performed on the GHQ yielded two factors – positive and negative. Logistic regressions for the GHQ factors and for the MMSE were conducted for explaining their variance, with demographic variables entered first, followed by health and then physical activity. The explained variance in the three steps was Cox and Snell R2 = 0.022, 0.023, 0.039 for the positive factor, 0.066, 0.093, 0.101 for the negative factor, and 0.204, 0.206, 0.209 for the MMSE.

Conclusions: Adherence to the recommended dose of physical activity accounted for better psychological functioning beyond demographic and health variables; however, the additional explained variance was small. More specific guidelines of physical activity may elucidate a stronger relationship, but only randomized controlled trials can reveal cause–effect relationship between physical activity and psychological functioning. More studies are needed focusing on the positive factor of psychological functioning.

Background: The medical care of elderly patients with psychotic disorders is a matter of major concern. The aim of the study was to investigate health conditions and treatment of elderly patients with psychotic disorders in France.

Methods: The SAGE (Schizophrenia AGEd) study (observational, cross-sectional) was a survey conducted among 123 physicians in France, regarding prescriptions of antipsychotic drugs in elderly patients (≥60 years) suffering from psychotic disorders. The survey was based on a questionnaire addressing the mental and somatic health management of the patients.

Results: Data from 930 patients (mean age: 70.4 years) were collected. Most patients (58.5%) suffered from schizophrenia, 20.8% had delusional disorder and 20.6% hallucinatory chronic psychosis (very-late-onset schizophrenia-like psychosis). 70.8% of them were outpatients, while 29.2% were inpatients. The severity of psychotic symptoms was assessed in 97.8% of patients, but cognitive function was only evaluated in 41.6%. Some 46.5% of patients were treated with atypical antipsychotics alone, 36.2% with classical antipsychotics alone and 17.3% received a combination of both, atypical and classical antipsychotics; 36.3% patients were given antiparkinsonian medication, of whom only 17.8% as preventive treatment; 51.1% of patients had somatic comorbidities, particularly cardiovascular disorders (34.0%). Evaluation of renal and/or liver function to adjust the dose of treatment was done in only 32.1% of patients. Over the previous 12 months, almost half of the patients had had no ECG, glycemia or creatininemia investigated and HDL-cholesterol and triglycerides were available for less than one-third of them.

Conclusions: Antipsychotic and antiparkinsonian drug prescriptions in French aged psychotic patients follow only partially the clinical guidelines and recommendations of consensus conferences. Moreover, cognitive, cardiac and metabolic aspects are not fully managed as expected.

Background: This paper determines care recipient and caregiver characteristics and caregiving dimensions – associated with depression among caregivers of older adults, using path analysis and assesses whether the identified path model differs between spousal and adult child caregivers.

Methods: Data from 1,190 dyads comprising care recipients (community-dwelling adults aged ≥75 years with at least one activity of daily living (ADL) limitation) and caregivers (family member/friend most involved in providing care/ensuring provision of care to care recipient), who were interviewed through the Singapore Survey on Informal Caregiving (2010–2011), were used. Using path analysis, we assessed the direct and indirect associations between primary stressors (care recipient's ADL and instrumental ADL status, and memory and behavior problems), caregiver health status, receipt of assistance from a foreign domestic worker/maid, amount of caregiving, negative reaction to caregiving, caregiver's self-esteem, perceived emotional support, and caregiver depressive symptoms.

Results: Our analysis showed that primary stressors, receipt of assistance from a foreign domestic worker/maid, perceived emotional support, and caregiver health status were directly or indirectly associated with caregiver depressive symptoms, and this association was mediated by negative reaction to caregiving. Caregiver self-esteem mediated the relationship between perceived emotional support and negative reaction to caregiving only among adult child caregivers.

Conclusions: The results provide insights into factors associated with depressive symptoms among spousal and adult child caregivers, and help identify targeted interventions for improving caregiver mood.

Background: Attitudes are known to exert a powerful influence on a range of behaviors. The objective of this study was to investigate the contribution of attitudes toward one's own aging to satisfaction with life and physical and mental health measured in a sample of community-dwelling older adults.

Methods: Adults who were part of a larger study of health and well-being in rural and regional Australia aged ≥60 years (N = 421) completed a cross-sectional postal survey comprising the Attitudes to Aging Questionnaire, the 12-Item Short Form Health Survey (SF-12), the Satisfaction with Life Scale, the Geriatric Anxiety Inventory, and the Center for Epidemiological Studies Depression Scale.

Results: Overall, attitudes to aging were positive in this sample. More positive attitudes to aging were associated with higher levels of satisfaction with life, better self-report physical and mental health on the SF-12, and lower levels of anxiety and depression, after controlling for confounding variables. Better financial status and being employed were both associated with more positive attitudes to aging and better self-reported physical health. Relationship status was also significantly associated with mental health and satisfaction with life, but not physical health.

Conclusion: The promotion of successful aging is increasingly becoming important in aging societies. Having positive attitudes to aging may contribute to healthier mental and physical outcomes in older adults. Overcoming negative stereotypes of aging through change at the societal and individual level may help to promote more successful aging.

Background: Subjective memory complaints are a requirement in the diagnosis of mild cognitive impairment (MCI) as they are thought to indicate a decline in objective memory performance. However, recent research suggests that the relationship between subjective memory complaint and objective memory impairment is less clear. Thus, it is possible that many people without subjective memory complaints who develop Alzheimer's disease are precluded from a diagnosis of MCI.

Methods: The present study examined the relationship between subjective memory complaint assessed using the Multifactorial Memory Questionnaire (MMQ) and objective memory impairment assessed using standard neuropsychological measures in cases of amnestic MCI (n = 48), non-amnestic MCI (n = 27), and unimpaired healthy participants (n = 64).

Results: Correlational and regression analyses indicated that subjective memory complaints displayed a poor relationship with objective memory performance. A subsequent discriminant function analysis indicated that subjective memory complaints failed to improve the diagnostic accuracy of MCI and resulted in increased rates of false negative and false positive diagnoses.

Conclusion: The results of the present study suggest that a diagnostic criterion of subjective memory complaint reduces the accuracy of MCI diagnosis, resulting in an elevated rate of false positive and false negative diagnoses. The results of this study in conjunction with recent research indicate that a criterion of subjective memory complaint should be discarded from emerging diagnostic criteria for MCI.

Background: Paratonia causes severe movement dysfunction in late stage dementia. Passive Movement Therapy (PMT) is often used to decrease high muscle tone, but the efficacy has never been shown. The objective of this study is to investigate the effect of PMT on muscle tone after two and four weeks of treatment.

Methods: This study comprised a multicenter single-blinded RCT. Nursing home residents with dementia (according to the DSM-IV-TR criteria) and moderate to severe paratonia were randomly assigned to either a PMT or control group. The PMT group received PMT three times a week over four weeks. The control group received no PMT. The primary outcome was the severity of paratonia as measured by the Modified Ashworth scale (MAS). Secondary outcomes were clinical change (Clinical Global Impression; CGI), caregiver's burden (modified patient specific complaints; PSC), and level of pain during morning care (Pain Assessment Checklist for Elderly with Limited Ability to Communicate, Dutch version; PACSLAC-D). All outcomes were assessed at baseline and after two and four weeks. The MAS, PACSLAC-D, and PSC data were subjected to multilevel mixed linear analysis, and the CGI data to cross-tabulation χ2 analysis.

Results: One-hundred-and-one patients from 12 Dutch nursing homes participated in the study; data from 47 patients in the PME group and 54 controls were analyzed. Patients receiving PMT performed no better in paratonia assessments, nor on CGI, PSC, or PACSLAC-D, than controls in two and four week's time.

Conclusion: PMT has no beneficial effects and should therefore not be recommended as an intervention in severe paratonia.

Trial registration: Current Controlled Trials ISRCTN43069940

Background: The Montreal Cognitive Assessment (MoCA) is an instrument for screening mild cognitive impairment (MCI). This study examined the psychometric properties and the validity of the Taiwan version of the MoCA (MoCA-T) in an elderly outpatient population.

Methods: Participants completed the MoCA-T, Mini-Mental State Examination (MMSE), and the Chinese Version Verbal Learning Test. The diagnosis of Alzheimer's disease (AD) was made based on the NINCDS-ADRDA criteria, and MCI was diagnosed through the criteria proposed by Petersen et al. (2001).

Results: Data were collected from 207 participants (115 males/92 females, mean age: 77.3 ± 7.5 years). Ninety-eight participants were diagnosed with AD, 71 with MCI, and 38 were normal controls. The area under the receiver operator curves (AUC) for predicting AD was 0.98 (95% confidence interval [CI] = 0.97–1.00) for the MMSE, and 0.99 (95% CI = 0.98–1.00) for the MoCA-T. The AUC for predicting MCI was 0.81 (95% CI = 0.72–0.89) using the MMSE and 0.91 (95% CI = 0.86–1.00) using the MoCA-T. Using an optimal cut-off score of 23/24, the MoCA-T had a sensitivity of 92% and specificity of 78% for MCI. Item response theory analysis indicated that the level of information provided by each subtest of the MoCA-T was consistent. The frontal and language subscales provided higher discriminating power than the other subscales in the detection of MCI.

Conclusion: Compared to the MMSE, the MoCA-T provides better psychometric properties in the detection of MCI. The utility of the MoCA-T is optimal in mild to moderate cognitive dysfunction.

Background: We aimed to examine the multidimensionality of the Zarit Burden Interview (ZBI) beyond the conventional dual-factor structure among caregivers of persons with cognitive impairment in a predominantly Chinese multiethnic Asian population, and ascertain how these dimensions vary across the spectrum of disease severity.

Methods: We studied 130 consecutive dyads of primary caregivers and patients attending a memory clinic over a six-month period. Caregiver burden was measured by the 22-item ZBI, and disease severity was staged via the Clinical Dementia Rating (CDR) scale. We performed principal component analysis (PCA) with varimax rotation to determine the factor structure of the ZBI. The magnitude of burden in each factor was expressed as the item to total ratio (ITR) and plotted against the stages of cognitive impairment. Descriptive and inferential statistics were applied to study the relationships between dimensions with disease and caregiver characteristics.

Results: We identified four factors: demands of care and social impact, control over the situation, psychological impact, and worry about caregiving performance. ITRs of the first three factors increased with severity of disease and were related to recipients’ functional status and disease characteristics. ITR in the dimension of worry about performance was endorsed highest across the spectrum of disease severity, starting as early as the stage of mild cognitive impairment and peaking at CDR 1.

Conclusion: Multidimensionality of ZBI was confirmed in our local setting. Each dimension of burden was unique and expressed differentially across disease severity. The dimension of worry about performance merits further study.