Does Caregiver Burden Correlate with Patient Cognitive Impairment?

Jessica Zwerling, MD, MS

When assessing the impact that caregivers have on the patients with cognitive impairment (CI) that they assist, the burden of caregiving that is placed on them is often overlooked—to both their and the patients’ detriment.

“Once you identify patients with a [cognitive] problem, you can use validated screening and tools to assess their CI and then navigate them through the health system,” Jessica Zwerling, MD, MS, a neurologist at Montefiore Medical Center’s Center for the Aging Brain, told MD Magazine. “When we have patients come in, we have a questionnaire we give so we can screen for caregiver burden beforehand. It starts by asking questions.”

It may be clear that poor outcomes for the patient and caregiver are more likely when the caregiver is dealing with too heavy a burden, but whether or not that burden correlates with the level of impairment their patient has, however, is less so.

Zwerling, along with a team of investigators led by Linda Esteban, MD, aimed to determine the relationship between CI and dementia (CID) and caregiver burden (CB) by utilizing practice tools such as the Picture-based Memory Impairment Screen (PMIS) and the American Medical Association Caregiver Self-Assessment Questionnaire (CSAQ). The team examined PMIS, CSAQ and Blessed Information-Memory-Concentration (BIMC) data from patient and caregiver pairs (n = 112) who presented at a multidisciplinary memory disorder center with cognitive complaints from 2014-2016.

As they expected, the BIMC and PMIS scores were negatively correlated (Pearson’s r = .61; P = .00001), revealing an indication that more errors were associated with less recall in the patient testing.

When performing chi-square analysis of the data, the relationship of PMIS (divided at <5; 45%) and CSAQ (divided at ≥9; 58%) scores was not statistically significant (P =.18). Although, when a T-test was used to examine the relationship between a CSAQ score dichotomized ≥9 and the BIMC raw score, the findings did trend toward statistical significance (P = .09).

“There seems to be a trend, but nothing of statistical significance,” Zwerling said. She noted while there are indications of a relationship, future studies need to include the use of other assessment tools such as the Caregiver Burden Inventory or Zarit Burden Interview and compare them with PMIS, BIMC & Global Depression Scale.

“Additional analysis incorporating demographics of the caregivers, including age, gender, ethnicity, educational level, income, hours per week spent caregiving, and financial burdens, as well as caregiver emotional status (i.e. depression), should be considered,” she and colleagues wrote.

Zwerling and colleagues acknowledged the limitations of the small sample size, driven by the low completion rates by caregivers of the CSAQ, as it was a voluntary portion of the center’s assessment. They noted the possibility that those with less CB may have been more inclined to finish the CSAQ.

At Montefiore’s center, the physicians are able to screen caregivers beforehand, which really gives them an edge to providing the resources the pairs need. “We can do a risk assessment on the first day,” Zwerling said. Those providing care for patients with CI conditions such as Alzheimer Disease are at a higher risk for morbidity themselves, which makes their health a concern as well. The need to educate the caregiver is also an important process, and if CB is high, that process can suffer.

“They have to buy in to the educational process,” Zwerling said. “There are different cultural sensitivities to this, though, so [at Montefiore,] we try to educate them as much as we can, and offer serves that are pertinent to the individual.”

“The strength is in recognition and asking the questions to ensure [caregivers] feel empowered and they’re educated. They’re really at high risk for things like stroke and heart events because of the high stress of caregiving,” she continued.

The study, “Examining the relationship between cognitive impairment and caregiver burden using practical tools,” was authored by L. Esteban, MD; R.B. Chalmer, MD; J.A. Cohen, MD; R. Malik, MD, MS; E.F. Weiss, PhD; H.M. Blumen, PhD; T. Santos, LCSW; and J. Zwerling, MD, MS; and presented at the American Geriatrics Society annual scientific meeting in Orlando, Florida. It was funded by The Fan Fox & Leslie R. Samuels Foundation, Inc.