Burden of care,social support,and sense of coherence in elderly caregivers living with individuals with symptoms of dementia

Abstract

Family members are often the care providers of individuals with dementia, and it is assumed that the need for this will increase. There has been little research into the association between the burden of care and the caregiver’s sense of coherence or receipt of social support. This study examined the relationship between the social support subdimensions and sense of coherence and the burden of care among older people giving care to a partner with dementia. The study was a cross-sectional observation study of 97 individuals, ≥65 years old and living with a partner who had symptoms of dementia. We used the Informant Questionnaire on Cognitive Decline in the Elderly, the Relative Stress Scale, the Social Provisions Scale, the Sense of Coherence Scale, and a questionnaire on sociodemographic variables. We used multiple regression analysis in a general linear model procedure. We defined statistical significance as p < 0.05. With adjustments for sociodemographic variables, the association with burden of care was statistically significant for the subdimension attachment (p < 0.01) and for sense of coherence (p < 0.001). The burden of care was associated with attachment and with sense of coherence. Community nurses and other health professionals should take necessary action to strengthen attachment and sense of coherence among the caregivers of people with dementia. Qualitative studies could provide deeper understanding of the variation informal caregivers experience when living together with their partner with dementia.

Keywords

dementia burden of care caregivers social support sense of coherence

Introduction

Providing informal care to an older person may lead to poor mental health (Butterworth, Pymont, Rodgers, Windsor, & Anstey, 2010). Caring for a home-dwelling family member with dementia has been described as a situation of “enduring stress and frustration” (Butcher, Holkup, & Buckwalter, 2001). The term caregiver burden is often used to describe this phenomenon (Etters, Goodall, & Harrison, 2008) and distinguishes between objective and subjective burden (Pearlin, Mullan, Semple, & Skaff, 1990). Objective burden refers to the primary stressors linked to the dependence and needs of assistance of the person with dementia. The subjective burden refers to secondary stressors as a mental reaction, such as distress, depression, anxiety, irritation, or feelings of exhaustion (Pearlin et al., 1990). Family members caring for people with dementia living in the community are reported to have a particularly high risk of developing stress-related symptoms (Bruvik, Ulstein, Ranhoff, & Engedal, 2013; Ulstein, 2007) and depression (Lavela & Ather, 2010; Papastavrou, Kalokerinou, Papacostas, Tsangari, & Sourtzi, 2007; Schoenmakers, Buntinx, & Delepeleire, 2010). They have more depressive symptoms than those caring for a family member with a different chronic condition (Nordtug, Krokstad, & Holen, 2011; Schoenmakers et al., 2010).

However, even though these negative consequences of informal caregiving are well documented, some caregivers have reported gains from the experience of caring for a chronically ill family member with dementia. One study (Schulz et al., 2007) suggested that the beneficial outcomes of caregiving may be due to the caregivers’ compassion for their partners. The informal caregivers of people with dementia have reported improvement in relationships within the family (Netto, Jenny, & Philip, 2009), and support from daughters was found to facilitate coping among male caregivers (Pretorius, Walker, & Heyns, 2009). It has also been reported that services providing tangible relief from the burden of caregiving may lead to a perception of reduced burden (McConaghy & Caltabiano, 2005); this stresses the importance of providing individually tailored formal caregiving. Research has documented that informal caregiving may lead to both negative and positive outcomes for the caregiver (Beach, Schulz, Yee, & Jackson, 2000; Kinney & Stephens, 1989; Netto et al., 2009; Sanders, 2005).

Social support refers to the qualitative aspect described as perceived social support, such as the availability of relationships with significant others (Sarason, Sarason, & Pierce, 1990). Robert Weiss (1974) identified and described six categories of relational provisions: attachment, social integration, opportunity for nurturance, reassurance of worth, reliable alliances, and guidance. Each provision is associated with a specific type of relationship, depending on age, life stage, and environmental circumstances (Weiss, 1974).

Several studies have shown the need for specific relational provisions, based on Weiss’ concept of social support among older people (Cutrona & Russell, 1987; Drageset, Eide, & Ranhoff, 2013; Mancini & Blieszner, 1992). Cutrona and Russell (1987) reported that social support may benefit the health of older people in the context of stressful life experiences. Mancini and Blieszner (1992) found that social provisions were important for people older than 65 years and were met by close relationships with significant others such as family and friends. Drageset, Eide, and Ranhoff (2013) reported that the social support subdimension attachment was correlated with less anxiety among nursing home residents without cognitive impairment.

The construct of sense of coherence (SOC) is based on Antonovsky’s (1987) theory of salutogenesis. According to Antonovsky, stress, in the sense of tension and appropriate load, is viewed as potentially health promoting. The assumption is that a strong SOC is associated with resources to cope with various kinds of stressful life events or situations. It is postulated that SOC has three components: comprehensibility, manageability, and meaningfulness. An individual’s SOC indicates the extent to which the individual has and is able to general resistance resources (GRRs). GRRs are the biological, material, and psychosocial factors that make it easier for people to perceive their lives as consistent, structured, and understandable. Social support has been defined to be one of several such GRRs (Antonovsky, 1987). Antonovsky (1985) claimed that older people should be provided with experiences that fit their remaining capacity.

An underlying assumption in this study is that the burden of care is related to an individual’s coping methods. In a study in Sweden (Andrén & Elmståhl, 2008), caregivers with a high burden of care reported a significantly lower SOC than did caregivers with a lower burden of care. A cross-sectional study in Belgium (Schoenmakers, Buntinx, & De Lepeleire, 2009) found that depression was related to coping strategies, the perceived burden of care, and the patient’s actual mental and physical condition. A systematic review by Schoenmakers, Buntinx, and Delepeleire (2010) found that caregiver characteristics tend to be associated with depression among caregivers. Further, high self-efficacy and strong internal locus of control seem to create less vulnerability to the negative consequences of informal caregiving (Contador, Fernández-Calvo, Palenzuela, Miguéis, & Ramos, 2012). A study in Norway (Bruvik et al., 2013) reported that strong internal locus of control was the strongest predictor of burden among the caregivers of people with dementia. Similarly, a review that focused on resilience factors (Harmell, Chattillion, Roepke, & Mausback, 2011) determined that caregivers with high levels of personal mastery and self-efficacy, together with the frequent use of positive coping strategies, were better able to handle the role of caregiver. Wolff and Ratner (1999) refer to studies showing that people with weak SOC seem to experience more suffering and anger when faced with stress and that they are more likely to report small burdens as chronic sources of stress.

In summary, studies that have examined the subdimensions of social support in relation to mental health among older people have shown that the various dimensions of social support were significant for older people (Cutrona & Russell, 1987; Drageset et al., 2013; Mancini & Blieszner, 1992), and different coping strategies and styles, including SOC, are associated with the burden of care among caregivers of partners with dementia. Based on this literature review, we hypothesized that coping (SOC) is associated with the burden of care and that social support subdimensions are associated with burden.

Aim and questions

The aim of this study was to examine the relationships between the social support subdimensions and SOC and the burden of care for those caring for a partner with dementia.

The research questions are the following.

Is there a relationship between social support subdimensions and the burden of care among the older caregivers of older partners with dementia who are living at home?

Is there a relationship between SOC and the burden of care among older caregivers of older partners with dementia who are living at home?

Methods

Design and study setting

This is a cross-sectional observation study of people giving informal care to a partner with dementia. We collected the data between February and June 2012. We recruited caregivers from seven municipalities of various sizes in western Norway to the study.

Sample

The inclusion criteria were the following: (1) the caregiver was the spouse or domestic partner of a person with dementia; (2) the relationship must have existed for at least 10 years; (3) both the caregiver and the person with dementia were 65 years or older; (4) they must live together at the same address for at least 50% of the time; and (5) the caregiver must consider the cognitive state of the partner to have deteriorated during the past 10 years. A formal diagnosis of dementia was not required.

Initially, 200 people wanted to participate. Of these, 110 filled out and returned the questionnaires, and of these, 13 could not be used because the person did not meet the inclusion criteria (10), or because he or she did not complete one or more of the questionnaires (3). We analyzed the answers from 97 caregivers. The response rate was 52%. We do not have any information about the people who dropped out of the study.

Data collection

Public community nursing services recruited the caregivers. Community nurses handed out the sets of questionnaires, which were then returned to the researcher by ordinary mail.

We collected data about the background variables (sex, age, level of education, duration of marriage or partnership, children, health, duration of symptoms of dementia, use of part-time nursing home or daycare center, and satisfaction with public health agencies) by using a questionnaire designed for this study.

To measure the cognitive decline of the person with dementia, we used the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), developed by Jorm (1994). The IQCODE is a 16-item scale, and a relative is asked to compare the person’s cognitive functioning today with that of 10 years ago. For example, the relative is asked to assess whether the person’s ability to remember conversations a few days after they took place has changed. The respondent then chooses from: 1 = much better, 2 = slightly better, 3 = about the same, 4 = slightly worse, or 5 = much worse. The IQCODE is widely used to test for dementia (Jorm, 2004; Nygaard, Naik, & Geitung, 2009), and it is the recommended method of assessing dementia in primary health care (Sørensen, Pinquart, & Duberstein, 2002), including in Norway (Norwegian Centre for Dementia Research, 2013; Nygaard et al., 2009). The questionnaire has been shown to have high reliability (alpha coefficient 0.93–0.97) and measures a general factor of cognitive decline (Jorm, 2004). It is well documented that it validly reflects past cognitive decline, and it has proven to be a good screening test for dementia (Jorm, 2004).

We used the Relative Stress Scale (RSS) (Greene, Smith, Gardiner, & Timbury, 1982; Norwegian version, 15 questions) to measure the caregiver burden. The RSS covers various aspects of burden, and in Norway, it is widely used in both clinical and research settings (Nordtug et al., 2011; Ulstein, Bruun Wyller, & Engedal, 2007). The questions are divided into three categories: emotional distress, social distress, and negative feelings. The same alternatives are offered for each question: 0 = never/no, 1 = rarely/slightly, 2 = sometimes/moderate, 3 = often/quite a bit, and 4 = always/very much: the range of the total score is from 0 to 60. A study of the RSS in Norway found Cronbach’s alpha to be 0.84 for emotional distress, 0.86 for social distress and 0.70 for negative feelings. A wide spectrum of both patients and caregivers enabled the results to be generalized (Ulstein et al., 2007). A factor analysis showed very similar results, strongly indicating that the RSS is useful over time and in various cultural settings (Greene et al., 1982; Ulstein et al., 2007).

Social support was assessed using the Norwegian version of the revised Social Provision Scale (SPS) (Cutrona & Russell, 1987). The original scale contains 24 items, four for each of the six provisions (attachment, social integration, opportunity for nurturance, reassurance of worth, reliable alliances and guidance) (Weiss, 1974). Because two categories, reliable alliance and guidance, have been shown to be highly correlated with the other six subscales (Mancini & Blieszner, 1992; Russell, Cutrona, Rose, & Yurko, 1984), they were omitted in the revised scale. This is also in accordance with Andersson and Stevens (1993). The four subscales in the revised scale are: attachment, social integration, nurturance, and reassurance of worth. The responses were scored as 1 = strongly disagree, 2 = disagree, 3 = agree and 4 = strongly agree. High scores indicate high social provision. The revised instrument has been used in studies of older people living in the community and has shown good reliability and high validity; the internal consistency within each subscale was high, with Cronbach’s alpha 0.83–0.92 (Andersson & Stevens, 1993; Drageset et al., 2009; Mancini & Blieszner, 1992; Sævareid, Thygesen, Lindstrom, & Nygaard, 2010). Cronbach’s alpha for the subdimensions of the SPS was 0.50 for attachment, 0.55 for both nurturance, and social integration and 0.74 for reassurance of worth.

The Sense of Coherence Scale (SOC-13, 13 items) was used to estimate the caregiver’s SOC. The total score of this 7-point rating scale can range from 13 to 91 (Antonovsky, 1987). The items measured were comprehensibility (5 items), manageability (4 items), and meaningfulness (4 items). The original SOC scale has 29 items. A systematic review of the validity and reliability of the shorter SOC-13 scale (Eriksson & Lindstrom, 2005) showed that it is generally acceptable among older people. The SOC-13 has been used in several studies, such as one studying the mentally intact residents of nursing homes (Drageset et al., 2008) and individuals with a mental disorder (Forsberg, Bjørkman, Sandman, & Sandlund, 2009). A review of the SOC-13, including 127 studies, reported that the SOC-13 has high internal consistency: Cronbach’s alpha 0.70–0.92 (Eriksson & Lindstrom, 2005). Cronbach’s alpha for the SOC-13 was 0.82.

Statistics

We performed statistical analysis using IBM SPSS Statistics (version 19; SPSS Inc., Chicago, IL). We defined statistical significance as p < 0.05.

Descriptive statistics summarized demographics and other characteristics for all participants and for women and men. We reported numbers and percentages for categorical variables. We estimated the internal consistency of the SPS subscales and the SOC-13 by using Cronbach’s alpha reliability coefficient. We performed linear regression analysis to examine relationships between (1) the SPS subdimensions and (2) the SOC-13 and the burden of care for those caring for a partner with symptoms of dementia. Further, to adjust for possible cofounders (Helbæk, 2009), we included the following sociodemographic variables in the regression model: age, sex, education, children, feeling healthy, and satisfaction with the public health services. We further adjusted for SOC-13 when we examined the burden of care and the SPS subdimensions.

Ethical considerations

We assured anonymity by giving the respondents a stamped envelope in which to return the set of questionnaires directly to the researcher by ordinary mail. We included the inclusion and exclusion criteria on an information sheet following the set of questionnaires, and we thus made these clear both to the community nurses who recruited the respondents and to the respondents themselves. We included a brief information pamphlet with the questionnaires, and it stated that the anonymity of the participants was ensured. To ensure that informed consent could be obtained, we also provided a summary of the study and requested that an enclosed statement of informed consent be signed and returned with the questionnaires.

The Western Norway Regional Committee for Medical and Health Research Ethics approved the study (reference 2011/1883/REKvest).

Results

Characteristics of the respondents

Table 1 presents the demographic characteristics of the 97 caregivers. The mean age was 79 years (range 65–96). Most of the respondents were women (64%). Most of the respondents had shared children with their spouse (90%), reported being satisfied with the help they received from the public health services (80%) and reported feeling healthy (70%). Most had attended upper-secondary school or vocational school (51%). Thirty-three percent had only a primary school education, and 16% had attended college or university.

Table 1.

Characteristics of the 97 respondents.^a

	Women		Men		Total
	n	%	n	%	n	%
Sex	62	64	35	36	97	100
Age (years)
65–74	20	33	8	22	28	29
75–84	35	57	16	46	50	52
85–94	6	10	11	31	17	18
95	0	0	2	5	2	2
Education
Primary school	24	41	7	21	31	33
Upper-secondary school or vocational school	31	53	16	47	47	51
College or university	4	7	11	32	15	16
Children
Yes	57	92	30	86	87	90
No	5	8	5	14	10	10
Feel healthy^b
Yes	42	69	25	71	67	70
No	19	31	10	29	29	30
Satisfaction with public services^b
Yes	48	77	30	86	78	80
No	8	13	2	6	10	10

The results are numbers followed by percentages.

These two questions had two answer alternatives: yes or no.

Burden of care and the subdimensions of social provision

The unadjusted statistical analysis (Table 2) showed a significant association between the experience of burden and the subdimension attachment (B = −1.80, 95% CI = −3.26, −0.33, p = 0.02). When adjusted for sociodemographic variables, the subdimension attachment was still significant (B = −2.58, 95% CI = −4.39, −0.77, p = 0.01) (Table 3). When we entered the subdimensions and the total score for SOC into one regression analysis related to burden, the association between the burden of care and attachment was nonsignificant (B = −1.72, 95% CI = −3.48, 0.04, p = 0.06).

Table 2.

Unadjusted associations between burden and the SPS subscales and between the SOC-13: linear regression analysis.

	B	Confidence interval	p
Social Provisions Scale
Attachment	−1.80	−3.26, −0.33	0.02
Nurturance	0.47	−0.88, 1.81	0.49
Social integration	−0.29	−1.49, 0.90	0.63
Reassurance of worth	−0.17	−1.13, 0.36	0.79
Sense of coherence	−0.41	46.57, 66.08	<0.001

B: regression coefficient.

Table 3.

Adjusted associations between burden and the SPS subscales: linear regression analysis.

	B	Confidence interval	p
Age (years)
66–74	10.09	(−5.34, 25.52)	0.20
75–84	6.01	(−9.31, 21.33)	0.44
85–94	6.05	(−9.49, 21.59)	0.44
≥95	Reference
Sex
Men	−5.69	(−11.02, −0.36)	0.04
Women	Reference
Education
Primary school	−1.64	(−8.95, 5.66)	0.66
Upper-secondary or vocational school	−1.99	(−9.33, 5.35)	0.59
College or university	Reference
Children
Yes	−5.64	(−13.77, 2.49)	0.17
No	Reference
Feel healthy
Yes	−4.49	(−9.55, 0.57)	0.08
No	Reference
Satisfaction with public services
Yes	5.28	(−2.67, 13.24)	0.19
No	Reference
Social Provisions Scale
Attachment	−2.58	(−4.39, −0.77)	0.01
Social integration	0.09	(−1.34, 1.16)	0.89
Nurturance	0.69	(−0.77, 2.11)	0.34
Reassurance of worth	0.69	(−0.71, 2.09)	0.33

B: regression coefficient.

Burden of care and SOC

In the unadjusted univariate analysis (Table 2), SOC was significantly correlated with burden; low SOC-13 scores indicate a heavier perceived burden of care. When adjusted for all the other factors (age, sex, education, children, own health and satisfaction with public health services), the association between burden of care and SOC was still significant (B = −0.35, 95% CI = −0.52, −0.17, p ≤ 0.001) (Table 4).

Table 4.

Adjusted associations between burden and SOC-13: linear regression analysis.

	B	Confidence interval	p
Age (years)
66–74	14.14	(0.02, 28.26)	0.05
75–84	12.09	(−1.64, 25.82)	0.09
85–94	8.77	(−5.28, 22.83)	0.22
≥95	Reference
Sex
Men	−1.72	(−6.64, 3.21)	0.49
Women	Reference
Education
Primary school	−0.35	(−7.03, 6.33)	0.92
Upper-secondary or vocational school	0.84	(−5.64, 7.32)	0.80
College or university	Reference
Children
Yes	−0.03	(−7.14, 7.08)	0.99
No	Reference
Feel healthy
Yes	−2.97	(−7.72, 1.78)	0.22
No	Reference
Satisfaction with public services
Yes	5.84	(−1.13, 12.82)	0.10
No	Reference
Sense of coherence scale	−0.35	(−0.52, −0.17)	<0.001

B: regression coefficient.

Discussion

This study showed that those caregivers who experienced the social provision attachment perceived less burden of care than those who felt less such support (Table 3). Other studies have also reported an association between less burden of care and social support (Andrén & Elmståhl, 2008; Nordtug et al., 2011; Schoenmakers et al., 2010). A study with a cross-sectional design carried out on a population in Sweden reported a strong association between burden (especially social isolation, disappointment and emotional involvement) with health and SOC (Andrén & Elmståhl, 2008). A systematic review of the literature on informal dementia caregiving (Schoenmakers et al., 2010) showed that perceived lack of support and understanding were the primary factors that caused caregivers to feel dejected and stressed. However, no previous study explicitly distinguished between the subdimensions of social support as in the present study. Nor did any previous study explicitly mention attachment as a dimension of social support (Andrén & Elmståhl, 2008; Nordtug et al., 2011; Schoenmakers et al., 2010). One study investigated the interaction between personality (neuroticism), mental health, and dementia in explaining the burden of care, but only the burden of care was measured using the same scale (the RSS) we used in our study (Nordtug et al., 2011). However, two of these previous studies (Andrén & Elmståhl, 2008; Schoenmakers et al., 2010) did not explicitly distinguish between the subdimensions of social support, and the study by Nordtug, Krokstad, and Holen (2011) did not consider social support.

According to Weiss’ (1974) theory, the social provision attachment is provided by particularly close relations, such as a partner or a close friend, and this relationship prevents feelings of loneliness and restlessness. In an attachment-providing relationship, individuals gain a sense of security (Weiss, 1974). The strong association between the burden of care and attachment may indicate that the closeness of the relationship between the caregiver and the partner with dementia can make the caretaking less burdensome. One explanation for our results may be that caring for a spouse with dementia feels less burdensome in relationships with strong feelings of mutual love over many years. Caregivers’ compassion for their partners may result in positive outcomes of caregiving (Schulz et al., 2007). Other studies have found that an affectionate, close, and interdependent relationship is associated with lower costs and burdens for the caregivers of people with dementia, and, indeed, it may be salutary (Fauth et al., 2012; Kinney & Stephens, 1989; López, López-Arrieta, & Crespo, 2005; Poulin et al., 2010). In contrast, the strong association between the burden of care and attachment may also indicate that caring for a partner with symptoms of dementia is especially burdensome in relationships with low interdependence (Poulin et al., 2010).

Another interesting finding from this study was a significant association between the burden of care and SOC (Table 4). This could indicate that caregivers who have higher SOC find meaning in the struggles, although they face great challenges on a daily basis. According to Antonovsky (1987), the three components of SOC are inextricably intertwined, the construct being a global sense of how the world is viewed. However, he also found that the most important component was meaningfulness, the extent to which an individual finds the demands worthy of commitment and engagement (Antonovsky, 1987). One can assume that older caregivers have lost some roles that they previously held, such as being a parent to co-dwelling children. Nevertheless, having these roles can crucially affect one’s life, and for some, these may make life emotionally sensible, meaningful, and worthwhile.

Older caregivers who recognize that they are doing something worthwhile have found that it gives direction to their lives (Kramer, 1997), and the recognition that one is capable of managing one’s environment may lead to personal growth and enhance self-acceptance (Kramer, 1997; Krause, Herzog, & Baker, 1992).

Caregivers with stronger SOC may have better cognitive understanding of the dementia symptoms deriving from cognitive impairment in their partner than caregivers with lower SOC. In our study, caregivers with college or university education had stronger SOC than caregivers with only primary school or upper-secondary school or vocational education, and caregivers with upper-secondary school or vocational education had stronger SOC than caregivers with only primary school education (Table 4). One could assume that, in general, caregivers reaching a certain level of education are more likely to have the ability to seek information about and make sense of knowledge about dementia and its symptoms.

In contrast, caregivers with lower SOC are likely to be negatively affected by caregiving and find their caregiver role especially burdensome (Andrén & Elmståhl, 2008).

Study limitations

We did not calculate the sample size before collecting data. The 97 caretakers were recruited to the study during a four-month period from March to June of 2012. However, two other studies investigating similar associations had 57 and 130 respondents (Andrén & Elmståhl, 2008; Semiatin & O’Connor, 2012).

According to some earlier studies (Jorm, 2004; Jorm et al., 1994; Nygaard et al., 2009), symptoms of depression in the informant and the quality of the relationship between the informant and the person being evaluated for dementia can affect the score of the IQCODE (Jorm, 2004).

Low scores on Cronbach’s alpha for the SPS is also a limitation of this study.

Even though all the caretakers who met the inclusion criteria were given the opportunity to participate, it can be assumed that those who answered had the greatest interest in the study and were the most healthy, since they were able and willing to make the effort to respond in full. Lack of information about who dropped out of the study is a limitation of this study.

Consequences for nursing practice

Our results indicate that caregivers with a lower SOC and caregivers who report less attachment report the greatest burden. This contributes to better understanding of who is most vulnerable to the consequences of their caregiving role. Such knowledge is necessary so that, at an early stage, nurses and other health care professionals can identify at-risk caregivers and take action to help to alleviate their burden. It has been suggested that health professionals could implement the SOC concept, by creating empowering dialogues to enforce the strengths of individuals (Malterud & Hollnagel, 1999). To enhance the caretaker’s SOC, nurses could support and encourage participation and commitment and could collaborate with them.

Researchers reviewing the effectiveness of educational programs reported that they significantly reduced the burden of the caregivers of older people with dementia (Marim, Silva, Taminato, & Barbosa, 2013). Dementia caregivers who have attended such educational program classes or otherwise have been taught about dementia and its symptoms may have gotten their SOC strengthened (cognitive component). This may be one way to enhance the caregivers’ SOC of which nurses should be aware.

When given the opportunity to do so, nurses and other formal caregivers should provide support that can strengthen the feelings of attachment of the person with dementia. It is important that community nurses see the couple as a unit and that they be aware that helping the informal caregiver will also help the person with dementia. Giving tailored support requires that clinicians be sensitive to the needs of each individual couple.

Conclusion

This study showed an association between the burden of care and the social provision attachment and between the burden of care and SOC. Community nurses and other health care professionals should be aware of the challenges faced by many people who cohabit with a partner with dementia. By being sensitive to the variation in burden the informal caregivers experience, nurses can take necessary action to strengthen attachment and SOC among the caregivers.

Further research

Qualitative studies should be carried out to obtain deeper understanding of the variety of challenges faced by an informal caregiver living with a partner; of particular interest is how the perceived burden of care is associated with social support and/or the ability to cope.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Kari Stensletten is a RN and Master of Health Science. She currently works as a lecturer at Bergen University College. The research article “Burden of care, social support and sense of coherence in elderly caregivers living with individuals with symptoms of dementia” is based on her Master thesis. Stensletten currently works as a lecturer at Bergen University College. Her clinical career thus far has involved working predominantly with elderly people and/or with people with mental health problems.

Jorunn Drageset (RN, PhD) is currently working as a and Professor at Department of Public Health and Primary Health Care, University of Bergen and at Bergen University College. Drageset work has mainly been within the following areas: cross-sectional study of quality of life, psychosocial health among the elderly, and health-related quality of life and prediction of psychosocial variables in cognitively healthy cancer patients.

Frøydis Bruvik is a RN and Master of Science in Health promotion and health psychology. Her work on psychosocial intervention to persons with dementia and their family carers was the focus of her doctoral studies. Her position is ahead of the Kavli Research Centre for Geriatric and Dementia, Haraldsplass Deaconess Hospital, Bergen, associated professor at the Haraldsplass Deaconess University College, Bergen and researcher at Norwegian Centre for Research, Education and Service Development, Ageing and Health, Tønsberg.

Birgitte Espehaug is a trained statistician. She is currently working as a Professor in Epidemiology at Centre of Evidence-Based Practice at Bergen University College and as a biostatistician at the Norwegian Arthroplasty and Hip Fracture Competence Center at Haukeland University Hospital. Espehaug has been involved in a range of clinical studies investigating the safety and effectiveness of medical devices and different treatment and medication regimens. Her present research focuses on issues related to evidence-based practice and evidence-based research.

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