Abstract

Most family caregiving research has relied on the perspective of the caregiver but has not systematically examined the views and opinions of the elder who is receiving care. The present study examined 63 caregiving dyads to determine how the responses of each member had an impact on the well-being of the other member of the dyad. Caregiver relationship strain predicted his or her own depression and negative health, but no significant association was found between caregiver and care recipient outcomes. Multilevel modeling was used to assess the level of dyadic discrepancy over the care recipient's needs and appraisal of caregiving difficulties. Results indicate that there is little disagreement over the care recipient's needs, but a significant amount of variation in how much the care recipient and caregiver agree on their appraisals of caregiving difficulties. Relationship strain perceived by the caregiver, but not the care recipient, was significantly associated with this disagreement.

Decsion Editor: Toni C. Antonucci, PhD

THERE is broad consensus in the caregiving literature that caring for an elderly relative places the caregiver at risk for compromised physical and mental health (e.g., Gallant and Connell 1997; George and Gwyther 1986; Schulz, O'Brien, Bookwala, and Fleissner 1995; Yee and Schulz 2000; Zarit, Stephens, Townsend, and Greene 1998; see review by Gatz, Bengtson, and Blum 1990; Whitlatch and Noelker 1996) and indeed, in the case of spouse caregivers, at greater risk for mortality (Schulz and Beach 1999).

Traditionally in the literature, the care recipient has been viewed as a potential stressor and the caregiver is seen in terms of his or her outcomes (e.g., depression, health). However, the caregiving relationship, by definition, is made up of two people. There is a great deal more to that relationship than just caregiver outcomes, including the strain both people experience in the relationship and their level of congruence and conflict about the care being provided. Caregiver and care recipient may disagree in their perception of key features of the situation, such as the need for care or how well the care recipient's needs are being met. Understanding the ways in which the care recipient and caregiver converge or diverge in their perspectives of situations and each other's needs has implications for how we plan interventions to improve the outcomes of both members of the dyad and also furthers our understanding of the validity and reliability of proxy measures in research and clinical assessments (Coriell and Cohen 1995). The present study examined the extent of dyadic congruence over care recipient impairment and appraisal of the caregiving situation as well as predictors of incongruence, including use of formal services and caregiving relationship strain.

Caring for a loved one can be an integral part of many close relationships throughout life but, there are times when the caregiving can come to dominate the relationship and outweigh previous interactions (Carter and Carter 1994; Pearlin, Mullan, Semple, and Skaff 1990). In some relationships, reciprocities can be greatly reduced with even affection becoming unidirectional over time (Pearlin et al. 1990). Some caregivers manage to find benefits to their new role (e.g., Cartwright, Archbold, Stewart, and Limandri 1994), but many find it an extremely stressful experience (Pearlin et al. 1990).

Caregiving research tends to underemphasize the care recipient and his or her perspective and outcomes (Pruchno, Burant, and Peters 1997; Zarit 1994). Instead, the care recipient is oftentimes included as an "objective" measure of caregiving stress, particularly in dementia research, rather than a contributor to our understanding of the caregiving situation or relationship (Cotrell and Schulz 1993; Gatz et al. 1990). Even in the absence of cognitive impairment, the care recipient's physical functioning and illness severity are used to explain caregiver well-being (e.g., Carter and Carter 1994; Townsend and Franks 1995). In studies that do include outcomes for the care recipient, the focus tends to be on his or her mental health (Walker, Martin, and Jones 1992) or delay in institutionalization (Jette, Tennstedt, and Crawford 1995; McKinlay, Crawford, and Tennstedt 1995). Some research has found the well-being of one spouse to be significantly associated with the well-being of the other spouse (Bookwala and Schulz 1996), but the emphasis still remains on the care recipient and caregiver as somehow separate from their dyadic interactions and the caregiving relationship.

Researchers have adopted a number of theories to explain the interactions between care recipient and caregiver in the caregiving relationship; for example, social exchange theory (e.g., Scharlach 1987; Walker et al. 1992), equity theory (e.g., Wright and Aquilino 1998), and communal relationship theory (e.g., Williamson and Schulz 1990; Williamson, Shaffer, and Schulz 1998). In addition, relationship quality has been linked to a caregiver's sense of role captivity and burden (Archbold, Stewart, Greenlick, and Harvath 1990; Lawrence, Tennstedt, and Assman 1998; Scharlach 1987; Williamson and Schulz 1990), anxiety, frustration, and time costs (Walker et al. 1992), depression (Williamson et al. 1998; Tower, Kasl, and Moritz 1997; Townsend and Franks 1995; Yates, Tennstedt, and Chang 1999), health (Uchino, Kiecolt-Glaser, and Cacioppo 1994), tension (Fingerman 1996), and the care recipient's well-being (Scharlach 1987). The quality of this relationship includes such components as cohesion, satisfaction and tension, and dyadic conflict, which is the focus of the present study.

All close relationships experience conflict to some degree, but frequent conflict in a strongly interdependent relationship such as the caregiving relationship can dominate the relationship to the exclusion of all else (Peterson 1983). Conflict arises when the goals or perspectives of the dyad are incongruent (Litvin 1992; Peterson 1983; Sayles-Cross 1993), as in the case of a caregiver who feels both guilty and unappreciated whereas her husband feels overprotected and dependent (Kelley 1981). Conflict can also arise from developmental differences (Fingerman 1996). As with any relationship, the caregiving relationship is not without its history (Peterson 1983), and in fact the caregiving situation can reawaken old family conflicts (Pearlin et al. 1990), which may "ripple" to other relationships (Johnson and Catalano 1983). Conflict has implications for the well-being of the care recipient and caregiver and influences the likelihood of success in meeting each of their needs (Coriell and Cohen 1995; Litvin 1992; Pratt, Jones, Shin, and Walker 1989).

Many studies obtain information about the care recipient only from the family caregiver because of dementia of the care recipient (Cotrell and Schulz 1993) and difficulty in recruiting care recipients (Long, Sudha, and Mutran 1998). In service settings as well, health care and social service professionals often rely on family members for an assessment of the care recipient to make decisions about care (Bookwala and Schulz 1998; Long et al. 1998). Research that has explored congruency between caregiver and care recipient reveals inconsistent findings, with some studies suggesting high congruency (Carter and Carter 1994; Chappell and Kuehne 1998; Long et al. 1998; Pearlin et al. 1990) and others suggesting low congruency (MacKenzie, Robiner, and Knopmen 1989; Teri and Wagner 1991; Wetle, Levkoff, Cwikel, and Rosen 1988; Zweibel and Lydens 1990), with a trend toward the primary caregiver often overstating the impairment or disability of the care recipient when compared with the care recipient's self-assessment (Bookwala and Schulz 1998; Kristjanson et al. 1998; Zweibel and Lydens 1990).

There has been controversy in the literature regarding the relationship between the caregiver's strain and his or her ability to make an assessment of the physical needs and health care status of the care recipient (Long et al. 1998). Researchers such as Pruchno and colleagues 1997 have suggested that caregivers who are extremely burdened or depressed may perceive the care recipient to be more impaired than he or she actually is. Alternatively, Bookwala and Schulz 1998 found that caregiver mastery and level of neuroticism played a role in how the caregiver's perception of care recipient impairment affected his or her strain. Finally, Zweibel and Lydens 1990 found that dyadic incongruence over instrumental activity of daily living (IADL) impairment was associated with the caregiver reporting difficulty fulfilling caregiving duties, the caregiver anticipating future problems about providing care, and the care recipient worrying that the caregiver was doing too much.

In light of recent demographic trends, the role of formal support in caregiving is increasingly important if elders are to remain in the community. Formal services have been found to reduce caregiver strain and negative well-being (e.g., Johnson and Catalano 1983; Zarit et al. 1998), but have also been associated with increased caregiver strain and depression (Morris, Morris, and Britton 1989), increased family conflict over treatment of the caregiver and/or care recipient (Mullan 1993), negative caregiving outcomes (Bass, Noelker, and Rechlin 1996), and negative relationship strain (Biegel, Bass, Schulz, and Morycz 1993). McKinlay and colleagues 1995 found that adult daughters who reported negative personal impact (negative effect on sleep, health, leisure, privacy, financial situation, and management of chores) and used large amounts of formal services had improved negative personal impact over time.

There is little research exploring the effects of formal services on the care recipient's well-being or the caregiving dyad. Evidence suggests that the use of formal services is associated with greater dyadic incongruence (Chappell and Kuehne 1998; Zweibel and Lydens 1990). Friedman and Kaye 1980 reported that one fifth of service plans were rejected and disrupted when family members, other than the care recipient, were not included in the decision-making process. It is possible that the receipt of formal services means different things to the caregiver and care recipient. The care recipient may view such services as unnecessary and may feel overprotected, leading them to resist the help (Pearlin et al. 1990), whereas the caregiver may perceive the extra help as a way to lower strain. This may, in turn, lead them to perceive the care recipient's impairment quite differently.

As was alluded to earlier, the relationship between caregiver stress and well-being may have more to do with the caregiver's appraisal of the situation than with the level of impairment and amount of care (e.g., Aneshensel, Pearlin, Mullan, Zarit, and Whitlatch 1995; Pearlin et al. 1990; Yates et al. 1999). Relationship strain has been associated with role captivity and overload (Lawrence et al. 1998; Yates et al. 1999) as well as caregiver effectiveness (Townsend and Franks 1997), variables that have been interpreted as appraisals of the caregiving situation (e.g., Aneshensel et al. 1995). The care recipient's appraisal of the situation is also important (Gatz et al. 1990). However, Zweibel and Lydens 1990 believe the relationship outcomes of the caregiver and care recipient are not determined so much by the individual perceptions of the caregiver and care recipient, but whether their perceptions of the same situation agree. Dyadic congruence has been associated with a closer relationship (Chappell and Kuehne 1998; Long et al. 1998), whereas Litvin 1992 found that perceived change in the quality of the relationship by caregiver and care recipient significantly predicted dyadic conflict. Thus, caregiving relationship quality may be the lens through which appraisal of the caregiving situation is made.

Family researchers have long promoted a move toward a more dyadic approach to relationships (Pruchno et al. 1997; Thompson and Walker 1982). In the past, there had been few analytic tools for assessing dyads, but in recent years several techniques have been applied to this problem (see Maguire 1999; Pruchno 1989). Maguire 1999 compared three separate techniques for analyzing marital dyads—intraclass correlations, repeated measures analyses of variance (ANOVAs) and multilevel modeling. Multilevel modeling allows for questions regarding dyadic congruence and direction of difference between the care recipient and the caregiver, similar to repeated measures ANOVA. In addition, it allows for questions regarding dyadic differences similar to intraclass correlations. Thus, multilevel modeling is a powerful, comprehensive method for assessing the degree of dyadic congruence (how well the care recipient and caregiver agree) and for uncovering which member of the dyad is scoring higher or lower (e.g., caregiver reports more impairment than care recipient). In addition, it also allows the researcher to predict dyadic incongruence. Thus, multilevel modeling was deemed an appropriate technique for the present study.

The present article focuses on the dyad as the unit of analysis to examine incongruence in the caregiving relationship. Specifically, we focus on the role that receiving formal services and caregiving relationship strain play in predicting dyadic incongruence in perception of care recipient IADL impairment and appraisals of the caregiving situation (e.g., help available from family and friends). Although we acknowledge that the precaregiving relationship has an important role to play, we have chosen to focus on the current caregiving relationship because of the problems associated with retrospective data and because we wanted to narrow our exploration to the way in which members of the dyad view their interaction within the context of the caregiving relationship. This study focused on three main research questions:

  1. Is there an association between the well-being of the caregiver and care recipient?

  2. Does receipt of formal services predict incongruence over the level of the care recipient's impairment?

  3. Does caregiving relationship strain predict incongruence over the appraisal of the caregiving situation?

Methods

Design and Procedure

The present sample is a result of combining samples from two different studies of caregivers in Cleveland, OH, conducted at the Benjamin Rose Institute. These studies were funded by the Retirement Research Foundation (RRF) and the National Institute of Mental Health (NIMH). The primary goal of the RRF study was to identify the resources and services used by long-term family caregivers living in shared households with their elderly relatives. The NIMH-funded study observed family problem solving and decision making, strain of family relationships in later life, and stress-coping factors in caregiving families that had a functionally impaired widowed or married parent living in a separate residence but within an hour's drive. These samples were merged by Deimling, Bass, Townsend, and Noelker 1989 to examine differences in care-related stress among caregivers in shared (spouse or adult child residing with care recipient) and nonshared (adult child caring for care recipient) households. This was possible because of common instrumentation and identical data-collection methodologies (Deimling et al. 1989).

The data were collected using purposive sampling—targeting particular groups including those caring for a married elder and those caring for a widowed elder. Structured interviews were conducted with the impaired care recipient, his or her spouse (if married), and at least one adult child (Townsend, Noelker, Deimling, and Bass 1989). Participants who were assisting an elderly relative with personal care were referred by community health or social service agencies, recreational or volunteer organizations, media sources, and word-of-mouth (Bass, Tausig, and Noelker 1988). This is, therefore, not a random sample. The advantage of combining the two samples is that the resulting sample is diverse in nature, including caregivers in both shared and nonshared environments and care recipients with a wide range of both physical and mental impairment. This variation in impairment allows for a greater representation of caregiving situations. For further information about this merged sample, see Deimling and colleagues 1989 and Smerglia and Deimling 1997.

Participants

Of the 178 families in the present merged sample, there were 63 care recipients who were successfully interviewed, allowing for 63 dyads to be analyzed. As would be expected, care recipients who were successfully interviewed had lower levels of impairment than care recipients who were not interviewed. Care recipients not available for dyadic analyses were significantly older, t(176) = 2.4, p < .05, more satisfied with their care arrangement according to their caregiver t(176) = 2.1, p < .05, experienced more problems with PADLs, t(176) = 3.8, p < .001, and IADLs, t(176) = 4.6, p < .0001, and were more cognitively impaired, t(173) = 4.7, p < .001, than their counterparts who were available for dyadic analyses. There were no significant differences for care recipient's gender, χ2(1, N = 178) = 0.3, p >.05, marital status, χ2(2, N = 178) = 0.3, p >.05, or behavioral problems, t(176) = 0.2, p > .05.

Consistent with these findings, there were some differences between caregivers in the dyadic sample and those in the nondyadic sample. Caregivers in the dyadic sample were less likely to live with their relative, χ2(1, N = 178) = 32.5, p < .001), spent less time each week caring for their relative, t(176) = 3.4, p < .001, and were less likely to report social restrictions that were due to caregiving, t(176) = 3.2, p < .01. All these differences are consistent with the finding that the dyadic sample had less impairment. By contrast, there were few differences between caregivers in the dyadic sample and other caregivers on sociodemographic characteristics. Caregivers in the dyadic sample were more likely to be White, χ2 (1, N = 178) = 6.6, p < .01, but did not differ in terms of gender, χ2(1, N = 178) = 0.7, p > .05, age, t(176) = 0.7, p > .05, marital status, χ2(4, N = 178) = 7.3, p > .05, employment status, χ2(3, N = 178) = 0.5, p > .05, household income, χ2(5, N = 178) = 6.8, p > .05, education, t(176) = −1.3, p > .05, duration of caregiving, χ2(1, N = 178) = 0.5, p > .05, appraisal of caregiving difficulties, t(176) = −0.5, p > .05, satisfaction with care arrangements, t(176) = 1.1, p > .05, health deterioration, t(102) = 1.6, p > .05, relationship strain, t(176) = −1.1, p > .05, and depression, t(106) = 0.5, p > .05.

It is important to be aware of the selective nature of this subsample and its limitations for generalizing to the caregiving population. The impairment level of the care recipient determines inclusion in the dyadic sample, and this limitation was borne in mind throughout the interpretive process. Any effort to incorporate the perspective of both members of the caregiving dyad inevitably excludes more severely impaired people who are unable to participate in the research interview for one reason or another.

Measures

IADLs.

This measure was completed independently by the caregiver and the care recipient and was derived from the work of Lawton and Brody 1969. It includes eight items assessing the care recipient's functional ability regarding telephone use, shopping, driving, medication administration, paying bills, meal preparation, laundry, and housekeeping. For example, each caregiver was asked, "Does your elder answer the telephone without any help?" whereas each care recipient was asked, "Do you answer the telephone without any help?" Response categories for each item were dichotomous ("yes" and "no" coded 0 and 1, respectively) and summed to yield the total number of IADL areas in which the care recipient required help. Higher scores indicated high levels of impairment (range = 0–8). The means for IADL impairment were 3.75 (SD = 2.45) and 3.35 (SD = 2.24), as reported by caregivers and care recipients, respectively, in the subsample. Cronbach's alpha for this scale was .84 for caregivers and .81 for care recipients.

Appraisal of the caregiving situation.

This measure was completed independently by both the caregiver and care recipient and requires the respondent to appraise 12 care-related difficulties. Items cover a wide range of difficulties that may be encountered while caregiving (e.g., family tension, insufficient money to meet care needs, too many demands being made and finding community services). For example, caregivers were asked, "Do you have a great deal of difficulty, some difficulty, or no difficulty with getting your family members to cooperate in caring for your elder?" whereas care recipients were asked, "Do you have a great deal of difficulty, some difficulty, or no difficulty with getting your family members to cooperate in caring for you?" Responses were coded on a scale of 0 to 2 (0 representing no difficulty and 2 representing a great deal of difficulty). Scores were summed to create a total score representing an appraisal of overall care-related difficulties, with higher scores indicating greater difficulty (range = 0–24). This measure was developed for the purposes of the original study and is described by Noelker, Townsend, and Deimling 1984. The means for level of care-related difficulty were 5.79 (SD = 4.55) and 3.19 (SD = 3.58) as reported by caregivers and care recipients, respectively. Cronbach's alpha for this scale was .83 for caregivers and .82 for care recipients.

Caregiver relationship strain.

This measure observes strain in the caregiving relationship that can be attributed to the caregiving process. The caregiver was asked whether he or she agreed with eight statements using the response categories "not at all," "somewhat," and "a great deal" (coded 0–2, respectively). The scale includes such statements as "I feel that my elder tries to manipulate me" and "My relationship with my elder makes me feel depressed." High scores on this scale indicated greater strain in the relationship with a possible range of 0 to 16 (for more information about the development of this measure, see Poulshock and Deimling 1984). The mean score on this scale for caregivers was 3.33 (SD = 3.67), and Cronbach's alpha was .89.

Care recipient relationship strain.

This measure observes the care recipient's perception of the caregiving relationship he or she has with his or her primary caregiver. The care recipient was asked eight questions such as "Does your caregiver do things to embarrass you?" and "Do you feel that your primary caregiver enjoys being with you?" Response categories for each question were "most of the time," "some of the time," and "not at all" (coded 2, 1, and 0, respectively). High scores indicated a negative caregiving relationship as perceived by the care recipient (range = 0–16). This scale was developed for the original study. The mean score on this scale for care recipients was 1.64 (SD = 2.67), and Cronbach's alpha was .61.

Formal support.

Care tasks provided to care recipients in the present study fell under four categories: health care, personal care, in-home care, and out-of-home care. Caregivers were asked to identify with which of these tasks they helped the care recipient. Caregivers were also asked to identify other family members and paid professionals who helped the care recipient with any of these tasks. On the basis of this information, we measured type of formal–informal support for this study by dividing the sample into three groups– family only, formal specialization, and formal supplementation (Noelker and Bass 1989). The family-only group captured those primary caregivers who were assisted by other family members but did not receive formal help. The formal-specialization group involved formal helpers who assisted with at least one care task the primary caregiver did not perform, and all other tasks were shared. Finally, formal supplementation involved formal helpers and primary caregivers who carried out similar care tasks. As type of formal help was a categorical variable, it was necessary to create a set of dummy variables coded with 1s and 0s. The family-only group was designated as the reference group. In the present sample, 35 (56%) caregivers fell under the family-only category, 17 (27%) fell under the formal-supplementation category, and 11 (17%) fell under the formal-specialization category.

Zung 1965 depression scale.

Depression in the caregiver and care recipient was assessed using the shortened 20-item Zung Self-Rating Depression Scale (Zung 1965). Caregivers and care recipients were asked if they agreed with 20 items using the following response categories; "none or a little of the time," "some of the time," "a good part of the time," and "most or all of the time" (coded 1–4, respectively). An index for depression is created by dividing the total raw score by the maximum score of 80 and converting it to a percentage (Zung 1965). Thus, the range of possible scores is 25 to 100. This is a widely used indicator of psychological well-being with well-established psychometric properties. Smerglia and Deimling 1997 and Townsend and colleagues 1989 have successfully used this measure in older populations. The means for this scale were 42.19 (SD = 11.96) and 42.19 (SD = 8.66) for caregivers and care recipients, respectively. Cronbach's alpha was .83 for caregivers and .74 for care recipients.

Caregiver's negative health index.

This health index was completed by the caregiver and measured the deterioration in the caregiver's physical and emotional health that was due to caregiving. The caregiver was asked how much he or she agreed with six statements about change in frequency of illness, aches and pains, physical health decline, irritability, nervousness, and sadness due to caregiving. An example sentence is "Because of caring for my elder I seem to get sick more often." Responses were coded on a scale of 0 to 3 (0 representing strongly disagree, 1 representing disagree, 2 representing agree and 3 representing strongly agree). High scores on this scale indicated greater health deterioration (range 0–18). This measure was developed for the original study (for a copy of all items and further description of the scale, see Bass et al. 1988). The mean for this scale was 6.11 (SD = 4.72) and Cronbach's alpha was .92.

Care recipient's negative health index.

This health index was completed by the care recipient and contains four questions about the health of the care recipient during the past month. The questions cover such areas as exhaustion, worry over health, aches and pains, and health interfering with activities. An example item is, "How often have you been bothered by aches and pains during the past month?" Responses were coded on a 0 to 4 scale (0 representing almost never, 1 representing once in a while, 2 representing sometimes, 3 representing frequently, and 4 representing almost always). High scores on this scale indicated poor health (range = 0–16). The mean health score for care recipients was 9.68 (SD = 4.59), and Cronbach's alpha was .76.

Caregiver social-activity restriction.

This measure was completed by the caregiver, and it assessed whether the caregiver's activities had been restricted because of the demands of caregiving using five questions. Questions concern the caregiver being restricted in taking part in religious activities, visiting friends and family, participating in group activities, volunteering, and being involved in social occasions. An example item is, "Because you've been caring for your elder do you visit with friends or family less often?" Response categories for each item were dichotomous ("yes" and "no" coded 1 and 0, respectively) and summed to yield the total number of areas in which the caregiver's activity was restricted. The possible range for this scale is 0 to 5 (for more information about the development of this measure, see Poulshock and Deimling 1984). The mean activity restriction for caregivers in this sample was 2.3 (SD = 1.93), and Cronbach's alpha was .89.

Analysis Plan

Our first study question is answered using zero-order correlations, whereas questions 2 and 3 are answered using multilevel modeling (as implemented by the hierarchical linear modeling (HLM) computer program of Raudenbush, Bryk, Cheong, and Congdon 2000). We used a two-level HLM model suggested by Raudenbush, Brennan, and Barnett 1995. Level 1, or the within-dyad approach, models the relationship between both members of the dyad on a common variable of interest, in this case the care recipient's impairment. For each dyad, the responses of the members are regressed on an indicator variable, here coded .5 for caregivers and −.5 for care recipients. The parameters of the regression model, an intercept and a slope, are interpreted in the following way. The intercept represents the dyad mean (impairment score averaged across the dyad members), because the regression coefficient represents the expected value of the outcome when the indicator score is 0. The slope represents the dyad difference score or discrepancy, as the regression coefficient represents the difference in the outcome for a 1-unit difference in the indicator variable. The values of these parameters are permitted to vary across dyads. Level 2, or the between-dyad approach, models variance in dyad means and dyad discrepancies as a function of dyad characteristics.

The first step is to fit a baseline (or unconditional) model, that is, a model with no level 2 predictors. This provides estimates of: (a) the average reliability of the dyad mean and discrepancy slope, (b) the population average values of the discrepancy score and dyad mean, (c) the covariation between the discrepancy slope and dyad mean, and (d) the variance of the dyad mean and discrepancy slope. If there is significant variation in the discrepancy score and dyad mean, it is appropriate to proceed with a Level 2 model in which predictors can be included to explain the variation in these parameters which have now become dependent variables (Bryk and Raudenbush 1987).

To fit a regression line for each dyad, it is necessary to have two data points for each member of the dyad—caregiver and care recipient. Thus, two parallel scales were created by first creating pairs of items matched on their standard deviations and then randomly assigning one item from each matched pair to IADL Scale A (or B). This step was done separately for care recipient and caregiver scales, producing two parallel scales measuring care recipients' IADL needs for each member of the dyad. The items on the caregiving difficulties scale were treated in similar fashion.

Results

Correlational Analyses

The first research question asked whether there was an association between the well-being of the caregiver and well-being care recipient. Table 1 contains zero-order correlations between the care recipient's well-being (depression, health, and relationship strain) and the caregiver's well-being (depression, health, activity restriction, and relationship strain) in addition to IADL impairment and appraisals of caregiving difficulties. After correcting for Type I error using the Bonferroni method, we can assume that correlations significant only at the .001 level are unrelated to chance. Caregiver relationship strain was positively associated with caregiver negative health (r = .47, p < .0001), caregiver depression (r = .52, p < .0001), and the care recipient's appraisal of the caregiving situation (r = .42, p < .0001). In addition, the way in which the caregiver and care recipient appraised the caregiving situation was significantly associated with their respective outcomes. Finally, care recipient IADL impairment reported by caregiver and care recipient were significantly associated (r = .82, p < .0001), as were caregiving difficulties as reported by both caregiver and care recipient (r = .45, p < .0001).

Disagreement Over IADL Impairment

The second research question explored whether formal services predicted the level of disagreement between the caregiver and care receiver regarding the care recipient's impairment. Regression lines were fit to each dyad on the basis of the observed scores for the two IADL parallel scales for both caregiver and care recipient in a baseline model. The Tau matrix contains the correlations among all Level 1 parameters, including the important correlation between the intercept (IADL dyad mean) and the slope (IADL dyad discrepancy). In this model, the estimate was .39 indicating that a dyad with a higher dyad mean (care recipient had higher level of dependence) would also have a higher discrepancy score (lack of similarity) and vice versa.

The reliability estimates for the discrepancy score and dyad mean are closely related to the variance within and between dyads. For instance, the proportion of the variance between dyads is estimated by the intraclass correlation ρ = τ00/(τ00 + σ2), which for IADL impairment is 57%. (τ is the dyad level 2 variance in IADL and σ2 is the individual level 1 variance.) Thus, there is slightly more variation between dyads than within dyads. To determine the reliability of the dyad mean estimate, researchers must adjust the intraclass correlation for group size using the formula λj = τ00/[τ00 + (σ2/nj)] where j represents a dyad. Reliability for the dyad mean was .90. Reliability for the discrepancy score was .20.

In this model, the dyad mean and discrepancy score for IADL needs were predicted only by their grand means. The sample dyad mean was 1.78 for IADL needs (Table 2 ) indicating that most dyads rated care recipients as having few IADL needs (the original range of the scale was 0–8). The mean for the discrepancy score was .19. The small magnitude indicates that, on average, care recipients and caregivers did not differ greatly in their perception of care recipients' needs. However, the positive sign indicates that, on average, caregivers rated the care recipients as more dependent than did the recipients themselves. Fig. 1 shows the fitted regression lines for a sample of 10 dyads. It can be seen that although the sample mean indicated a relatively low level of IADL needs, there was a substantial amount of variance in the IADL mean for each dyad. However, the slopes for this sample did not display much variance and were very similar to the sample average slope of .19. Thus, it was found that the dyad mean-variance component was significantly different from zero, χ2(62, N = 126) = 631.17, p < .0001, whereas the discrepancy score variance component was not, χ2(62, N = 126) = 77.10, p > 0.1. It was, therefore, worthwhile to add Level 2 predictors representing type of formal support received to explain the variance in dyad mean.

Table 3 shows the results when the dummy variables formal supplementation and formal specialization were added as Level 2 predictors. Both variables were significant predictors of the variation in the dyad mean (level of IADL needs). The relationship was positive, suggesting that dyads in which the care recipient's IADL needs were reported as high were significantly more likely to be receiving formal help as opposed to family help; the converse was true when IADL needs were low.

Disagreement Over Appraisals of Caregiving Difficulties

The third research question explored whether relationship strain predicted disagreement between the caregiver and care recipient on appraisals of caregiving difficulties. The first step involved the baseline model. The estimate of the correlation between the intercept (average caregiving difficulties level) and dyadic slope (discrepancy) was .34, indicating that a dyad reporting a high level of caregiving difficulties would also tend to have a high discrepancy score. The reliability estimates for discrepancy score and dyad mean were .67 and .87, respectively.

The sample dyad mean was 2.24 for caregiving difficulties (Table 4 ), indicating that most dyads rated few caregiving difficulties (the original range of the scale was 0–24). The mean discrepancy score was 1.28, indicating that care recipients and caregivers differed in their reporting of caregiving difficulties. Caregivers appeared to report more caregiving difficulties than care recipients did. Fig. 2 shows the fitted regression lines for a sample of 10 dyads. Although the population average mean indicated a relatively low level of caregiving difficulties, there was a substantial amount of variance in the means across dyads. Similarly, the slopes for this sample display substantial variance. This variation in slope is in stark contrast to the slopes of IADL impairment shown in Fig. 1. The dyad mean variance component was significantly different from zero, χ2(62, N = 126) = 488.21, p < .0001, as was the discrepancy score variance component, χ2(62, N = 126) = 187.59, p < .0001.

Table 5 contains the results of adding relationship strain (as perceived by both the care recipient and caregiver) as Level 2 predictors of the dependent-variables dyad mean and discrepancy score (for caregiving difficulties). Relationship strain, as perceived by the caregiver, was a significant predictor of both dyad mean caregiving difficulties and discrepancy. The coefficients were positive, indicating that dyads whose caregivers perceived high relationship strain were more likely to report more caregiving difficulties and experience greater discrepancy on average (caregivers reported more caregiving difficulties than care recipients did).

Finally, as the original samples merged by Deimling and colleagues 1989 differed primarily by type of caregiver (i.e., spouse or adult–child), the above models were reestimated to include a dummy variable indicating caregiver type as a control variable in Level 2 analyses. No significant association was found for IADL impairment or caregiving difficulties. Cognitive impairment was also not significantly associated with IADL impairment or caregiving difficulties.

Discussion

Two important goals of the present study were to examine the caregiving dyad as a unit rather than as individual members, and to assess the level of dyadic congruence. The first question explored the relationship of caregiver and care recipient outcomes, including depression and negative health. Caregiver outcomes were not significantly related to care recipient outcomes; however, caregiver relationship strain was associated with caregiver negative health and depression. The present study also attempted to predict dyadic discrepancy over perceptions of care recipient impairment and appraisals of caregiving difficulties. Type of formal help predicted dyadic level but not disagreement over care recipient impairment. Relationship strain of the caregiver, but not of the care recipient, was a predictor of dyadic discrepancy over the appraisal of caregiving difficulties, with greater relationship strain predicting greater discrepancy.

This study builds on research that previously explored proxy measures and congruence over the care recipient's level of physical impairment. Although level of care recipient impairment was low in this sample, there was high agreement between the caregiver and care recipient over the level of this impairment. However, caregivers were slightly more likely to rate the care recipient as more dependent than were care recipients. These findings are in keeping with much of the research in this area (e.g., Bookwala and Schulz 1998; Long et al. 1998; Zweibel and Lydens 1990). As there was so little discrepancy over the care recipient's needs, it was not possible to assess the role of formal support in predicting incongruence.

The appraisal of the caregiving situation has been linked to important caregiver outcomes. In the present study, caregiving difficulties revolved around instrumental and emotional support (both formal and informal) available to the caregiving dyad and cooperation between the dyad. Whereas the level of caregiving difficulties was low in the present sample, there was a discrepancy in the number of difficulties experienced by each dyadic member, with caregivers perceiving more than care recipients did. In other words, caregivers perceived less support and cooperation than care recipients did. As the level of caregiving difficulties increased, discrepancy increased. Caregiver relationship strain significantly predicted the level of caregiving difficulties experienced, with greater relationship strain predicting more difficulties. In addition, caregiver relationship strain predicted discrepancy. This finding supports previous research that has found caregiver characteristics to be more important to caregiver well-being and congruence than care recipient characteristics are (Chappell and Kuehne 1998; George and Gwyther 1986). This may be due in part to low variance in how care recipients rated relationship strain in the present dyadic sample. Alternatively, caregivers who perceive the caregiving relationship in a negative light may be more inclined to disagree with the care recipient over support from family and formal sources available and to perceive the care recipient as less cooperative.

Although the finding that poor relationship quality predicts dyadic disagreement may seem obvious, it is worth noting that such an association is not always the case. For instance, Pakenham 1998 found that couples who differed in their coping styles had significantly better individual and dyadic adjustment and outcomes. In addition, relationship quality does not always behave in predictable ways. Lawrence and colleagues 1998 found that for caregivers who had a high level of relationship quality with the care recipient, care recipient impairment was associated with greater levels of perceived overload, whereas Williamson and Schulz 1990 found that for women who were low in communal orientation, depression was associated with having a close preillness relationship. Thus, relationship quality is a complex concept that is greatly influenced by the past and present, but has important consequences for both members of the dyad. The role of relationship quality in predicting dyadic disagreement may largely depend on what the disagreement is about.

The lack of significant association between caregiver and care recipient outcomes in the present sample is in contrast to previous research (e.g., Bookwala and Schulz 1996; Walker et al. 1992). There may be a number of reasons for this. First, this sample was small, so statistical relationships may be more difficult to find. Second, the present study only included negative outcomes for both caregiver and care recipient. It is possible that a broader range of outcomes including benefits to the caregiving relationship might have resulted in more significant associations.

As noted in the introduction, previous research has found the caregiver's assessment of the situation to be influenced by his or her level of stress (Pruchno et al. 1997). The same could be the case for the care recipient. Although it is important to reduce such confounding through prospective studies, it does not change the resulting disagreement within the dyad. In fact, dyadic disagreement may well fluctuate over time as a function of the stress of both members of the dyad.

Implications of this study are twofold. The first advocates the involvement of both the care recipient and caregiver in research and care planning where possible. Health care and social service professionals need to recognize and understand both perspectives to increase the success of fulfilling the needs of both members of the dyad. Advanced cognitive impairment can make interviewing problematic; however, recent research indicates care recipients with mild to moderate cognitive impairment are able to answer questions about their own care and preferences with a high degree of accuracy and reliability (Whitlatch and Feinberg 1999). The second implication emphasizes the importance of relationship quality. Interventions targeting the caregiving relationship may offset some of the disagreement over the caregiving situation and related strain. Such interventions might include promoting communication between care recipient and caregiver about the caregiving situation and their respective needs.

There are a number of limitations in the present study that need to be borne in mind when generalizing to larger, more recent samples of caregivers and care recipients. First, the cross-sectional design does not allow for causality to be determined, nor does it allow for the exploration of the dynamic nature of the constructs under investigation and how such relationships may change over time. Second, the data used in the present sample were collected in the mid-1980s. Community services are more available and accessible now than when the data were collected, but there is also greater demand for them. Thus, caregivers may have more resources available to them, but the importance of relationship quality and dyadic congruence has remained current in the literature, and we feel our findings still contribute to our knowledge of the caregiving situation. Third, the dyadic subsample was both small and select, weakening generalizability of the findings. Also, with only 63 dyads, power was reduced, and it was not possible to look at dyadic discrepancy as a predictor of caregiver and care recipient well-being.

Future research should build on the present findings by incorporating such constructs as care preferences, attitudes to formal service use, and beliefs about familial obligations from both the caregiver and the care recipient. More research is needed on the caregiving dyad and positive outcomes for both members. The caregiving dyad includes the care recipient's perspective, but it also produces invaluable information about potential issues of conflict between the caregiver and care recipient. Consistent with previous findings, we found less disagreement over care recipient impairment (a relatively objective construct), than over caregiving difficulties (a more subjective construct). However, the present study differed from previous research in using the dyad as the unit of analysis by using a relatively new methodology in dyadic research and by including both caregiver and care recipient predictors of such disagreement. In this respect, we believe the present study makes an important contribution to the current research.

Table 1.

Zero-Order Correlations Between Well-Being and Perceived Relationship Quality for Elders and Caregivers (n = 63)

Variable and Scale 10 11 
Caregiver Variables            
1. Elder IADL impairment —           
2. Caregiving difficulties .26 —          
3. Relationship strain .11 .69 —         
4. Negative health .40 .57 .47 —        
5. Depression .36 .55 .52 .66 —       
6. Activity restriction .46 .28 .34 .63 .42 —      
Elder Variables            
7. Elder IADL impairment .82 .19 .01 .36 .25 .40 —     
8. Caregiving difficulties .11 .45 .42 .28 .34 .22 .15 —    
9. Relationship strain .28 .33 .34 .30 .23 .25 .25 .38 —   
10. Negative health .15 .22 .12 .24 .20 .23 .29 .45 .31 —  
11. Depression .21 .26 .14 .11 .10 .21 .37 .40 .30 .70 — 
Variable and Scale 10 11 
Caregiver Variables            
1. Elder IADL impairment —           
2. Caregiving difficulties .26 —          
3. Relationship strain .11 .69 —         
4. Negative health .40 .57 .47 —        
5. Depression .36 .55 .52 .66 —       
6. Activity restriction .46 .28 .34 .63 .42 —      
Elder Variables            
7. Elder IADL impairment .82 .19 .01 .36 .25 .40 —     
8. Caregiving difficulties .11 .45 .42 .28 .34 .22 .15 —    
9. Relationship strain .28 .33 .34 .30 .23 .25 .25 .38 —   
10. Negative health .15 .22 .12 .24 .20 .23 .29 .45 .31 —  
11. Depression .21 .26 .14 .11 .10 .21 .37 .40 .30 .70 — 

Notes: Correlations between .26 and .30 are significant at p < .05; correlations between .33 and .38 are significant at p < .01; correlations equal to .40 and greater are significant at p < .001. IADL = instrumental activity of daily living.

Table 2.

Hierarchical Linear Modeling Baseline Model of Dyadic Discrepancy and Level of Care Recipient's Impairment

Effect Coefficient SE Variance Component df t ratio χ2 
Fixed        
Dyad Mean 1.78 0.14   12.92  .000 
Discrepancy Score 0.19 0.10   1.98  .047 
Random        
IADL Level   1.09 62  631.17 .000 
IADL Discrepancy   0.12 62  77.10 .094 
Level 1 Error   0.48     
Effect Coefficient SE Variance Component df t ratio χ2 
Fixed        
Dyad Mean 1.78 0.14   12.92  .000 
Discrepancy Score 0.19 0.10   1.98  .047 
Random        
IADL Level   1.09 62  631.17 .000 
IADL Discrepancy   0.12 62  77.10 .094 
Level 1 Error   0.48     

Notes: IADL = instrumental activity of daily living.

Table 3.

Hierarchical Linear Modeling Level 2 Model With Formal Support as a Covariate

Fixed Effect for IADL Coefficient SE 
Dyad Level (β0)    
Intercept (γ001.49 0.18 0.000 
Formal Specialty (γ010.74 0.37 0.020 
Formal Supplemental (γ020.60 0.31 0.056 
Dyad Discrepancy (β1)    
Intercept (γ100.11 0.11 0.318 
Formal Specialty (γ11−0.02 0.23 0.920 
Formal Supplemental (γ120.30 0.25 0.239 
Fixed Effect for IADL Coefficient SE 
Dyad Level (β0)    
Intercept (γ001.49 0.18 0.000 
Formal Specialty (γ010.74 0.37 0.020 
Formal Supplemental (γ020.60 0.31 0.056 
Dyad Discrepancy (β1)    
Intercept (γ100.11 0.11 0.318 
Formal Specialty (γ11−0.02 0.23 0.920 
Formal Supplemental (γ120.30 0.25 0.239 

Note: IADL-instrumental activity of daily living.

Table 4.

Hierarchical Linear Modeling Baseline Model of Dyadic Discrepancy and Level of Caregiving Difficulties

Effect Coefficient SE Variance Component df t ratio χ2 
Fixed        
Dyad Mean 2.24 0.22   10.33  0.000 
Discrepancy Score 1.28 0.27   4.76  0.000 
Random        
Difficulty Level   2.63 62  488.21 0.000 
Difficulty Discrepancy   3.09 62  187.59 0.000 
Level 1 Error   1.53     
Effect Coefficient SE Variance Component df t ratio χ2 
Fixed        
Dyad Mean 2.24 0.22   10.33  0.000 
Discrepancy Score 1.28 0.27   4.76  0.000 
Random        
Difficulty Level   2.63 62  488.21 0.000 
Difficulty Discrepancy   3.09 62  187.59 0.000 
Level 1 Error   1.53     
Table 5.

Hierarchical Linear Modeling Level 2 Model With Relationship Strain, Perceived by Caregiver and Care Recipient Separately, as Covariates

Fixed Effect for Difficulty Coefficient SE 
Dyad Level (β0)    
Intercept (γ001.07 0.22 .000 
Relationship Strain 0.29 0.04 .000 
Caregiver (γ01   
Care Recipient (γ020.14 0.07 .069 
Dyad Discrepancy (β1)    
Intercept (γ100.59 0.30 .051 
Relationship Strain 0.25 0.08 .002 
Caregivers (γ11   
Care Recipient (γ12−0.08 0.12 .475 
Fixed Effect for Difficulty Coefficient SE 
Dyad Level (β0)    
Intercept (γ001.07 0.22 .000 
Relationship Strain 0.29 0.04 .000 
Caregiver (γ01   
Care Recipient (γ020.14 0.07 .069 
Dyad Discrepancy (β1)    
Intercept (γ100.59 0.30 .051 
Relationship Strain 0.25 0.08 .002 
Caregivers (γ11   
Care Recipient (γ12−0.08 0.12 .475 

Figure 1.

Fitted regression lines for elders' impairment superimposed on observed data points for a sample of 10 dyads. IADL = instrumental activity of daily living.

Figure 1.

Fitted regression lines for elders' impairment superimposed on observed data points for a sample of 10 dyads. IADL = instrumental activity of daily living.

Figure 2.

Fitted regression lines for caregiving difficulties superimposed on observed data points for a sample of 10 dyads.

Figure 2.

Fitted regression lines for caregiving difficulties superimposed on observed data points for a sample of 10 dyads.

This research was originally funded by The National Institute of Mental Health Grant MH35360 and The Retirement Research Foundation Grant 83-4. This study was conducted as part of Karen S. Lyons's doctoral dissertation under the direction of Dr. Zarit. This study was presented at the 1999 Annual Scientific Meeting of The Gerontological Society of America in San Francisco, California. We gratefully acknowledge The Benjamin Rose Institute for use of this data.

References

Aneshensel C. S., Pearlin L. I., Mullan J. T., Zarit S. H., Whitlatch C. J.,
1995
.
Profiles in caregiving: The unexpected career
  Academic Press, San Diego, CA.
Archbold P. G., Stewart B. J., Greenlick M. R., Harvath T. A.,
1990
. Mutuality and preparedness as predictors of caregiver role strain.
Research in Nursing & Health
 
13:
375
-384.
Bass D. M., Noelker L. S., Rechlin L. R.,
1996
. The moderating influence of service use on negative caregiving consequences.
Journal of Gerontology: Social Sciences
 
51B:
S121
-S131.
Bass D. M., Tausig M. B., Noelker L. S.,
1988
. Elder impairment, social support and caregiver strain: A framework for understanding support's effects.
The Journal of Applied Social Sciences
 
13:
80
-115.
Biegel D. E., Bass D. M., Schulz R., Morycz R.,
1993
. Predictors of in-home and out-of-home service use by family caregivers of Alzheimer's disease patients.
Journal of Aging and Health
 
5:
419
-438.
Bookwala J., Schulz R.,
1996
. Spousal similarity in subjective well-being: The Cardiovascular Health Study.
Psychology and Aging
 
11:
582
-590.
Bookwala J., Schulz R.,
1998
. The role of neuroticism and mastery in spouse caregivers' assessment of and response to a contextual stressor.
Journal of Gerontology: Psychological Sciences
 
53B:
P155
-P164.
Bryk A. S., Raudenbush S. W.,
1987
. Application of Hierarchical Linear Models to assessing change.
Psychological Bulletin
 
101:
147
-158.
Carter R. E., Carter C. A.,
1994
. Marital adjustment and effects of illness in married pairs with one or both spouses chronically ill.
The American Journal of Family Therapy
 
22:
315
-326.
Cartwright J. C., Archbold P. G., Stewart B. J., Limandri B.,
1994
. Enrichment processes in family caregiving to frail elders.
Advanced Nursing Science
 
17:
31
-43.
Chappell N. L., Kuehne V. K.,
1998
. Congruence among husband and wife caregivers.
Journal of Aging Studies
 
12:
239
-254.
Coriell M., Cohen S.,
1995
. Concordance in the face of a stressful event: When do members of a dyad agree that one person supported the other?.
Journal of Personality and Social Psychology
 
69:
289
-299.
Cotrell V., Schulz R.,
1993
. The perspective of the patient with Alzheimer's disease: A neglected dimension of dementia research.
The Gerontologist
 
33:
205
-211.
Deimling G. T., Bass D. M., Townsend A. L., Noelker L. S.,
1989
. Care-related stress: A comparison of spouse and adult-child caregivers in shared and separate households.
Journal of Aging and Health
 
1:
67
-82.
Fingerman K. L.,
1996
. Sources of tension in the aging mother and adult daughter relationship.
Psychology and Aging
 
11:
591
-606.
Friedman S. R., Kaye L. W.,
1980
. Homecare for the frail elderly.
Journal of Gerontological Social Work
 
2:
109
-123.
Gallant M. P., Connell C. M.,
1997
. Predictors of decreased self-care among spouse caregivers of older adults with dementing illnesses.
Journal of Aging and Health
 
9:
373
-395.
Gatz M., Bengtson V. L., Blum M. J.,
1990
. Caregiving families. Birren J. E., Schaie K. W., , ed.
Handbook of the psychology of aging
  3rd ed.
404
-426. Academic Press, San Diego, CA.
George L. K., Gwyther L. P.,
1986
. Caregiver well-being: A multidimensional examination of family caregivers of demented adults.
The Gerontologist
 
26:
253
-259.
Jette A. M., Tennstedt S., Crawford S.,
1995
. How does formal and informal community care affect nursing home use?.
Journal of Gerontology: Social Sciences
 
50B:
S4
-S12.
Johnson C. L., Catalano D. J.,
1983
. A longitudinal study of family supports to impaired elderly.
The Gerontologist
 
6:
612
-618.
Kelley H. H.,
1981
. Marriage relationships and aging. Fogel R. W., Hatfield E., Kiesler S. B., Shanas E., , ed.
Aging: Stability and change in the family
 
275
-300. Academic Press, New York.
Kristjanson L. J., Nikoletti S., Porock D., Smith M., Lobchuk M., Pedler P.,
1998
. Congruence between patients' and family caregivers' perceptions of symptom distress in patients with terminal cancer.
Journal of Palliative Care
 
14:
24
-32.
Lawrence R. H., Tennstedt S. L., Assman S. F.,
1998
. Strain of the caregiver–care recipient relationship: Does it offset negative consequences of caregiving for family caregivers?.
Psychology and Aging
 
13:
150
-158.
Lawton M. P., Brody E.,
1969
. Assessment of older people: Self-maintaining and instrumental activities of daily living.
The Gerontologist
 
9:
179
-186.
Litvin S. J.,
1992
. Status transitions and future outlook as determinants of conflict: The caregiver's and care receiver's perspective.
The Gerontologist
 
32:
68
-76.
Long K., Sudha S., Mutran E. J.,
1998
. Elder–proxy agreement concerning the functional status and medical history of the older person: The impact of caregiver burden and depressive symptomatology.
Journal of American Geriatrics Society
 
46:
1103
-1111.
Mackenzie T. B., Robiner W. N., Knopmen D. S.,
1989
. Differences between patient and family assessments of depression in Alzheimer's disease.
American Journal of Psychiatry
 
146:
1174
-1178.
Maguire M. C.,
1999
. Treating the dyad as the unit of analysis: A primer on three analytic approaches.
Journal of Marriage and Family
 
61:
213
-223.
McKinlay J. B., Crawford S. L., Tennstedt S. L.,
1995
. The everyday impacts of providing informal care to dependent elders and their consequences for the care recipients.
Journal of Aging and Health
 
7:
497
-528.
Morris L. W., Morris R. G., Britton P. G.,
1989
. Social support networks and formal support as factors influencing the psychological adjustment of spouse caregivers of dementia sufferers.
International Journal of Geriatric Psychiatry
 
4:
47
-51.
Mullan J. T.,
1993
. Barriers to the use of formal services among Alzheimer's caregivers. Zarit S. H., Pearlin L. I., Schaie K. W., , ed.
Caregiving systems: Informal and formal helpers
 
241
-259. Erlbaum, Hillsdale, NJ.
Noelker L. S., Bass D. M.,
1989
. Home care for elderly persons: Linkages between formal and informal caregivers.
Journal of Gerontology:Social Sciences
 
44:
S63
-S70.
Noelker L. S., Townsend A. L., Deimling G. T.,
1984
.
Caring for elders and the mental health of family members: A report on the study's first three years (1980–1983)
  The Benjamin Rose Institute, Cleveland, OH.
Pakenham K. I.,
1998
. Couple coping and adjustment to Multiple Sclerosis in care receiver–carer dyads.
Family Relations
 
47:
269
-277.
Pearlin L. I., Mullan J. T., Semple S. J., Skaff M. M.,
1990
. Caregiving and the stress process: An overview of concepts and their measures.
The Gerontologist
 
30:
583
-594.
Peterson D. R.,
1983
. Conflict. Kelley H. H., Berscheid E., Christensen A., Harvey J. H., Huston T. L., Levinger G., et al. , ed.
Close relationships
 
360
-396. W. H. Freeman and Company, New York.
Poulshock S. W., Deimling G. T.,
1984
. Families caring for elders in residence: Issues in the measurement of burden.
Journal of Gerontology
 
39:
230
-239.
Pratt C. C., Jones L. L., Shin H., Walker A. J.,
1989
. Autonomy and decision making between single older women and their caregiving daughters.
The Gerontologist
 
29:
792
-797.
Pruchno R. A.,
1989
. Alzheimer's disease and families: Methodological advances. Light E., Lebowitz B. D., , ed.
Alzheimer's disease treatment and family stress: Directions for research
 
174
-195. National Institute of Mental Health, Bethesda, MD.
Pruchno R. A., Burant C. J., Peters N. D.,
1997
. Understanding the well-being of care receivers.
The Gerontologist
 
37:
102
-109.
Raudenbush S. W., Brennan R. T., Barnett R. C.,
1995
. A multivariate hierarchical model for studying psychological change within married couples.
Journal of Family Psychology
 
9:
161
-174.
Raudenbush S. W., Bryk A. S., Cheong Y. F., Congdon R. T.,
2000
.
HLM5: Hierarchical linear and non-linear modeling
  Scientific Software International, Chicago.
Sayles-Cross S.,
1993
. Perceptions of familial caregivers of elder adults.
IMAGE: Journal of Nursing Scholarship
 
25:
88
-92.
Scharlach A. E.,
1987
. Relieving feelings of strain among women with elderly mothers.
Psychology and Aging
 
2:
9
-13.
Schulz R., Beach S. R.,
1999
. Caregiving as a risk factor for mortality.
Journal of the American Medical Association
 
282:
2215
-2219.
Schulz R., O'Brien A. T., Bookwala J., Fleissner K.,
1995
. Psychiatric and physical morbidity effects of dementia caregiving: Prevalence, correlates, and causes.
The Gerontologist
 
35:
771
-791.
Smerglia V. L., Deimling G. T.,
1997
. Care-related decision-making satisfaction and caregiver well-being in families caring for older members.
The Gerontologist
 
37:
658
-665.
Teri L., Wagner A. W.,
1991
. Assessment of depression in patients with Alzheimer's disease: Concordance among informants.
Psychology and Aging
 
6:
280
-285.
Thompson L., Walker A. J.,
1982
. The dyad as the unit of analysis: Conceptual and methodological issues.
Journal of Marriage and the Family
 
44:
889
-900.
Tower R. B., Kasl S. V., Moritz D. J.,
1997
. The influence of spouse cognitive impairment on respondents' depressive symptoms: The moderating role of marital closeness.
Journal of Gerontology: Social Sciences
 
52B:
S270
-S278.
Townsend A. L., Franks M. M.,
1995
. Binding ties: Closeness and conflict in adult children's caregiving relationships.
Psychology and Aging
 
10:
343
-351.
Townsend A. L., Franks M. M.,
1997
. Quality of the relationship between elderly spouses: Influence on spouse caregivers' subjective effectiveness.
Family Relations
 
46:
33
-39.
Townsend A., Noelker L., Deimling G., Bass D.,
1989
. Longitudinal impact of interhousehold caregiving on adult children's mental health.
Psychology and Aging
 
4:
393
-401.
Uchino B. N., Kiecolt-Glaser J. K., Cacioppo J. T.,
1994
. Construals of preillness relationship quality predict cardiovascular response in family caregivers of Alzheimer's disease victims.
Psychology and Aging
 
9:
113
-120.
Walker A. J., Martin S. K., Jones L. L.,
1992
. The benefits and costs of caregiving and care receiving for daughters and mothers.
Journal of Gerontology Social Sciences
 
47:
S130
-S139.
Wetle T., Levkoff S., Cwikel J., Rosen A.,
1988
. Nursing home resident participation in medical decisions: Perceptions and preferences.
The Gerontologist
 
28:
32
-38.
Whitlatch, C. J., & Feinberg, L. F. (1999, November). Making hard choices: Respecting both voices. Paper presented at the 52nd Annual Scientific Meeting of The Gerontological Association of America, San Francisco, CA.
Whitlatch C. J., Noelker L. S.,
1996
. Caregiving and caring. Birren J. E., , ed.
Encyclopedia of Gerontology
 
253
-268. Academic Press, New York.
Williamson G. M., Schulz R.,
1990
. Relationship orientation, quality of prior relationship, and distress among caregivers of Alzheimer's patients.
Psychology and Aging
 
5:
502
-509.
Williamson G. M., Shaffer D. R., Schulz R.,
1998
. Activity restriction and prior relationship history as contributors to mental health outcomes among middle-aged and older spousal caregivers.
Health Psychology
 
17:
152
-162.
Wright D. L., Aquilino W. S.,
1998
. Influence of emotional support exchange in marriage on caregiving wives' burden and marital satisfaction.
Family Relations
 
47:
195
-204.
Yates M. E., Tennstedt S., Chang B.,
1999
. Contributors to and mediators of psychological well-being for informal caregivers.
Journal of Gerontology: Psychological Sciences
 
54B:
P12
-P22.
Yee J. L., Schulz R.,
2000
. Gender differences in psychiatric morbidity among family caregivers: A review and analysis.
The Gerontologist
 
40:
147
-164.
Zarit S. H.,
1994
. Research perspectives on family caregiving. Cantor M. H., , ed.
Family caregiving: Agenda for the future
 
9
-24. American Society on Aging, San Francisco.
Zarit S. H., Stephens M., Townsend A., Greene R.,
1998
. Stress reduction for family caregivers: Effects of adult day care use.
Journal of Gerontology: Social Sciences
 
53B:
S267
-S277.
Zung W.,
1965
. A self-rating depression scale.
Archives of General Psychiatry
 
12:
63
-70.
Zweibel N., Lydens L. A.,
1990
. Incongruent perceptions of older adult/caregiver dyads.
Family Relations
 
39:
63
-67.