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Understanding Stress, Immunity, and Sleep Disturbances in Caregivers of Persons with Dementia

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Understanding Stress, Immunity, and Sleep Disturbances in Caregivers of Persons with Dementia UNDERSTANDING STRESS, IMMUNITY, AND SLEEP DISTURBANCES IN CAREGIVERS OF PERSONS WITH DEMENTIA By BRANDY L. LEHMAN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008 1 © 2008 Brandy L. Lehman 2 To my husband, who always provided support for my education with love, Brandy L. Lehman 3 ACKNOWLEDGMENTS This endeavor represents the climax of an “impossible dream” of one who has spent many years in academic pursuits. Many individuals have influenced my development along the way but are too numerous to be listed here. The following warrant special recognition. Foremost among these individuals is my advisor and chairperson, Dr. Meredeth Rowe, RN, PhD. From the onset of my doctoral studies through the completion of this dissertation, she willingly shared her knowledge and experience. Her patience and understanding as well as her interest in my education and professional growth are deeply appreciated. Each member of my graduate committee has contributed to the development, refinement, and completion of this dissertation. Appreciation is expressed to the following committee members: Dr. Shawn Kneipp, RN, PhD; Dr. Deidre Pereira, PhD; and Dr. Susan McMillan, RN, PhD. My committee went well beyond their duty in helping me with this dissertation reading and copiously commenting on the numerous drafts. They also provided encouragement and honest analysis of my work. Their collective insight greatly increased the quality of this dissertation. Special thanks go to Dr. Maureen Groer, RN, PhD for her assistance in data collection, use of the University of South Florida Biobehavioral Nursing Laboratory, and purchasing salivary cortisol and IgA kits. Thanks are also due to Prima Hower, Faculty Support in the USF College of Nursing, for her professional, friendly, and efficient assistance with many major and minor requests and enquiries. I would also like to thank her for assistance with editing and the many small but significant matters that impact on the quality of a product such as this. Special appreciation is extended to staff, social workers, and psychiatrists at the USF Memory Disorders Clinic for their assistance in securing subjects for the pilot study. Without their assistance, this project would not have been completed. 4 To my caregivers, I am especially appreciative. I thank them for sharing their thoughts with me. Due to their willingness to share experiences, hopefully, nurses, other health care workers, and researchers can better understand life as a caregiver. My deepest appreciation is expressed to friends, family, and faculty members who contributed directly or indirectly to my personal and professional growth. Special thanks go to my in-laws, my sister, and my classmates in the doctoral program, who were always there when I needed something during the program. An enormous thank you goes to my mother-in-law, Gloria Lehman, for her unconditional love, enthusiastic support, unwavering encouragement, patience during times when I doubted myself and my abilities, and her steadfast faith in me. Special thanks are also extended to my best friends, Chris Garrison and Judy Campbell, for their friendship and support over the last 4 years. I am deeply grateful for their astonishing support, kindness, and generosity. I am eternally indebted to our friendship. I would also like to thank my loving husband, Lorne Lehman, and my four children for their constant and extraordinary support. They brought encouragement and joy to this process. I am particularly indebted to my husband, who has continually supported me during my nursing career. Words cannot express my love and appreciation for his love, support, and many sacrifices. My husband’s enduring love makes me the most fortunate graduate student of all. It is obvious to me, as it should be to everyone, that I could not have done this without him. With all my love to my husband, I dedicate this dissertation. 5 TABLE OF CONTENTS Page ACKNOWLEDGMENTS ...............................................................................................................4 LIST OF TABLES ...........................................................................................................................9 LIST OF FIGURES .......................................................................................................................10 LIST OF ABBREVIATIONS ........................................................................................................11 ABSTRACT ...................................................................................................................................13 CHAPTER 1 INTRODUCTION ..................................................................................................................15 Alzheimer’s Caregivers ..........................................................................................................15 Caregiver Burden .............................................................................................................16 Importance of Sleep .........................................................................................................18 Sleep and Older Adult .....................................................................................................19 Causes for Sleep Changes in Dementia Caregiver ..........................................................22 Consequences of Fragmented Sleep ................................................................................23 Stress Response ...............................................................................................................24 Statement of the Problem ........................................................................................................25 Introduction to Stress, Coping, and Adaptation ......................................................................26 Conceptual Framework ...................................................................................................26 Stress, Coping, and Adaptation model ............................................................................28 Stressor ............................................................................................................................28 Appraisal ..........................................................................................................................29 Person and Environment Antecedents .............................................................................30 Immediate and Long-Term Affects .................................................................................35 Conclusion .......................................................................................................................36 2 THEORETICAL MODEL AND REVIEW OF LITERATURE............................................39 Introduction .............................................................................................................................39 Stressors in Caregiving Situation ............................................................................................39 Person Variables ..............................................................................................................39 Environment Variables ....................................................................................................42 Sleep and Nighttime Behavioral Disturbances in the Care Recipient .............................47 Perceived Stress in Caregiver ..........................................................................................48 Primary Appraisal ............................................................................................................50 Secondary Appraisal ........................................................................................................53 Emotion-Focused Coping ................................................................................................55 Problem-Focused Coping ................................................................................................62 Effects of Sleep Changes on Physical Health ..................................................................66 Caregiver’s Physiological Well-Being ............................................................................67 6 Salivary Cortisol and Physiologic Changes ....................................................................69 Salivary Cortisol and Older Adults .................................................................................73 Salivary IgA and Physiologic Changes ...........................................................................75 3 MATERIALS AND METHODS ...........................................................................................78 Design .....................................................................................................................................79 Sample ....................................................................................................................................79 Participant Characteristics/Caregiver ..............................................................................80 Exclusion criteria .............................................................................................................80 Participant Characteristics/Care Recipient ......................................................................80 Sample Size ............................................................................................................................81
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