the caregiver as part of the dementia management team

The Caregiver as Part of theDementia Management TeamSteven M. AlbertGertrude H. Sergievsky Center, Columbia University, New York, New York, USA

ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3291. Triads of Care: Physicians, Patients, Family Caregivers . . . . . . . . . . . . . . . . . . . . . . . . . 330

1.1 Caregiver Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3321.2 The Role of the Caregiver in Home-Based Disease Management . . . . . . . . . . . . . . . . 3321.3 Caregiver Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

2. Physicians as Partners with Family Caregivers in Dementia Management . . . . . . . . . . . . . . 3353. Communication Between Caregivers and Physicians in Medical Encounters . . . . . . . . . . . . 3354. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336

Abstract Care for older people with dementia living in the community involves not onlya physician and the patient, but also a family member as the ‘primary caregiver’.This caregiver communicates medical information from the physician to the pa-tient (screening this information as necessary), ensures that treatment plans arecarried out, and relays patient (and family) concerns to the physician. Optimalpatient care depends, in part, on inclusion of such caregivers in the dementiamanagement team. However, review of the literature suggests that physicians donot make optimal use of family members as partners in disease management.Further research is required to assess the effect of efforts to include family care-givers as part of the dementia management team and to determine how best tosupport family members in their role as partners in dementia management.

REVIEW ARTICLE Dis Manage Health Outcomes 1999 Jun; 5 (6): 329-3371173-8790/99/0006-0329/$04.50/0

© Adis International Limited. All rights reserved.

Care for the frail older person in many casesinvolves not only a physician and the patient, butalso a family member.[1-4] This family member as-sumes the role of ‘primary caregiver’ and serves asthe conduit of communication between the physi-cian and other family members. For reasons some-what unclear, we rarely find more than one familymember assuming this role; evidently, both internalfamily dynamics and the exigencies of communi-cation with medical providers encourage recruit-ment of a single family member as part of the dis-ease management team.

Silliman[3] points out that the addition of a thirdperson makes an already complex relationshipeven more difficult. She states that balancing bothpatient and caregiver needs in a time-driven andincreasingly competitive world is not easy. Physi-cians not only need better preparation to meet thechallenges of caring for frail older patients, butthey also need changes in reimbursement policiesso that they can afford to spend the time needed tomanage the complexities inherent in the doctor-patient-family caregiver relationship. These com-plexities include management of the effect of pa-

tient disability on the caregiver and the need to pro-vide caregivers with as much information as possi-ble. It may also mean establishing a care plan forprimary caregivers, often the ‘hidden patient’ in suchencounters.[1,5] A large amount of literature hasnow established the adverse psychosocial and healtheffects of caregiving to the chronically ill older per-son;[6-8] fewer studies are available that have exam-ined the efficacy of interventions designed to alle-viate the burden of caregiving experienced byfamily caregivers.[9,10]These considerations raise the larger question of

how best to support family members in their roleas members of a disease management team. Chang-ing reimbursement policies would allow physi-cians greater scope to discuss patient care withfamily, to educate family caregivers, and to providesupport to those who bear the brunt of daily carefor elders. Assuming change in reimbursement pol-icies, it will be important to determine if suchchanges are associated with better outcomes for el-ders with neuropsychiatric disorders, as indicatedin less use of the emergency room or better man-agement of symptoms. It would also be expectedthat caregivers would have an easier time provid-ing care to these patients, as indicated by less ‘burnout’ and fewer health problems linked to caregiv-ing. Such effects are difficult to demonstrate, as hasbeen shown by programmes designed to supportcaregivers or demonstrate the benefits of compre-hensive geriatric assessment. Still, we are unawareof any randomised trial that has explicitly assessedthe effect of efforts to include family caregivers aspart of the disease management team. Perhaps thetime is ripe now for such an effort.This review is limited to discussion of the care-

giver as part of the dementia management team.Other neuropsychiatric conditions, which are likelyto have different implications for caregiver in-volvement in disease management, are not consid-ered. Also, we do not cover the mental and physicalhealth effects of dementia care on caregivers,which are well summarised in a number of reviewarticles,[8,11] nor do we review interventions de-signed to benefit dementia caregivers, such as adult

day care and other respite programmes.[9,10] Ourtarget is more narrowly focused on the tasks familymembers perform as caregivers, and more particu-larly, the extent to which physicians help care-givers to perform these tasks, and the extent towhich caregivers use their experience to help phy-sicians provide optimal patient care.This review is framed by a number of questions.

First, to what extent do physicians involve familymembers in dementia management? To examinethis issue, we provide a review of the literature,supplemented by our own clinical experience. Sec-ondly, when family members do play a role in de-mentia management, what does such involvemententail? What do family caregivers actually do? Howeffective are they? To address these questions, wesummarise results from recent research but also re-port on an ethnographic study we have conductedwith caregivers to elderly people with dementia.We also summarise studies of communication be-tween physicians, patients and caregivers.

1. Triads of Care: Physicians, Patients,Family Caregivers

There are a number of gaps in our knowledge ofthe role of family members in diseasemanagement.For example, we have been able to identify veryfew studies that report how often family membersaccompany patients on physician visits and howoften physicians interview family members aboutpatients. It is still unclear how often family care-givers independently call physicians on behalf ofpatients, and how often physicians actively incor-porate family members into care planning. Haug[1]states that we still know very little about doctor-patient-caregiver relationships ‘in terms of thecharacteristics of the players, content, processessuch as initiations or terminations, conflicts, or ac-commodations, and outcomes’.Some insight, however, is available from studies

of geriatric assessment units and more general sur-veys. In the case of diabetic care for older adults,for example, Silliman et al.[12] found that 36% offamily members regularly participated in patients’medical encounters. Between 22% and 50% of

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© Adis International Limited. All rights reserved. Dis Manage Health Outcomes 1999 Jun; 5 (6)

family members reported helping with different as-pects of diabetes care.[5] Family members were morelikely to participate in medical encounters whenpatients were older and more frail, and when fam-ily members were more knowledgeable about dia-betes care and otherwise helped patients with dailyactivities.Haug[1] sampled 90 caregivers of patients with

Alzheimer’s disease in a postal survey. The samplewas not representative of Alzheimer’s caregiversand results should be interpreted with caution.However, the survey revealed that physicians didnot, for the most part, include caregivers as part-ners in disease management. Less than half thephysicians could be counted on to return telephonecalls from caregivers, and only one-third made anunsolicited call to check on the patient or caregiver.About half the caregivers reported that physiciansdid not provide full explanations regarding medi-cations for the patient, the rationale for diagnostictests, or test results. While the caregivers usuallyaccompanied elders during physician encounters,only half reported that physicians had given rea-sons for the patients’behaviour. Notably, only 40%reported that physicians recognised the value of theinformation they had provided about patients.Another study, involving a broader age group of

patients, partly confirms these findings.[13] In astudy of 138 family physicians, who saw 4454 out-patients over 2 days, the authors noted that patientswere accompanied by family members in 32% ofvisits.[13] This study also noted that the health ofother family members was discussed in 18% of theencounters. The authors reported that some physi-cians took the family as the unit of care rather thanthe individual patient, but that others used inquiriesabout the family only to direct care for the patient.Greene and colleagues[4] reported that in 15 of

96 naturally occurring hospital-based, primary-care encounters involving older adults (16%), theencounter involved a third person. Patient-physiciancommunication in these encounters differed inimportant ways from communication in a matchedseries of 2-person encounters. In the triadic group,elders raised fewer topics in all content areas and

participated less in decision-making. However, itis likely that the elders accompanied by a familymember were more impaired than elders who wereseeing physicians independently.Fortinsky et al.,[14] reported results from a vig-

nette study that confirms these findings. The vig-nette study included a daughter accompanying amildly or moderately demented elder to the doctor.Analyses of a large panel of office-based primary-care physicians showed that physicians were farmore likely to communicate a diagnosis of prob-able Alzheimer’s disease to the daughter than to theelder.An ethnographic study should also be mentioned

in this context. Hasselkus[15] reported that somecaregivers reject physician recommendations onthe grounds that they feel they understand patientneeds better than the physician. Would this sort ofadversarial relationship be less common if physi-cians included caregivers as part of the diseasemanagement team? This, too, would be worth a for-mal study. On the other hand, development of suchadversarial relationships may be inherent to thephysician-patient-caregiver relationship.Adelman et al.[2] have catalogued the many ways

this triad may collapse into 2-party coalitions: doc-tor and caregiver against patient, patient and care-giver against doctor, doctor and patient against care-giver.In summary, these studies have shown that care-

givers are involved in patient-physician encoun-ters in only a minority of cases, i.e. perhaps 15 to35% of such encounters. The rate is likely to bemuch higher among elders with dementia, who aremore likely to have home visits and outpatient hos-pital visits for primary care,[16] and who are unlikelyto get to the doctor’s office unaided. However, wehave not been able to identify large studies of pa-tient-physician encounters that have examined theprevalence of triadic encounters among elderlypatients with and without dementia.Participation in a medical encounter is only one

indicator of caregiver involvement in the dementiamanagement team, but it is likely to be one thatis relatively amenable to research. Notably, the

The Caregiver in the Dementia Management Team 331


Council on ScientificAffairs of theAmericanMed-ical Association[17] recommends that physiciansenter into a partnership with the caregivers to theirpatients to secure optimal support for caregiversand effective management of patients.

1.1 Caregiver Selection

If physicians are to involve family members indementia management, it is worth asking whichfamily member they should be talking to. Howdoes a family member become the primary care-giver for an impaired elder? Much has been writtenon the process of ‘caregiver selection’, beginningwith Ikels’s[18] examination of common predictorsof selection to this role. These are, for themost part,sociodemographic factors and include status as anonly child, being single, not working or workingpart time, and residential proximity to an elder.Less has been said about the process by which anadult child or spouse comes to recognise that he orshe is a caregiver, someone who has passed beyondoccasional helper and gone on to adopt a new iden-tity as a caregiver.[19] How do caregivers recognisethat they have entered some new contract with aspouse or parent, an agreement to provide increas-ingly more demanding care to a person likely toexperience irreversible decline?While some caregivers do not recognise a single

moment or discontinuity between pre-caregivingand caregiving, the moment is not lost on others.We examined this question in an ethnographic studyof nearly 100 caregivers to functionally dependentelders.[20] The study was completed at the Philadel-phia Geriatric Center (1988 to 1993) and involvedthe recruitment of a large sample of caregivers de-fined according to the length of time they had beenproviding assistance to elders in the activities ofdaily living. In this longitudinal study, ‘new’ (<12months), ‘long term’ (>12 months) and ‘finished’(elder had died or been admitted to nursing home)caregivers were surveyed. The ethnographic studysample was randomly drawn from this larger poolof nearly 700 caregivers. In the ethnographic study,caregivers completed semi-structured interviewslasting 2 to 3 hours conducted in patient homes.

One topic of the ethnographic interview was themoment when these adult children or spousesrecognised that they had become caregivers ratherthan ‘someone who helps out once in a while’.Nearly one-third of the caregivers in the ethno-graphic sample reported that they were in someway ‘groomed’ or ‘picked out’ by their families tobecome caregivers for the parent with dementia.These adult children were more likely not to havemarried and less likely to have established inde-pendent households. They were also in many casesquite dependent on elders, both emotionally andeconomically. Recognition of these features offamily caregivers may be important for under-standing constraints to caregiver involvement indementia management. That is, some caregiverswill be unable to assume a directive role for care ofan elder and will require more involvement by phy-sicians and the medical team.

1.2 The Role of the Caregiver inHome-Based Disease Management

After establishing who serves as caregiver, it isimportant to identify the content of ‘caregiving’,i.e. what caregivers actually do. In our ethnographicstudy, family members were asked to describe intheir own words the tasks they regularly do andinclude as caregiving duties and also to fill out atime budget for themselves and their elders, detail-ing exactly what they and their elder were doing atevery interval across the prior day. Results showthe extent to which caregiving tasks dominate theday for most respondents caring for elders with de-mentia. Some caregivers could not even make alist; for them the entire day is caregiving. As oneput it, ‘my whole day revolves around her. I get herup, to the bathroom, bathed, dressed. I cook andhelp with her feeding. I’m basically with her all thetime. I help her move.’Caregiver involvement can be extreme, as indi-

cated in another caregiver’s account of her day. Hertime budget (see table I) well illustrates the demandsof care for an elderly person with dementia and thecomplete absorption of her day into elder care.

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This caregiver was providing 24-hour/day carefor an 82-year-old with severe Alzheimer’s dis-ease, with virtually no help from family or paidcaregivers. The caregiver was rarely able to sleepat night because of constant episodes of elder agi-tation. The result was a reshaping of the caregiver’sday to match the elder’s. Truly, this caregiver didnothing else but care for her mother. She routinelyended up sleeping on a mattress next to her moth-er’s bed, a typical response when elders frequentlywake at night. The most extreme demands of de-mentia care arewell illustrated in this case and con-firm research showing that psychiatric symptomsin Alzheimer’s disease are the most important pre-dictor of caregiving burden and recourse to nursinghome placement.[11]As expected, caregivers to less severely ill par-

ents stress different tasks. Here the emphasis is lesson personal care than on socioemotional supportand concern for the broader environment in whichthe elder lives. A primary task for these caregiversis the emotional health of elders. As one reported,‘You attend to her needs. She needs to feel inde-pendent. To make her feel good about herself, youmake her look good. Then it’s her body: it’s got tobe clean. And her mind: she’s got to be active, vis-iting people. And her health: she’s got to eat well’.

These tasks, and their rough correlation withlevels of elder impairment, confirm dimensions ofstandardised functional assessment. Personal caretasks (involving the basic activities of daily living)were most frequently mentioned by caregivers toseverely impaired elders, while help with instru-mental activities (using a telephone, handlingmoney,taking medications, going outside on supervisedexcursions) was most frequently mentioned by care-givers to less impaired elders. However, other fea-tures of caregiving need to be recognised, such ascare management (i.e. supervising home parapro-fessional care, making appointments with physi-cians), environmental monitoring (assuring safetyin the home) and concern for an elder’s emotionalwell-being.When asked about the ways they carry out these

tasks, family caregivers were quick to mention theimportance of routines. Success in caregiving wasexplicitly linked to the development of effectiveroutines, because such routines allow caregivers todeliver care efficiently while freeing up time forthemselves. These routines evolve by trial and error.Most caregivers report an interval of 3 to 6 monthsas the period in which they perfected their routine.As one reported, ‘I’ve gotten better from a time-efficiency standpoint. In a half-hour, I canget her fed,washed, dressed and out of the house. I have every-thing set out’.Caregivers are also ‘health monitors’ and are

attuned to recognition of new symptoms in elders.Theymay become self-perceived health experts, asin the case of the caregiver who claimed she hadonly one patient, unlike the elder’s doctor, who hadmany: ‘I knowwhen she’s sick. I can tell when some-thing’s different. You watch bowel movements, diet,nose bleeds, cuts and scratches, sores and bruises.I watch for any kind of cough, cold and sneeze. Youlook for different signs’.These considerations are important when we

contemplate inclusion of caregivers as part of thedementia management team. Family caregivers arean important source of information about patients.This information that may be critical for makingthe diagnosis of Alzheimer’s disease or for manag-

Table I. Time budget from caregiver providing care to a severelydemented elder

7:00-7:30am Try to calm her down; give her breakfast; goto toilet with her

7:30-10:00 Try to sleep a little12:00-1:00pm Make her eat soup; go to toilet with her; give

medicines3:00-3:30 Try to make her walk to get calmer; go to

toilet with her; cook5:00-6:00 Help her eat; go to toilet with her; walk her;

give medicines7:00-8:00 Make her walk; toilet9:30-10:30 Bathe her; try to calm her10:30 Try to get her to sleep1:00am She called out, agitated; awake 2 hours3:00 Toilet; give second sleeping pill5:00 Agitated; toilet; walk her to calm her; awake

2 hours



ing the patient. These caregivers may also developexpertise that may complement physician efforts.On the other hand, caregivers’ home care experi-ence may lead them to question or challenge phy-sician recommendations. In some cases, this mayrepresent ‘intelligent non-compliance’; in others itmay compromise patient management.

1.3 Caregiver Competency

Caregivers report various skills and ‘tricks’ tomake caregiving tasks easier. They learn their tradefrom home health aides and visiting nurses, fromobservation of care during an elder’s hospitalisa-tion, or through trial and error. Aminority mentioninformation obtained from support groups or pub-lished sources. As one caregiver reported, ‘I had tolearn everything. When she came home from thehospital the first time, she came home with a bed-sore. I didn’t know anything about bedsores. I hadto go out and talk to people. People would call mewith information, advice on how to heal this bed-sore. I had to learn all these things. Mymother nowdoes not have a bedsore. I keep supplies for han-dling bedsores. I’ve learned.’The varied tricks caregivers have adopted are

worth a chapter in themselves. We cannot help butnotice the satisfaction caregivers feel in their abil-ity to get done what needs to be done with a mini-mum of friction. An important trick in caregivingfor elders with neuropsychiatric disease is to knowwhen to let an elder do activities at his or her ownpace, even if the pace is excruciatingly slow. Thisis part of a more general acceptance of reducedelder competence. ‘Letting go’, admitting that anelder can no longer do what a caregiver would likethe patient to do, may be a fundamental principlein successful caregiving. As one caregiver reportedof her mother with dementia, ‘My way of dealingwith her slowness is to leave. If I leave, I don’t haveto watch her take 15 minutes to clean 3 dishes. Ihad to learn that.’Tricks for managing a parent with dementia may

have to be more ingenious. To handle incessanttelephone interruptions at her office, one caregiverused an answering machine with her recorded voice.

She recognised that what the elder really wished tohear was the caregiver’s voice, so the answering ma-chine was a reasonable solution. Another caregiverinstalled a fence around an open porch; this al-lowed the elder to sit outside without leaving thehome. Such alterations of the environment clearlygo a long way in caregiving and in assuring patientsocioemotional health, as well as safety.Family caregivers defined success in caregiving

as meeting an elder’s needs. Vigilance in recognis-ing such needs was considered essential to success-ful caregiving: ‘I watch the things that seem to causedifficulty’. When asked if she was a good care-giver, one women reported, ‘Yes. I’m not shy aboutit. When my mother came out of the hospital, shewent to a nursing home for convalescence. But theyput a diaper on her. She wasn’t getting attention.We took her out of there the next day. Whateverthey were doing there, I can do better here’. Suc-cess also includes satisfaction with getting thejob done: ‘I was able to give her what she neededwhen she needed it, almost all the time. That’s suc-cess’.Failure in caregiving was mostly described as

inappropriate emotional responses to caregivingdemands. These involve guilt: ‘You’re hemmed in.You become hostile. Then she turns around and doessomething nice. So you feel guilty’. An alternativeview of failure, expressed by some caregivers, isfailing to meet an elder’s needs, not so much be-cause these needs are overwhelming, but becauseof fear. For these caregivers, failure is not knowinghow to respond to a medical emergency and anxi-ety at the thought of one day having to witness (andofficiate) the death of the elder.Recently, researchers have focused on ‘doing

caregiving well’, an attempt to measure the nursingand psychosocial skills family caregivers naturallydevelop when they become effective caregivers.[21]An important area for future research is to examinethe role of caregiver-physician partnerships as apredictor of such effective caregiving.

334 Albert


2. Physicians as Partners with FamilyCaregivers in Dementia Management

The other side of dementia management is ef-fective physician care for patients with dementia,which, as we have seen, includes an effective alli-ance with family caregivers. The practice patternsof physicians caring for elders with dementia inambulatory care and hospital settings are now wellunderstood and show that physicians are increas-ingly better skilled in the diagnosis and medicalmanagement of dementia, but less effective in thedomains of emotional support, discharge planning,providing referral and information, and inclusionof families in care planning for elders.[22-24] Unfor-tunately, use of standardised cognitive screeningprotocols may still be somewhat haphazard, butyounger physicians appear to be more aware ofissues in the diagnosis and management of demen-tia.[25,26]An important additional consideration is the

number of physicians which patients with demen-tia typically see. In one study, caregivers to elderswith dementia reported that elders had seen morethan 4 physicians, on average, over the course ofthe illness.[23] This study, however, did not specifyif more than one physician was involved in demen-tia care at any given time. In such cases, fosteringpartnerships between family caregivers and physi-cians may be more difficult.

3. Communication Between Caregiversand Physicians in Medical Encounters

Research involving patient-physician commu-nication is well developed. The primary researchtechnique is analysis of audiotaped dialogue be-tween physicians and patients. Less developed isresearch on physician-caregiver communication,and, in particular, comparisons between what phy-sicians tell patients and what they tell family mem-bers. Understanding physician-caregiver commu-nication is clearly a prerequisite for understandinghow best to include caregivers in disease manage-ment efforts.

A strength of this research is its focus on theactual language used by patients and their physi-cians, along with sophisticated sociolinguisticanalysis of conversation: who initiates discussionof particular topics, how often interlocutors inter-rupt one another, turn-taking in conversation,length of time allocated to particular topics, andrelated issues. Levinson and Roter[27] have shownthat physicians who stress psychosocial aspects ofpatient care are likely to communicate with pa-tients differently than physicians who do not stresssuch psychosocial aspects of care. These physi-cians are more likely to reassure patients, expressempathy, and let patients speak at length abouttheir symptoms and concerns, and their patientsask more questions. These patients and their fami-lies report greater satisfaction with medical care andare more likely to adhere to medication regimes.[28]Greene and Adelman[29] report similar differencesin communication. It may be that families actuallyseek out such empathetic physicians, but we havenot been able to identify studies that have exam-ined this issue.Conversational analysis of this sort is useful for

understanding prescribing patterns involving psy-chiatric medicines, an important element of de-mentia care. Who initiates the request for a psy-chotropic medication, patient or physician? Onestudy of elders without dementia showed that re-quests for new prescriptions involving psycho-tropic medications came from patients in only 20%of the cases that were assessed.[30] It is unclear ifdementia caregivers seek such prescriptions athigher rates. Sociodemographic factors may be rel-evant here, as patients on higher incomes in onestudy were more likely to make such requests thanpatients with lower incomes.[30]Less is known about communication between

physicians and caregivers. An important finding inone study was that physicians often communicatewith family caregivers indirectly, rather than di-rectly. In a study of family conferences in hospitalsettings, the authors found that the conferenceswere more often used for providing family mem-bers with information than for providing informa-



tion to patients about their illness or treatment. Theconference, however, was a key element in the fam-ily’s collective decision-making about the patient’sfuture care.[31] More research of this type is neededto develop ways to incorporate family caregiversinto disease management efforts.

4. Conclusions

Studies of physician and patient behaviour haveshown that the flow of information in medical de-cision-making can proceed in 2 ways: (i) physi-cians can transfer information to patients to helpthem make informed decisions; or (ii) patients cancommunicate their preferences to physicians tohelp them make informed decisions on behalf ofpatients. In theory, both approaches should lead tothe same outcome. Yet it is likely to be easier andmore feasible for physicians to transfer informa-tion to patients than for a patient to transfer his orher preferences for treatment to a physician.[32]Gafni et al.,[32] have found that it is more feasibleto design contracts to motivate physicians to trans-fer information to patients than to design contractsto motivate physicians to find out their patients’utility functions.In the case of dementia management, family

caregivers are essential to the successful executionof these contracts because they:• are aware of the patient’s utilities for treatment• are monitors of patient health outside of the ex-amination room and hospital

• deliver the day-to-day care required by these pa-tients

• are a primary source of information about pa-tients.Review of the literature and our own observa-

tions suggest that caregivers already function inthis capacity, serving as a critical, if sometimes hid-den, third party in patient-physician transactions.Yet this review has also shown that caregivers arenot, for the most part, effectively used as partnersin disease management, and that physicians do nothave proper incentives to support caregivers in thisrole.

We have identified a number of areas in need offurther research. First, it would be valuable to con-duct a randomised trial of an intervention designedexplicitly to make caregivers partners in dementiamanagement. This would more clearly establishthe likely benefit patients and caregivers can ex-pect when family caregivers are included as part ofthe disease management team. Secondly, it wouldbe valuable to know more about the natural historyof caregiver involvement in elder medical care. Forexample, how common are the adversarial relation-ships mentioned in anecdotal reports? How oftendo satisfying partnerships emerge under managedcare as opposed to fee-for-service systems? To-gether, these 2 approaches will allow a better under-standing of the ways families can most effectivelycontribute to disease management, and how theycan best be supported within the constraints of cur-rent service arrangements.

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About the Author: Steven M. Albert, Ph.D., M.Sc., is Assis-tant Professor of Neuropsychology and Public Health atColumbia University, New York. He is currently investigat-ing the effect of cognitive deficit on functional disabilityand on health service use. He has recently published articleson the risk of hospitalisation associated with Alzheimer’sdisease.Correspondence and reprints: Dr Steven M. Albert, Ger-trude H. Sergievsky Center, P&S Box 16, Columbia Univer-sity, 630 West 168th St. (PH-19), New York, NY 10032, USA.E-mail: [email protected]



the caregiver as part of the dementia management team

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