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Stress in medicine: Strategies for caregivers, patients, clinicians—The burdens of caregiver stress
Author(s)
Michael G. McKee, PhD

The number of people in the United States who spend a significant part of each week working as unpaid caregivers is considerable, and the toll exacted for such work is high. Understanding the profi le of the caregiver, the nature of the duties performed, the stress imposed by such duties, and the consequences of the stress can assist the clinician in recognizing the caregiver in need of intervention.

A PROFILE OF THE CAREGIVER

A recent survey estimated that more than 65 million Americans provide unpaid assistance annually to older adults with disabilities.1 The value of that labor has been estimated at $306 billion annually, or nearly double the combined cost of home health care and nursing home care.2,3

The typical caregiver is a woman, about 48 years old, with some college education, who spends 20 hours or more each week providing unpaid care to someone aged 50 years or older.1 The recipients of care often have long-term physical disabilities; mental confusion or emotional problems frequently complicate care.

Figure. Percentage of caregivers who assist with instrumental activities of daily living (IADL).1
Caregivers help patients with instrumental activities of daily living (IADL), in addition to helping with tasks such as getting dressed and bathing. IADL might include assisting with transportation, housework, grocery shopping, preparing meals, managing fi nances, giving medications, and arranging for paid services such as nursing care (Figure).1

PSYCHOLOGIC AND PHYSICAL COSTS

Caregiving may take a toll on the caregiver in a variety of ways: behavioral, in the form of alcohol or substance use4; psychologic, in the form of depression or other mental health problems5; and physical, in the form of chronic health conditions and impaired immune response.6 About three-fifths of caregivers report fair or poor health, compared with one-third of noncaregivers, and caregivers have approximately twice as many chronic conditions, such as heart disease, cancer, arthritis, and diabetes, compared with noncaregivers.2,7 Caregiving also exacts a financial toll, as employees who are caregivers cost their employers $13.4 billion more per year in health care expenditures.8 In addition, absenteeism, workday interruptions, and shifts from full-time to part-time work by caregivers cost businesses between $17.1 and $33.6 billion per year.9

The cost of caregiving is higher for women, who exhibit higher levels of anxiety and depression and lower levels of subjective well-being, life satisfaction, and physical health.10,11 The stress of caregiving has also been identified as a risk factor for morbidity among older (66 to 96 years old) caregivers, who have a 63% greater mortality than noncaregivers of the same age.12

PSYCHOSOCIAL STRESS, UNHEALTHY BEHAVIORS, AND ILLNESS ARE LINKED

Psychosocial stress is a predictor of disease and can lead to unhealthy behaviors such as smoking, substance abuse, overeating, poor nutrition, and a sedentary lifestyle; these, in turn, can lead to physical and psychiatric illness. Behaviors adopted initially as coping skills may persist to become chronic, thereby promoting either continued wellness (in the case of healthy coping behaviors) or worsening levels of illness (in the case of unhealthy coping behaviors).

McEwen and Gianaros13 have suggested that these stress mechanisms arise from patterns of communication between the brain and the autonomic, cardiovascular, and immune systems, which mutually influenceone another. These so-called bidirectional stress processes affect cognition, experience, and behavior.

An integrated model of stress that maps the bidirectional causal pathways among psychosocial stressors, resulting unhealthy behaviors, and illness is needed. Although the steps from unhealthy behaviors to illness are fairly well understood, the links from psychosocial stress, such as those exhibited by caregivers, to unhealthy behaviors are not as clear. Several mediators are under study:

  • Personality mediators can be either ameliorative (resilience, self-confi dence, self-control, optimism, high self-esteem, a sense of mastery, and finding meaning in life) or exacerbating (neuroticism and inhibition, which together form the so-called type D personality).
  • Environmental mediators include social support, financial support, a history of a significant life change, and trauma early in life, which may increase one’s subsequent vulnerability to unhealthy behaviors.
  • Biologic mediators may include prolonged sympathetic activation and enhanced platelet activation, caused by increased levels of depression and anxiety in chronically stressed caregivers.14

IMPLICATIONS FOR INTERVENTION

A significant percentage of caregivers do not need a clinician’s intervention to help them cope with stress or unhealthy coping skills. Among caregivers aged 50 years or older, 47% indicated in a recent study that the burden of caregiving is low (ie, 1 or 2 on a 5-point scale).1 Those who respond to stressors as challenges rather than threats tend to be resilient people who exert control over their lives, often through meditation or similar techniques, and have a strong social support network. Many report that caregiving provides them with an opportunity to act in accordance with their values and feel helpful rather than helpless.

Cognitive-behavioral interventions to alleviate stress-related symptoms appear to be more effective if offered as individual rather than group therapy. Teaching caregivers effective coping strategies, rather than merely providing social support, has been shown to improve caregiver psychologic health.15 Chief among the goals of intervention should be to alter brain function and instill optimism, a sense of control and self-esteem.13

References
  1. The National Alliance for Caregiving, in collaboration with the American Association of Retired Persons. Caregiving in the U.S. 2009. National Alliance for Caregiving Web site. http://www.caregiving.org/data/Caregiving_in_the_US_2009_full_report.pdf. Published November 2009. Accessed March 21, 2011.
  2. Family Caregiver Alliance. Caregiver health. A population at risk. National Alliance for Caregiving Web site. http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1822. Published 2006. Accessed March 21, 2011.
  3. Family Caregiver Alliance. Prevalence, hours, and economic value of family caregiving, updated state-by-state analysis of 2004 national estimates. National Alliance for Caregiving Web site. http://www.caregiver.org/caregiver/jsp/content/pdfs/State_Caregiving_Data_Amo_20061107.pdf. Published 2006. Accessed March 21, 2011.
  4. Evercare. Study of caregivers in decline: a close-up look at the health risks of caring for a loved one. National Alliance for Caregiving Web site. http://www.caregiving.org/data/Caregivers%20in%20Decline%20Study-FINAL-lowres.pdf. Published 2006. Accessed March 21, 2011.
  5. Pinquart M, Sörensen S. Differences between caregivers and noncaregivers in psychological health and physical health: a metaanalysis. Psychol Aging 2003; 18:250–267.
  6. Vitaliano PP, Zhang J, Scanlan JM. Is caregiving hazardous to one’s physical health? A meta-analysis. Psychol Bull 2003; 129:946–972.
  7. Ho A, Collins S, Davis K, Doty M. A look at working-age caregivers’ roles, health concerns, and need for support (issue brief). New York, NY: The Commonwealth Fund; 2005.
  8. MetLife study of working caregivers and employer health care costs. MetLife Web site. http://www.metlife.com/assets/cao/mmi/publications/studies/2010/mmi-working-caregivers-employers-health-carecosts.pdf. Published July 2006. Accessed March 21, 2011.
  9. MetLife caregiving cost study: productivity losses to U.S. business. National Alliance for Caregiving Web site. http://www.caregiving. org/data/Caregiver%20Cost%20Study.pdf. Published July 2006. Accessed March 21, 2011.
  10. Pinquart M, Sörensen S. Gender differences in caregiver stressors, social resources, and health: an updated meta-analysis. J Gerontol B Psychol Sci Soc Sci 2006; 61:P33–P45.
  11. Johnson RW, Wiener JM. A profi le of frail older Americans and their caregivers. Urban Institute Web site. http://www.urban.org/UploadedPDF/311284_older_americans.pdf. Published February 2006. Accessed March 21, 2011.
  12. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA 1999; 282:2215–2219.
  13. McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Ann NY Acad Sci 2010; 1186:190–222.
  14. Aschbacher K, Mills PJ, von Känel R, et al. Effects of depressive and anxious symptoms on norepinephrine and platelet P-selectin responses to acute psychological stress among elderly caregivers. Brain Behav Immun 2008; 22:493–502.
  15. Selwood A, Johnston K, Katona C, Lyketsos C, Livingston G. Systematic review of the effect of psychological interventions on family caregivers of people with dementia. J Affect Disord 2007; 101:75–89.
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Michael G. McKee PhD
Section of General and Health Psychology, Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH

Correspondence: Michael G. McKee, PhD, Section of General and Health Psychology, Department of Psychiatry and Psychology, Cleveland Clinic, 9500 Euclid Avenue, P57, Cleveland, OH 44195; [email protected]

This article was developed from an audio transcript of Dr. McKee's presentation and panel discussion at the 2011 Heart-Brain Summit. The transcript was edited by the Cleveland Clinic Journal of Medicine staff for clarity and conciseness, and was then reviewed, revised, and approved by Dr. McKee.

Dr. McKee reported that he has no financial relationships that pose a potential conflict of interest with this article.

Publications
Cleveland Clinic Journal of Medicine
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S54-S56
Author(s)
Michael G. McKee, PhD
Author(s)
Michael G. McKee, PhD
Author and Disclosure Information

Michael G. McKee PhD
Section of General and Health Psychology, Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH

Correspondence: Michael G. McKee, PhD, Section of General and Health Psychology, Department of Psychiatry and Psychology, Cleveland Clinic, 9500 Euclid Avenue, P57, Cleveland, OH 44195; [email protected]

This article was developed from an audio transcript of Dr. McKee's presentation and panel discussion at the 2011 Heart-Brain Summit. The transcript was edited by the Cleveland Clinic Journal of Medicine staff for clarity and conciseness, and was then reviewed, revised, and approved by Dr. McKee.

Dr. McKee reported that he has no financial relationships that pose a potential conflict of interest with this article.

Author and Disclosure Information

Michael G. McKee PhD
Section of General and Health Psychology, Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH

Correspondence: Michael G. McKee, PhD, Section of General and Health Psychology, Department of Psychiatry and Psychology, Cleveland Clinic, 9500 Euclid Avenue, P57, Cleveland, OH 44195; [email protected]

This article was developed from an audio transcript of Dr. McKee's presentation and panel discussion at the 2011 Heart-Brain Summit. The transcript was edited by the Cleveland Clinic Journal of Medicine staff for clarity and conciseness, and was then reviewed, revised, and approved by Dr. McKee.

Dr. McKee reported that he has no financial relationships that pose a potential conflict of interest with this article.

Article PDF
media_2b0ff26_S54.pdf
Article PDF
media_2b0ff26_S54.pdf

The number of people in the United States who spend a significant part of each week working as unpaid caregivers is considerable, and the toll exacted for such work is high. Understanding the profi le of the caregiver, the nature of the duties performed, the stress imposed by such duties, and the consequences of the stress can assist the clinician in recognizing the caregiver in need of intervention.

A PROFILE OF THE CAREGIVER

A recent survey estimated that more than 65 million Americans provide unpaid assistance annually to older adults with disabilities.1 The value of that labor has been estimated at $306 billion annually, or nearly double the combined cost of home health care and nursing home care.2,3

The typical caregiver is a woman, about 48 years old, with some college education, who spends 20 hours or more each week providing unpaid care to someone aged 50 years or older.1 The recipients of care often have long-term physical disabilities; mental confusion or emotional problems frequently complicate care.

Figure. Percentage of caregivers who assist with instrumental activities of daily living (IADL).1
Caregivers help patients with instrumental activities of daily living (IADL), in addition to helping with tasks such as getting dressed and bathing. IADL might include assisting with transportation, housework, grocery shopping, preparing meals, managing fi nances, giving medications, and arranging for paid services such as nursing care (Figure).1

PSYCHOLOGIC AND PHYSICAL COSTS

Caregiving may take a toll on the caregiver in a variety of ways: behavioral, in the form of alcohol or substance use4; psychologic, in the form of depression or other mental health problems5; and physical, in the form of chronic health conditions and impaired immune response.6 About three-fifths of caregivers report fair or poor health, compared with one-third of noncaregivers, and caregivers have approximately twice as many chronic conditions, such as heart disease, cancer, arthritis, and diabetes, compared with noncaregivers.2,7 Caregiving also exacts a financial toll, as employees who are caregivers cost their employers $13.4 billion more per year in health care expenditures.8 In addition, absenteeism, workday interruptions, and shifts from full-time to part-time work by caregivers cost businesses between $17.1 and $33.6 billion per year.9

The cost of caregiving is higher for women, who exhibit higher levels of anxiety and depression and lower levels of subjective well-being, life satisfaction, and physical health.10,11 The stress of caregiving has also been identified as a risk factor for morbidity among older (66 to 96 years old) caregivers, who have a 63% greater mortality than noncaregivers of the same age.12

PSYCHOSOCIAL STRESS, UNHEALTHY BEHAVIORS, AND ILLNESS ARE LINKED

Psychosocial stress is a predictor of disease and can lead to unhealthy behaviors such as smoking, substance abuse, overeating, poor nutrition, and a sedentary lifestyle; these, in turn, can lead to physical and psychiatric illness. Behaviors adopted initially as coping skills may persist to become chronic, thereby promoting either continued wellness (in the case of healthy coping behaviors) or worsening levels of illness (in the case of unhealthy coping behaviors).

McEwen and Gianaros13 have suggested that these stress mechanisms arise from patterns of communication between the brain and the autonomic, cardiovascular, and immune systems, which mutually influenceone another. These so-called bidirectional stress processes affect cognition, experience, and behavior.

An integrated model of stress that maps the bidirectional causal pathways among psychosocial stressors, resulting unhealthy behaviors, and illness is needed. Although the steps from unhealthy behaviors to illness are fairly well understood, the links from psychosocial stress, such as those exhibited by caregivers, to unhealthy behaviors are not as clear. Several mediators are under study:

  • Personality mediators can be either ameliorative (resilience, self-confi dence, self-control, optimism, high self-esteem, a sense of mastery, and finding meaning in life) or exacerbating (neuroticism and inhibition, which together form the so-called type D personality).
  • Environmental mediators include social support, financial support, a history of a significant life change, and trauma early in life, which may increase one’s subsequent vulnerability to unhealthy behaviors.
  • Biologic mediators may include prolonged sympathetic activation and enhanced platelet activation, caused by increased levels of depression and anxiety in chronically stressed caregivers.14

IMPLICATIONS FOR INTERVENTION

A significant percentage of caregivers do not need a clinician’s intervention to help them cope with stress or unhealthy coping skills. Among caregivers aged 50 years or older, 47% indicated in a recent study that the burden of caregiving is low (ie, 1 or 2 on a 5-point scale).1 Those who respond to stressors as challenges rather than threats tend to be resilient people who exert control over their lives, often through meditation or similar techniques, and have a strong social support network. Many report that caregiving provides them with an opportunity to act in accordance with their values and feel helpful rather than helpless.

Cognitive-behavioral interventions to alleviate stress-related symptoms appear to be more effective if offered as individual rather than group therapy. Teaching caregivers effective coping strategies, rather than merely providing social support, has been shown to improve caregiver psychologic health.15 Chief among the goals of intervention should be to alter brain function and instill optimism, a sense of control and self-esteem.13

The number of people in the United States who spend a significant part of each week working as unpaid caregivers is considerable, and the toll exacted for such work is high. Understanding the profi le of the caregiver, the nature of the duties performed, the stress imposed by such duties, and the consequences of the stress can assist the clinician in recognizing the caregiver in need of intervention.

A PROFILE OF THE CAREGIVER

A recent survey estimated that more than 65 million Americans provide unpaid assistance annually to older adults with disabilities.1 The value of that labor has been estimated at $306 billion annually, or nearly double the combined cost of home health care and nursing home care.2,3

The typical caregiver is a woman, about 48 years old, with some college education, who spends 20 hours or more each week providing unpaid care to someone aged 50 years or older.1 The recipients of care often have long-term physical disabilities; mental confusion or emotional problems frequently complicate care.

Figure. Percentage of caregivers who assist with instrumental activities of daily living (IADL).1
Caregivers help patients with instrumental activities of daily living (IADL), in addition to helping with tasks such as getting dressed and bathing. IADL might include assisting with transportation, housework, grocery shopping, preparing meals, managing fi nances, giving medications, and arranging for paid services such as nursing care (Figure).1

PSYCHOLOGIC AND PHYSICAL COSTS

Caregiving may take a toll on the caregiver in a variety of ways: behavioral, in the form of alcohol or substance use4; psychologic, in the form of depression or other mental health problems5; and physical, in the form of chronic health conditions and impaired immune response.6 About three-fifths of caregivers report fair or poor health, compared with one-third of noncaregivers, and caregivers have approximately twice as many chronic conditions, such as heart disease, cancer, arthritis, and diabetes, compared with noncaregivers.2,7 Caregiving also exacts a financial toll, as employees who are caregivers cost their employers $13.4 billion more per year in health care expenditures.8 In addition, absenteeism, workday interruptions, and shifts from full-time to part-time work by caregivers cost businesses between $17.1 and $33.6 billion per year.9

The cost of caregiving is higher for women, who exhibit higher levels of anxiety and depression and lower levels of subjective well-being, life satisfaction, and physical health.10,11 The stress of caregiving has also been identified as a risk factor for morbidity among older (66 to 96 years old) caregivers, who have a 63% greater mortality than noncaregivers of the same age.12

PSYCHOSOCIAL STRESS, UNHEALTHY BEHAVIORS, AND ILLNESS ARE LINKED

Psychosocial stress is a predictor of disease and can lead to unhealthy behaviors such as smoking, substance abuse, overeating, poor nutrition, and a sedentary lifestyle; these, in turn, can lead to physical and psychiatric illness. Behaviors adopted initially as coping skills may persist to become chronic, thereby promoting either continued wellness (in the case of healthy coping behaviors) or worsening levels of illness (in the case of unhealthy coping behaviors).

McEwen and Gianaros13 have suggested that these stress mechanisms arise from patterns of communication between the brain and the autonomic, cardiovascular, and immune systems, which mutually influenceone another. These so-called bidirectional stress processes affect cognition, experience, and behavior.

An integrated model of stress that maps the bidirectional causal pathways among psychosocial stressors, resulting unhealthy behaviors, and illness is needed. Although the steps from unhealthy behaviors to illness are fairly well understood, the links from psychosocial stress, such as those exhibited by caregivers, to unhealthy behaviors are not as clear. Several mediators are under study:

  • Personality mediators can be either ameliorative (resilience, self-confi dence, self-control, optimism, high self-esteem, a sense of mastery, and finding meaning in life) or exacerbating (neuroticism and inhibition, which together form the so-called type D personality).
  • Environmental mediators include social support, financial support, a history of a significant life change, and trauma early in life, which may increase one’s subsequent vulnerability to unhealthy behaviors.
  • Biologic mediators may include prolonged sympathetic activation and enhanced platelet activation, caused by increased levels of depression and anxiety in chronically stressed caregivers.14

IMPLICATIONS FOR INTERVENTION

A significant percentage of caregivers do not need a clinician’s intervention to help them cope with stress or unhealthy coping skills. Among caregivers aged 50 years or older, 47% indicated in a recent study that the burden of caregiving is low (ie, 1 or 2 on a 5-point scale).1 Those who respond to stressors as challenges rather than threats tend to be resilient people who exert control over their lives, often through meditation or similar techniques, and have a strong social support network. Many report that caregiving provides them with an opportunity to act in accordance with their values and feel helpful rather than helpless.

Cognitive-behavioral interventions to alleviate stress-related symptoms appear to be more effective if offered as individual rather than group therapy. Teaching caregivers effective coping strategies, rather than merely providing social support, has been shown to improve caregiver psychologic health.15 Chief among the goals of intervention should be to alter brain function and instill optimism, a sense of control and self-esteem.13

References
  1. The National Alliance for Caregiving, in collaboration with the American Association of Retired Persons. Caregiving in the U.S. 2009. National Alliance for Caregiving Web site. http://www.caregiving.org/data/Caregiving_in_the_US_2009_full_report.pdf. Published November 2009. Accessed March 21, 2011.
  2. Family Caregiver Alliance. Caregiver health. A population at risk. National Alliance for Caregiving Web site. http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1822. Published 2006. Accessed March 21, 2011.
  3. Family Caregiver Alliance. Prevalence, hours, and economic value of family caregiving, updated state-by-state analysis of 2004 national estimates. National Alliance for Caregiving Web site. http://www.caregiver.org/caregiver/jsp/content/pdfs/State_Caregiving_Data_Amo_20061107.pdf. Published 2006. Accessed March 21, 2011.
  4. Evercare. Study of caregivers in decline: a close-up look at the health risks of caring for a loved one. National Alliance for Caregiving Web site. http://www.caregiving.org/data/Caregivers%20in%20Decline%20Study-FINAL-lowres.pdf. Published 2006. Accessed March 21, 2011.
  5. Pinquart M, Sörensen S. Differences between caregivers and noncaregivers in psychological health and physical health: a metaanalysis. Psychol Aging 2003; 18:250–267.
  6. Vitaliano PP, Zhang J, Scanlan JM. Is caregiving hazardous to one’s physical health? A meta-analysis. Psychol Bull 2003; 129:946–972.
  7. Ho A, Collins S, Davis K, Doty M. A look at working-age caregivers’ roles, health concerns, and need for support (issue brief). New York, NY: The Commonwealth Fund; 2005.
  8. MetLife study of working caregivers and employer health care costs. MetLife Web site. http://www.metlife.com/assets/cao/mmi/publications/studies/2010/mmi-working-caregivers-employers-health-carecosts.pdf. Published July 2006. Accessed March 21, 2011.
  9. MetLife caregiving cost study: productivity losses to U.S. business. National Alliance for Caregiving Web site. http://www.caregiving. org/data/Caregiver%20Cost%20Study.pdf. Published July 2006. Accessed March 21, 2011.
  10. Pinquart M, Sörensen S. Gender differences in caregiver stressors, social resources, and health: an updated meta-analysis. J Gerontol B Psychol Sci Soc Sci 2006; 61:P33–P45.
  11. Johnson RW, Wiener JM. A profi le of frail older Americans and their caregivers. Urban Institute Web site. http://www.urban.org/UploadedPDF/311284_older_americans.pdf. Published February 2006. Accessed March 21, 2011.
  12. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA 1999; 282:2215–2219.
  13. McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Ann NY Acad Sci 2010; 1186:190–222.
  14. Aschbacher K, Mills PJ, von Känel R, et al. Effects of depressive and anxious symptoms on norepinephrine and platelet P-selectin responses to acute psychological stress among elderly caregivers. Brain Behav Immun 2008; 22:493–502.
  15. Selwood A, Johnston K, Katona C, Lyketsos C, Livingston G. Systematic review of the effect of psychological interventions on family caregivers of people with dementia. J Affect Disord 2007; 101:75–89.
References
  1. The National Alliance for Caregiving, in collaboration with the American Association of Retired Persons. Caregiving in the U.S. 2009. National Alliance for Caregiving Web site. http://www.caregiving.org/data/Caregiving_in_the_US_2009_full_report.pdf. Published November 2009. Accessed March 21, 2011.
  2. Family Caregiver Alliance. Caregiver health. A population at risk. National Alliance for Caregiving Web site. http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1822. Published 2006. Accessed March 21, 2011.
  3. Family Caregiver Alliance. Prevalence, hours, and economic value of family caregiving, updated state-by-state analysis of 2004 national estimates. National Alliance for Caregiving Web site. http://www.caregiver.org/caregiver/jsp/content/pdfs/State_Caregiving_Data_Amo_20061107.pdf. Published 2006. Accessed March 21, 2011.
  4. Evercare. Study of caregivers in decline: a close-up look at the health risks of caring for a loved one. National Alliance for Caregiving Web site. http://www.caregiving.org/data/Caregivers%20in%20Decline%20Study-FINAL-lowres.pdf. Published 2006. Accessed March 21, 2011.
  5. Pinquart M, Sörensen S. Differences between caregivers and noncaregivers in psychological health and physical health: a metaanalysis. Psychol Aging 2003; 18:250–267.
  6. Vitaliano PP, Zhang J, Scanlan JM. Is caregiving hazardous to one’s physical health? A meta-analysis. Psychol Bull 2003; 129:946–972.
  7. Ho A, Collins S, Davis K, Doty M. A look at working-age caregivers’ roles, health concerns, and need for support (issue brief). New York, NY: The Commonwealth Fund; 2005.
  8. MetLife study of working caregivers and employer health care costs. MetLife Web site. http://www.metlife.com/assets/cao/mmi/publications/studies/2010/mmi-working-caregivers-employers-health-carecosts.pdf. Published July 2006. Accessed March 21, 2011.
  9. MetLife caregiving cost study: productivity losses to U.S. business. National Alliance for Caregiving Web site. http://www.caregiving. org/data/Caregiver%20Cost%20Study.pdf. Published July 2006. Accessed March 21, 2011.
  10. Pinquart M, Sörensen S. Gender differences in caregiver stressors, social resources, and health: an updated meta-analysis. J Gerontol B Psychol Sci Soc Sci 2006; 61:P33–P45.
  11. Johnson RW, Wiener JM. A profi le of frail older Americans and their caregivers. Urban Institute Web site. http://www.urban.org/UploadedPDF/311284_older_americans.pdf. Published February 2006. Accessed March 21, 2011.
  12. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA 1999; 282:2215–2219.
  13. McEwen BS, Gianaros PJ. Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Ann NY Acad Sci 2010; 1186:190–222.
  14. Aschbacher K, Mills PJ, von Känel R, et al. Effects of depressive and anxious symptoms on norepinephrine and platelet P-selectin responses to acute psychological stress among elderly caregivers. Brain Behav Immun 2008; 22:493–502.
  15. Selwood A, Johnston K, Katona C, Lyketsos C, Livingston G. Systematic review of the effect of psychological interventions on family caregivers of people with dementia. J Affect Disord 2007; 101:75–89.
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