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RESEARCH ARTICLE |
a Freie Universitaet Berlin, Germany
b Evangelisches Geriatriezentrum, Berlin, Germany
Susanne Zank, Freie Universität Berlin, Fachbereich für Erziehungswissenschaften und Psychologie, Arbeitsbereich für Prävention und psychosoziale Gesundheitsforschung Arbeits-gruppe Gerontologie, Habelschwerdter Allee 45, 14195 Berlin, Germany E-mail: fu03c2bh{at}zedat.fu-berlin.de.
Decision Editor: Margie E. Lachman, PhD
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Abstract |
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Most elderly people have the strong wish to stay in their own home or apartment as long as possible and to avoid institutionalization. This preference sometimes creates problems for very old persons, aged 80 and older, who are likely to suffer from multiple diseases, including dementia (P. B. Baltes and Mayer 1999
). If these persons do not have caregiving relatives, they are in danger of becoming isolated and lonely. If caregiving relatives do exist, they are often stressed and overloaded by the burden of providing care (Alspaugh, Stephens, Townsend, Zarit, and Greene 1999).
In Germany, public policy aims at supporting elderly persons as well as their caregiving relatives. One method is the establishment of rehabilitative geriatric day care units. These institutions are available for everyone, although a prescription by a physician is required for admission. Medical and social indications are possible. The day care units are rather expensive; each day costs between U.S. $50 and $70, and patients visit from 1 to 5 days per week. Costs are covered by general care insurance—if patients are eligible—or by the patients themselves, social welfare, or a combination of these parties.
The general care insurance was introduced in 1994, and this complicated law stipulates that every citizen has to pay 1.7% of her or his gross income into a general care insurance. It is important to realize that this insurance pays only for care, not for treatment of diseases. These latter costs are covered by the German health insurance. Coverage provided by care insurance is only approved following an expert assessment of the medical service. This assessment ascertains whether a considerable need for care exists or whether rehabilitative measures can be substituted. The care insurance follows three main principles: First, all measures that prevent, treat, and rehabilitate diseases and so reduce need for care have priority. Second, home care is given preference so that people can stay at home as long as possible. Third, part-time care institutions (day care, night care) have precedence over long-term institutional solutions. With regard to home care, clients have the choice between direct monetary reimbursement (to pay family or neighbor caregivers), services paid by the insurance, or a combination of both. Direct monetary reimbursement amounts to considerably less than payment for services. The care insurance pays for assistance in basic activities of daily living (ADLs: washing oneself, using the toilet, getting dressed, preparing meals) as well as household assistance (cleaning). The care insurance is a third party insurance, that is, it does not cover all expenses. This policy is harshly criticized because it fails to fulfill the original goal of care insurance, namely that people do not become dependent on social welfare when they need care. In the case that the general care insurance does not cover the total costs of a patient's day care visits, the patient has to pay the rest by her- or himself, or, if she or he has a very low income, social welfare will cover the difference. The social welfare system in Germany is very different from the U.S. system. It secures a basic income for every citizen who has very low or no income. It consists of a basic monthly payment of approximately U.S. $300 together with additional supplements for rent and clothing expenses. Many of the current cohorts of older people feel ashamed that they have to depend on social welfare. Because of the present day high cost of part-time and long-term care institutions, many patients in need of care are unable themselves to cover these costs and therefore become dependent on this social welfare.
The day care units aim at enhancing patients' well-being and competence and reducing the burden placed on caregivers. Patients are picked up by a driving service in the morning and are brought home in the afternoon. The program is very similar in the different units and consists of everyday life activities (e.g., shopping, preparation of meals), games, individual training, and outings. Each unit has 12 to 15 patients per day. Sometimes informational groups for caregivers are offered. Staff members consist of trained nurses, geriatric nurses, and untrained young men doing community work instead of military service. Originally, a maximum stay of 1 year for patients was planned, but patients tend to remain as long as possible. In addition to day care, almost all patients receive assistance in morning and evening self-care from home-based community services. These services are available 7 days a week and up to five times per day. They assist in basic self-care (e.g., washing, dressing, using the toilet), medication (e.g., distribution of tablets for patients with dementia, injections), or basic housework. These services also have to be prescribed by a physician, and they are paid for by either health insurance, care insurance, patients, or social welfare.
There are very few evaluation studies of geriatric day care, and most of them were conducted in the U.S. These studies focused on the effects on caregiving relatives only, and their results were ambiguous. Guttman 1991 and Gottlieb and Johnson 1995 reported that perceived stress, anxiety, and somatic symptoms of caregivers were reduced. Strain, Chappell, and Blandford 1988 observed an increase in life satisfaction. However, Henry and Capitman 1995 found no reduction of stress, and Lawton, Brody, and Saperstein 1989 failed to detect any positive effects.
Some authors suspect that these inconsistent findings are due to methodological flaws (Knight, Lutzky, and Macofsky-Urban 1993; R. J. V. Montgomery and Kosloski 1995; Zarit 1990). A detailed review of the methodological criticism is provided by Zarit, Stephens, Townsend, and Greene 1998. These authors tried to avoid six of the common methodological problems in their own study: (a) They investigated an experimental group that attended the intervention day care in a substantial manner, for example, a minimum of 2 days per week; (b) they used a largely untreated control group; (c) the experimental group was interviewed for the first time shortly after the beginning of the intervention; (d) the two groups had no significant intervention prior to this study; (e) they explored short-term as well as long-term effects; and (f) variables were derived by the stress process model of Pearlin, Mullan, Semple, and Skaff 1990.
The study was restricted to caregivers only. Results show that the experimental group had significantly lower scores than the control group on overload, strain, depression, and anger after 3 months. After 1 year, findings showed that the experimental group continued to have significantly lower scores on overload and depression than the control group (Zarit et al. 1998).
The present study also fulfills the above mentioned criteria. In contrast to previous studies, we have focused our investigation on patients as well as on caregiving relatives. The described rehabilitative aims for the patients such as enhancing patients' well-being and competencies were investigated within the theoretical framework of life span developmental and clinical psychology (P. B. Baltes 1987). This perspective allows the differentiation of individual gains and losses throughout the course of development and—in the case of severe losses—as a result of rehabilitative efforts. It stresses biographically influenced changes and describes the multidimensionality, multifunctionality, and multidirectionality of developmental processes in various domains (M. M. Baltes 1996; P. B. Baltes 1987). In their metatheory of development, Baltes and Baltes described selective optimization with compensation as being effective strategies for dealing with challenges throughout the life span (M. M. Baltes and Carstensen 1996; P. B. Baltes 1997; P. B. Baltes and Baltes 1990). Within this life span perspective, our evaluation of geriatric day care tries to identify the effects of this intervention on patients in different domains (well-being, cognition, everyday competence), which can be explained by the strategies of selection, optimization, and compensation.
The potential effects on caregivers were investigated within the theoretical model of Pearlin and colleagues 1990, which distinguishes between context variables, the appraisal of primary stressors, secondary role strains, mediators, secondary intrapsychic strains, and outcomes (Aneshensel, Pearlin, Mullan, Zarit, & Whitlach, 1995; Pearlin et al. 1990). The present study operationalized context variables by using socioeconomic status (SES) characteristics. The appraisal of primary stressors was studied using objective and subjective deficits of the patients as well as the caregivers' subjective feelings of burden. Family conflict and conflict between job and caregiving were indicators for secondary role strains, with social support as a potential mediator. Self-esteem was considered a measure of secondary intrapsychic strains. Outcomes measures were life satisfaction, depression, and health.
Our investigation had two aims. The first was to detect whether the intervention day care has any effects on the patients. The second aim was to find out whether the intervention day care visits of an elderly relative have any effects on caregivers. A two-fold multimethodological approach was implemented. On the one hand, various sources of information (patients, relatives, staff members, trained observers) were used. On the other hand, both quantitative and qualitative data were collected.
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Study 1: Effects on Patients |
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A quasi-experimental, longitudinal control group design was implemented. Every patient who started to use one of the centers was asked to participate in the study if she or he visited the center at least twice a week and intended to stay for more than 3 months. These criteria were chosen to ensure a potential impact of the intervention on the patient. The patient was asked for permission to question his family caregivers and staff members. After permission was granted, family caregivers were asked to participate as well. In the case of more severe cognitive decline and the presence of a legal guardian, the guardian had to agree with the inclusion of the patient in the study.
The control group consisted of a matched sample that did not use day care but did receive some home-based community care such as household or dressing assistance. Because every patient using the day care service also received help from these community services in the morning and evening (see above), this represented an ideal context for recruitment of a control group. Members of the control group did not use day care facilities and received no more home-based support than the intervention group. Matching criteria of the two groups were physical and mental health status, age, gender, and SES. Our research team informed six community care service units about our study and the kind of patients we were looking for as participants for the control group. Staff members of the community service asked suitable patients whether they would like to participate in a study. In the case that patients indicated their interest, staff members informed us, and we contacted the patients. We do not know how many patients refused to participate.
Data were collected at three measurement points and one follow-up: T1 took place during the first 10 days of day care use, T2 was conducted 6 months later, and T3 took place 9 months after the beginning of service use. The follow-up consisted of a telephone interview with formal or informal caregivers 6 months after T3.
Interviewers were graduate students who had received a 2-month intensive training. They assisted the participants in filling out the questionnaires, if necessary. This means that in some cases they read the items aloud, explained the answering format repeatedly, and marked the ratings on the questionnaire. Because we were interested in patients' evaluation, we did not include interviewer impressions and the item was rated as missing when the patient was not able to give a clear, independent answer. Training of the interviewers included methodological aspects to minimize interviewer biases, information about psychiatric disorders among older adults, and video examples of different stages of demented and depressed patients.
In the literature, it has often been questioned whether it is possible to gather valid and reliable data about subjective well-being of patients suffering from dementia. Because of our multimethodological approach, we could demonstrate that our data from patients with mild or moderate dementia are valid and reliable (Zank and Leipold 2001). In that study, reliability (internal consistency) on various self-report scales concerning life satisfaction, perceived social support, and depression (for a description of the scales see Study 1 below) were between .80 and .90. The validity of data were checked by a comparison between self-report data on depressive symptoms (Center for Epidemiological Studies–Depression Scale; CES-D) and depressive symptoms rated by an interviewer (Montgomery and Asberg Depression Rating Scale; MADRS). The Spearman correlation between CES-D and MADRS was .63 (p < .001).
During data collection, interviewers were offered continuous supervision. Because of the naturalistic character of this study, interviewers were not blind to the group status of participants. Every interviewer gathered data with respondents of the day care group and participants of the control group to minimize interviewer bias.
Predictions
The day care units offer a rehabilitation program based on clinical experience and gerontological knowledge. This program is tailored to the individual patient with his or her unique biography, specific weaknesses, and strengths. One main aim is to stabilize patients' emotional well-being. To this end, new social contacts and constructive activities are built into the program to reduce loneliness and depressive symptoms. The establishment of a structured daily routine and individual training of residual competencies are other strategies used to stabilize well-being, especially in patients suffering from dementia. Therefore, we expected an effect of day care on the emotional well-being of patients with different diseases and on the ADLs. We did not expect an improvement of general health in patients with chronic diseases or an improvement of cognitive functioning in patients suffering from dementia.
Participants
One hundred forty-eight participants took part at T1, 83 day care visitors and 65 controls. At T2, 51 participants remained in the experimental group, and 44 individuals remained in the control group. At T3, 43 participants from the experimental group and 40 participants from the control group remained in the study. The total drop-out rate, therefore, was 44%; 48% for day care visitors and 39% for the control group. This means that a total of 83 participants remained in the study. No participant denied further participation. The reasons for drop-out were a stop in using the facilities (27%), institutionalization (43%), or death (30%). Logistic regression analyses revealed that neither age nor morbidity nor existence of caregiving relatives was a predictor of drop out. The only significant predictor was dementia, which was significant in both groups (Zank 2000).
Table 1 shows the characteristics of the longitudinal sample. Participants were about 79 years old (range 60–96 years), predominantly female, and widowed. Treatment and control participants suffered from an average of 4.2 and 4.9 diseases, respectively. Seventy-nine percent of the day care users and 63% of the control group suffered from dementia. Twenty-six percent of the treatment group and 15% of the control group suffered from depression. Participants had moderate deficits in managing the ADLs, which is also reflected by the fact that they received 5 to 6 hr assistance per week from home-based care services.
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A comparison of the sample in this study with the sample of the representative data of the Berlin Aging Study (BASE) reveals a high degree of similarity. Twenty-four percent of the total BASE sample older than age 70 were still married, but only 9% older than age 85 were. Thirty percent of the female sample of BASE had never had children (Wagner, Schutze, and Lang 1999). The average income of women was 1850 DM (Mayer, Maas, and Wagner 1999). On average, the BASE participants suffered from five diseases (Steinhagen-Thiesen and Borchelt 1999). The important difference between the BASE sample and this study is the psychiatric morbidity. In BASE, 14% of the total sample suffered from a dementia, and about 20% of the sample aged 80 years and older did. The prevalence of depression (Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. rev.) was 9% (Helmchen et al. 1999). For obvious reasons, the rate of psychiatric diseases is much higher in the day care sample and, therefore, probably the main reason for use of these services.
Instruments
Life satisfaction.
A shortened, 28-item version of the Life Satisfaction Questionnaire (Closs and Kempe 1986) was administered (e.g., "In my life, there are many things which make me sad"). The potential score ranged from 0 to 3, a higher score indicating greater life satisfaction. The reliability was .92 (Cronbach's alpha, internal consistency).
Perceived social support.
A 15-item shortened version of an instrument developed by Fydrich, Sommer, Menzel, and Holl 1987 was administered. Items referred to emotional ("I have friends who listen to me when I need to talk") and practical ("There are people with whom I have a sense of belonging") elements of perceived social support. The potential score ranged from 0 to 3, a higher score indicating more social support. The reliability was .81 (Cronbach's alpha).
Depression.
In addition to the diagnosis by physicians, depression was measured by the German version of the MADRS (S. A. Montgomery and Asberg 1979). It consists of 10 items (e.g., apparent sadness, reported sadness, suicidal thoughts) which are rated by a trained interviewer. Ratings range from 0 (symptom not observable) to 6 (extreme). The reliability was .83 (Cronbach's alpha).
Self-esteem.
This instrument is an extension of an earlier version (Silbereisen and Zank 1984) and consists of six items (e.g., "I like myself"). The potential score ranged from 0 to 3, a higher score indicating higher self-esteem. The reliability was .77 (Cronbach's alpha).
Cognitive impairment.
The German version of the Mini-Mental State Examination (MMSE) was administered (Folstein, Folstein, and McHugh 1975). Scores range between 0 and 30, and a higher score indicates better cognitive functioning. The recommended cutoff score for the diagnosis of dementia is greater than or equal to 24. In addition, change-sensitive tasks of the Nuremberg Aging Inventory (Oswald and Fleischmann 1982), a psychometric test battery, were administered (repeating numbers, recognition of words, recall of words).
Noncognitive dementia symptoms.
The memory and behavior problems checklist by Zarit and Zarit 1983; Zarit and Zarit 1990 was translated into German and adapted for the purpose of this study. Informal and formal caregivers were asked to answer 25 items such as "Patient asks the same question over and over again." Response possibilities were 0 (problem never occurred), 1 (did not occur during the last two weeks), 2 (occurred 1–5 times during the last two weeks), 3 (occurred 6–13 times during the last two weeks), 4 (occurred daily or more often). The reliability was .86 for family caregivers and .87 for formal caregivers. In addition, the German version of the Alzheimer's Disease Assessment Scale was administered (Ihl and Weyer 1993). It measures depressive symptoms, hallucinations, and psychotic symptoms. An interviewer rated these symptoms (0 = did not occur, 5 = severe). The reliability was .65. The subscale "agitation" consisted of three items and had a reliability of .61 (Cronbach's alpha).
ADLs.
Family caregivers and formal caregivers were asked to answer the Nuremberg Aging Observation Scale (Oswald and Fleischmann 1982). It consists of 15 items (e.g., dressing, washing, shopping). A score of 0 indicates no deficits, a score of 30 reveals maximum incompetence. The reliability was .76 for formal caregivers and .74 for family caregivers. In addition, the patient was asked to rate her or his own competence with a corresponding instrument. Furthermore, data were collected on whether 14 leisure activities had been performed during the last 2 weeks (e.g., watching TV, going for a walk, reading a book).
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Results |
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Data were analyzed following a two-step procedure, taking into account the longitudinal character of the study. In a first step, individual growth curves were estimated (e.g., Collins 1996; Rogosa 1995). Using the three measurement occasions as a predictor, we chose a linear model to represent the overall shape of growth. Two parameters were estimated for each individual and each variable: an intercept parameter reflecting the individual's score at the beginning of the study and a slope parameter reflecting the individual's rate of change per month. In a second step, differences were then tested in the slope parameters between the treatment and control groups with multivariate analyses of variance. The independent variable in these analyses was group (treatment vs. control), and the dependent variables were the slope parameters pertaining to subjective well-being, cognitive and noncognitive dementia symptoms, health indicators, and ADL parameters.
Table 2 shows the results from subjective well-being, which was measured by life satisfaction, perceived social support, depression, and self-esteem. There was a significant multivariate effect, F(4,78) = 6.13, p = .000, indicating that groups differed in their rate of change. Univariate comparisons revealed that there were significant effects in perceived social support, F(1,81) = 13.31, p = .000, depression, F(1,81) = 8.11, p 
.006, and life satisfaction, F(1,81) = 6.48, p .013. Slope data indicated that in life satisfaction and perceived social support, the treatment group stabilized, whereas the control group declined. In the MADRS data, there was an increase in depression scores for the control group, and a decrease in the treatment group. There was no significant difference between the groups with regard to self-esteem, F(1,81) = 2.1. The average intercept parameters are also presented in Table 2 (Columns 4 and 6) for illustrative purposes. However, intercept parameters were not considered in multivariate and univariate analyses of variance.
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.004. Univariate tests indicated that this multivariate effect was due to a significant effect in recognition of words, F(1,81) = 12.04, p .001. Slope data showed that the treatment group improved and the control group worsened on this test. There were no effects in reproduction of words, F(1,81) = 2.20, the MMSE, F(1,81) < 1, and reproduction of numbers, F(1,81) < 1.
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.028. There was no effect in the memory and behavior problems checklist, F(1,81) = 1.4.
Diseases, subjective health rating, medication, and hours of home-based care were entered in a multivariate analysis as indicators of general health. Table 4 shows that there was no multivariate effect, F(4,78) = 1.65. The only nearly significant difference was found for diseases, F(1,81) = 3.09, p .08. The participants of the control group started with more diseases and tended to worsen more than the treatment group. We entered leisure time activities and an ADL test from the Nuremberg test battery into a multivariate analysis of variance to investigate changes in everyday competence. Table 4 shows that there were no effects on everyday competence, F(2,8) < 1.
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2(1, N = 76) = 4.2, p .03. There were no differences in depression or memory and behavior problems. In ADLs, the control group showed a tendency toward higher deficits than the treatment group. |
Study 2: Effects on Caregivers |
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Participants
In the longitudinal follow-up sample, more than 80% of the caregivers were women, and they had a mean age of 57 years (Table 5 ). More control-group caregivers were partners of the patients (39%) than were the caregivers of day care users (25%). Fifty percent of the caregivers of day care patients worked, compared with 39% of the caregivers of the control group. The average number of diseases were higher among caregivers of the control group (3.6 vs. 2.7), the length of caregiving was longer (54 months vs. 37 months), and the percentage of caregivers living with the patient was higher (65% vs. 60%). None of these differences were significant. The total group of patients who were taken care of by these caregivers was mostly women who had severe cognitive deficits (MMSE M = 14.5) and suffered from an average of five diseases. The day care patients had a mean age of 78.7 years; the patients of the control group, 82.1 years; this difference was not significant. These patients did not differ from the total sample in Study 1 (see Table 1 ).
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Perceived social support.
(See above in Study 1.) The reliability in the caregivers sample was .85 (Cronbach's alpha).
Self-esteem.
(See above in Study 1.) The reliability in the caregivers sample was .77 (Cronbach's alpha).
Depression.
The German version of the 20-item CES-D (Hautzinger 1988; Radloff 1977) was used. With this scale, a variety of symptoms ("I was depressed") was presented and participants reported how often they had experienced each symptom in the past 2 weeks on a 4-point scale (0 = less than two days, 1 = 2–5 days, 2 = 6–9 days, 3 = 10–14 days). The potential range of total score was 0 to 60, with a higher score representing a greater level of depression. The reliability was .78 (Cronbach's alpha).
Objective and subjective deficits.
The memory and be-havior problems Checklist by Zarit and Zarit 1983(/Zarit and Zarit 1990) was translated into German. This checklist consists of 25 items and one open-ended question concerning potential behavior problems of the patients rated by the caregivers ("Asks the same question over and over again"). Objective deficits were the reported frequency of the behaviors (0 = never occurred, 4 = daily), and the reliability was .86 (Cronbach's alpha). Subjective deficits were the caregivers' reaction to these deficits (0 = never bothered, 4 = extremely bothered). The reliability of this scale was .85 (Cronbach's alpha).
Burden interview.
The Burden Interview of Zarit and Zarit 1983(/Zarit and Zarit 1990) consists of 22 questions (e.g., "Do you feel strained when you are around your relative?") with five response possibilities (0 = never, 4 = nearly always). The reliability of the German version was .87 (Cronbach's alpha).
Family conflict.
A 12-item scale developed by Pearlin and colleagues 1990 was translated (e.g., "How much disagreement have you had with anyone in your family because they don't spend enough time with your relative?") Four response categories were given (1 = no disagreement, 4 = quite a bit of disagreement). The reliability of the scale was .84 (Cronbach's alpha).
Job–Caregiving Conflict scale.
This five-item scale developed by Pearlin and colleagues 1990 was translated (e.g., "In the last 2 months or so you have had less energy for your work"). Four response categories were provided (1 = strongly disagree, 4 = strongly agree). The reliability was .61 (Cronbach's alpha).
Positive or negative effects of day care.
The caregivers of day care patients were asked semi-open questions about their experiences with day care. They were asked to specify any positive or negative outcomes.
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Table 6 shows the results from a multivariate analysis of variance of the caregivers' subjective well-being, which was measured by life satisfaction, perceived social support, self-esteem, and depression as dependent variables and the two groups (caregivers of day care patients vs. caregivers of the control group) as independent variables. No significant effect was found, F(4,37) = 0.35.
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Concerning the patients, less improvement was mentioned. Eleven percent of the caregivers reported a reduction in relational strain after 9 months, and 5% reported a slowing down of decline in the patient. Eleven percent already noticed an improvement of depressive mood at T1, but this was not changed at T3.
No negative effects of day care were mentioned by any of the caregivers. The only criticism was that several caregivers expressed wishes for longer opening hours of the day care centers.
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Summary and Discussion |
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; P. B. Baltes and Baltes 1990; Pearlin et al. 1990; Zarit 1990; Zarit and Zarit 1983/Zarit and Zarit 1990). Like them, when we began our research in 1994, we wanted to address some of the methodological flaws in earlier research on adult day care. In particular, in contrast to most research, which is restricted to caregivers only, the goal of the present study was to systematically evaluate effects on patients using a longitudinal control-group design. Our results show a positive effect of day care units on patients. An improvement or stabilization of the subjective well-being and dementia symptoms in the treatment group in comparison with the control group has been demonstrated. Multivariate analyses of variance of the individual growth curves showed a highly significant effect in subjective well-being. Univariate tests show that there are effects in life satisfaction, perceived social support, and depression. All results follow the same pattern: At the beginning of the study, the treatment group had worse scores than the control group. During the intervention, the treatment group remained stable or improved over the 9 months, and the scores of the control group worsened.
The self-esteem questionnaire probably touches deeper dimensions of self-experience that might be more resistant toward change. Results from longitudinal studies have suggested stable retest correlations for neuroticism or self-confidence (Costa and McCrae 1988; Haan, Millsap, and Hartka 1986). Some of the day care units have set the goal of enhancing the self-esteem of their visitors, but our data cannot show any intervention effect here.
The results show significant changes in cognitive and noncognitive dementia symptoms. Symptoms of agitation decrease in day care patients (and not through medication), and they increase in the control group. The results concerning cognitive symptoms, however, must be interpreted with caution. First, only parts of the administered cognitive battery could be analyzed because of missing data of the more complex instruments (e.g., complete SIDAM). Second, the multivariate effect is due to one significant change in the test "recognition of words." This test is probably the easiest one, and the effect size is small. Nevertheless, results show that partial cognitive abilities can be improved by general day care interventions even in participants with reduced capacity.
There were no significant differences in health indicators or in everyday competence between the groups over the 9-month study period. There seemed to be an advanced decline in health in the control group that might be influenced by the fact that participants of the control group showed a nonsignificant but noticeable higher morbidity at the beginning of the study. A substantial improvement in morbidity could not be expected by this intervention in patients who suffered mostly from chronic conditions. An improvement of everyday competence, however, is an explicit aim of the day care units. No effects could be found in this study. On the one hand, this could be due to instruments insensitive toward change. On the other hand, this result is supported by in vivo observational data (Zank 2000). Probably, the day care units could improve their service by introducing individual specific training programs for lost everyday competence.
The follow-up data show a surprising difference between the two groups. Formal and informal caregivers report a decline in health in half of the control group but in less than one-third of the treatment group. This may be due to the above mentioned higher morbidity of the control group. However, it might also be a long-term effect of day care because 6 months after the end of the 9-month study, 37 participants of the treatment group were still visiting the day care units. It could be argued that these patients underwent 15 months of day care treatment and that this long treatment led to a significant difference in health between day care patients and patients of the control group. Because these data do not result from medical investigations, further research is needed to clarify this effect.
The positive effects of day care on patients can be explained within the theoretical framework of selective optimization with compensation of life span developmental and clinical psychology (P. B. Baltes 1987, P. B. Baltes 1997; P. B. Baltes and Baltes 1990). Patients select a supportive environment (or their caregiving relatives select this environment for the patients) that allows them to optimize abilities and compensate for deficits. Day care offers the possibility for rehabilitative processes in different domains of functioning. The enhancement of emotional well-being of patients is probably due to successful compensation of objective and subjective deficits in social relations. The improvement of some patients in a cognitive test is an example of optimization of reduced capacities. It remains an open question whether these patients could profit even more from a 24-hr supportive environment such as that found in nursing homes (Zank 2001).
In contrast to the positive findings for the patients, the quantitative data show no effects of day care on caregivers. Positive effects on neither well-being nor burden could be demonstrated. Nevertheless, the descriptive data stemming from the semi-open questions revealed positive effects. Such contradictory findings are not without precedent in the literature (Biegel, Sales, and Schulz 1991). In this study, several reasons might be responsible for these results.
First, many caregivers already reported a reduction in burden at T1. Because of ethical and logistic constraints, a randomized control group design with pretest before entering day care could not be administered. Therefore, a quasi-experimental design was chosen, and T1 took place within the first 10 days of day care. Apparently, the intervention day care had already had effects on the caregivers within these few days as shown by their answers to the semi-open questions. This fast reduction in burden reduced possible long-term comparison affects. Using the stress-process model of Pearlin and colleagues 1990, we found that day care mainly affects the appraisal of primary stressors. In our study we found a reduction of supervisional and practical tasks. We also observed some effects on secondary role strains, especially job conflicts and conflicts between personal needs and caregiving tasks.
Second, the longitudinal sample size is rather small. This might also be the reason that these findings are contradictory to the ones reported by Zarit and colleagues 1998, who investigated a larger sample. At least, the findings of this study concerning secondary role strains (conflict between job demands and caregiving tasks) would have reached significance in a larger sample. The main target of this research project was an evaluation of effects of day care on the patients, and a reasonable longitudinal sample was achieved there. Unfortunately, many of the day care patients (43%) did not have any caregiving relatives. Because most of the caregivers are children of the patients, our results show that many day care patients either do not have children (31%) or their children do not provide care for various reasons (e.g., living in another city). The high level of childlessness in this study matches precisely the results of the representative sample of the Berlin Longitudinal Study (Wagner et al. 1999). The degree of childlessness is due to a cohort effect in Germany, which is especially pronounced in Berlin.
Third, standardized measures proved to be rather insensitive toward change, especially in caregiving research. This repeated finding has prompted discussion about the necessity of more qualitative research (Miller 1998). Our own findings were in line with that notion (Schacke 2000; Zank 2000).
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Acknowledgments |
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This research project was funded by German Ministry for Family, Seniors, Women, and Youth Grant 314—1720-314/1.
Received for publication August 21, 2000. Accepted for publication October 22, 2001.
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 S. H. Zarit, M. A. P. Stephens, A. Townsend, R. Greene, and E. E. Femia Give Day Care a Chance To Be Effective: A Commentary J. Gerontol. B. Psychol. Sci. Soc. Sci., May 1, 2003; 58(3): P195 - 196. [Full Text] [PDF]
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S. Zank and C. Schacke Science Is A Matter of Cumulative Learning: Authors' Reply to the Commentary J. Gerontol. B. Psychol. Sci. Soc. Sci., May 1, 2003; 58(3): P197 - 199. [Full Text] [PDF]
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