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Anxiety and depression symptoms among caregivers of care-recipients with subjective cognitive decline and cognitive impairment

Abstract

Background

Caregivers of care-recipients with mild cognitive impairment (MCI) or dementia experience high caregiver burden; however, the psychiatric burden of caregivers of care-recipients with subjective cognitive decline (SCD) has not been investigated. We aimed to explore the prevalence of and risk factors for anxiety and depression symptoms among the caregivers of care-recipients with SCD and cognitive impairment.

Methods

The Hospital Anxiety and Depression Scale (HADS) was used to examine the anxiety and depression symptoms among the caregivers of 343 care-recipients (84 with SCD, 120 with MCI and 139 with dementia) treated at the Memory Clinic of Huashan Hospital in Shanghai, China from May 2012 to October 2014. A logistic regression was used to explore the factors associated with caregiver’s anxiety and depression symptoms.

Results

In total, 26.5 % of caregivers had anxiety symptoms, and 22.4 % had depression symptoms. Totals of 17.9, 30.0 and 28.8 % of caregivers of care-recipients with SCD, MCI or dementia, respectively, had anxiety symptoms (P = 0.1140), whereas 22.6, 24.2 and 20.9 %, respectively, had depression symptoms (P = 0.8165). The risk factors for caregiver’s anxiety symptoms were increased caregiver age as well as having care-recipients who were male, had higher Cohen Mansfield Agitation Inventory (CMAI) scores, and higher Geriatric Depression Scale (GDS) scores. The risk factors for caregiver’s depression symptoms were increased caregiver age as well as caring for care-recipients with MCI or SCD, those with lower Toronto Empathy Questionnaire (TEQ) scores, and those with higher GDS scores.

Conclusions

Caregivers of care-recipients with SCD showed the same level of depression symptoms as those of care-recipients with MCI. Caregiver’s depression and anxiety symptoms were associated with their care-recipients’ psychiatric and behavioral syndromes.

Peer Review reports

Background

Caregiver burden is common in dementia. This condition is not only associated with adverse emotional states and psychiatric morbidity but also poorer physical condition and worse financial and social consequences. Factors in three other domains are also relevant: care-recipient characteristics, caregiver characteristics and living conditions [13]. Previous studies have reported that approximately 22 % of caregivers experience clinical depression [4], and approximately 75 % of caregivers experience significant depression and anxiety symptoms [5, 6]. Mild cognitive deficits are not sufficient for a diagnosis of dementia; however, care-recipients with mild cognitive impairment (MCI) have a 10–12 % annual probability of progression to dementia [711]. One study also indicated that caregivers of care-recipients with MCI showed anxiety and depression symptoms [12].

Subjective cognitive decline (SCD) in older adults is increasingly recognized as a potential indicator of non-normative cognitive decline, and some people with this condition eventually progress to dementia [1317]. The core of the definition of SCD is self-experienced concerns about persistent decline in one or more aspects of cognitive function that are typically informant-corroborated; however, they show no impairment in activities of daily living and typically scores within normal limits on standard neuropsychological tests [1820]. A previous study showed that the annual conversion rate (ACR) of SCD to dementia is 2.33 % (95 % CI: 1.93–2.78 %), and that of SCD to MCI is 6.67 % (95 % CI: 4.70–8.95 %) [17].

Regarding the persistent cognitive decline and the high rate of its conversion, we assumed that both care-recipients and their caregivers would suffer from cognitive complaints. However, psychiatric symptoms among SCD-caregivers have been under-researched. This study explored the prevalence of and risk factors for anxiety and depression symptoms among caregivers of care-recipients with SCD and cognitive impairment using data from the Memory Clinic of Huashan Hospital in Shanghai.

Methods

Design and participants

A hospital-based cross-sectional survey of 343 pairs of care-recipients and their caregivers was conducted at the Memory Clinic of Huashan Hospital in Shanghai from May 2012 to October 2014. A caregiver was defined as someone who spent at least 8 h per week caring for a care-recipient, regardless of whether they lived together. The inclusion criteria were: the care-recipient was diagnosed with mild or moderate dementia, MCI or SCD; one primary caregiver cared for one care-recipient; the principal family caregiver was over 18 years old and took care of or lived with the care-recipient; the caregiver’s relationship with the care-recipient and their caring time were also considered when recruiting participants, therefore, spouses, daughters, sons, daughters-in-law and other relatives were included, regardless of whether they lived with their care-recipients. Those who simultaneously provided care for another family member with a chronic medical condition were excluded.

Demographic factors and medical history

Demographic characteristics, including age, gender and education, were collected from the care-recipients and their caregivers. Additional information was collected regarding the caregiver such as their working status, experience in caring for care-recipients with dementia, familiarity with the care-recipient and their relationship with the care-recipient.

Neurological, psychiatric and neuropsychological assessments

For each care-recipient, cognitive function scales covering domains of global cognition (i.e., executive function, visuospatial ability, memory, language and attention) were administered, including the Mini Mental State Examination (MMSE) [21], the Memory and Executive Screening (MES) [22], the Montreal Cognitive Assessment (MOCA) [23], the Rey-Osterrieth Complex Figure Test (CFT) [24], the Stroop Color Word Test (CWT) [25], the Boston Naming Test (BNT) [26], the Auditory Verbal Learning Test (AVLT) [27], the Symbol Digit Modalities Test (SDMT) [28], the Event-Based Prospective Memory Test (EBPM) and the Time-Based Prospective Memory Test (TBPM) [29, 30], the Animal Verbal Fluency Test (VFT) [31],the Trail Making Test (TMT) [32], the Judgement of Line Orientation (JLO) [33], the Word Memory Test (WMT) [34],the Visual Object and Space Perception (VOSP) [35], and the Clinical Dementia Rating Scale (CDR) [36]. Furthermore, the Geriatric Depression Scale (GDS) [37] and the Zung Self-Rating Anxiety Scale (ZSAS) [38] were also administered for each care-recipient. For each caregiver, the 16-item version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) [39], the Toronto Empathy Questionnaire (TEQ) [40], the Cohen-Mansfield Agitation Inventory (CMAI) [41] and the Apathy Evaluation Scale (AES) [42] were administered to evaluate the psychiatric and neuropsychological symptoms of care-recipients.

The Hospital Anxiety and Depression Scale (HADS) is a popular clinical and research instrument used to screen for anxiety and depression symptoms in both hospital and community settings [43, 44]. The HADS facilitates the early identification of both anxiety and depression symptoms simultaneously; furthermore, it provides a separate score for each domain. It is easy to score and simple to interpret. The Chinese version of the HADS is available and shows acceptable reliability and validity [4547]. Therefore, we used the HADS to evaluate the anxiety and depression symptoms of each caregiver. The HADS is composed of 14 items, seven of which relate to anxiety symptoms and seven concern depression symptoms. Each item is coded from 0 to 3. Therefore, the total scores for anxiety symptoms and depression symptoms can both vary from 0 to 21, representing the presence and severity of the symptoms. We used the score of 8 to define “caseness” for both anxiety symptoms and depression symptoms [43, 48, 49].

Four experienced neurologists and one neuropsychologist (QG, DD, QZ, FL, and ZH) who work at top institutions of neurology in China (Huashan Hospital and Fuxing Hospital) reviewed the functional, medical, neurological, psychiatric, and neuropsychological data, and reached a consensus regarding the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for dementia [50]. Only care-recipients who were not diagnosed with dementia were considered for a diagnosis of MCI based on the Petersen’s criteria [51]. The other care-recipients were diagnosed with SCD using a broad research criteria for pre-MCI SCD, which included two presentations: (1) the care-recipients had to report self-experienced persistent decline in cognition compared to previous statue and that was unrelated to an acute event; (2) care-recipients have normal age-, gender-, and education-adjusted performance on standardized cognitive tests used to classify MCI.

Statistical analysis

Continuous variables were expressed as mean and standard deviation (SD), and categorical variables were expressed as frequencies (%). We divided all care-recipients and caregivers into four groups according to the caregiver’s performance on the HADS: with anxiety [anxiety(+)], without anxiety [anxiety(−)], with depression [depression(+)], and without depression [depression(−)]. The Wilcoxon rank sum test and the Kruskal-Wallis H rank sum test were used to compare continuous variables, whereas Pearson Chi-squared test was used to compare categorical variables. Backward logistic regression models were used to explore risk factors for anxiety and depression symptoms among caregivers. Risk factors were presented as odds ratio (OR) with 95% confidence interval (95 % CI). The possible risk factors we adjusted for care-recipients included their gender, age, education, diagnosis, and presence of stroke as well as their IQCODE, TEQ, CMAI, GDS, ZSAS and AES scores; those for caregivers included their gender, age, education level, working status, and experience in caring for care-recipients with dementia as well as their familiarity with the care-recipient and their relationship with the care-recipient. Two-tailed tests were used for all analyses at a significance level of P < 0.05. The data were analyzed using SAS 9.3 (SAS Institute Inc., Cary, NC, USA).

Results

The demographic, medical history, neurology tests, psychiatric assessment and neuropsychological assessment data of the 343 pairs of care-recipients and caregivers are shown below.

Comparison of caregiver characteristics between caregiver groups with or without anxiety and depression

Totals of 17.9, 30.0 and 28.8 % of caregivers of care-recipients with SCD, MCI or dementia had anxiety symptoms (P = 0.1140), respectively; 22.6, 24.2 and 20.9 % of these caregivers had depression symptoms (P = 0.8165), respectively. Although caregivers of care-recipients with SCD had relatively low anxiety symptoms and relatively high depression symptoms, anxiety or depression symptoms were not associated with cognitive impairment severity (Table 1).

Table 1 Comparison of caregiver characteristics between caregiver groups with or without anxiety and depression

Table 1 also shows that 146 (43.7 %) caregivers were men, and the mean age was 55.0 (SD 16.4) years. The education levels of the caregivers included illiteracy (49, 14.7 %), primary education (73, 21.9 %), middle education (154, 46.3 %), junior and college education (15, 4.5 %), and university and higher education (42, 12.6 %). The following caregiver characteristics significantly differed: gender and education level regarding anxiety symptoms, and education level and age regarding depression symptoms. When caregivers were women or had low education levels, they were more likely to have anxiety symptoms; when caregivers were older or had low education levels, they were more likely to have depression symptoms.

Comparison of care-recipient characteristics between caregiver groups with or without anxiety and depression

A total of 84 (24.5 %) care-recipients had SCD, 120 (35.0 %) had MCI, and 139 (40.5 %) had mild to moderate dementia (Table 1). Their mean age was 66.5 (SD 10.6) years. Moreover, 53.9 % were men, and their mean years of education were 8.9 (SD 3.6) years. The IQCODE, TEQ, CMAI, AES, ZSAS and GDS scores of care-recipients significantly differed between the two groups of caregivers with or without anxiety symptoms. Compared with the care-recipients of caregivers without anxiety symptoms, those of caregivers with anxiety symptoms had higher IQCODE scores (55.6 vs 50.8), lower TEQ scores (38.0 vs 41.8), higher CMAI scores (41.5 vs 35.4), lower AES scores (27.1 vs 31.6), higher ZSAS scores (36.9 vs 34.7) and higher GDS scores (6.5 vs 4.7s). The TEQ, CMAI, AES and GDS scores of care-recipients significantly differed between the groups of caregivers with or without depression symptoms. Compared with the care-recipients of caregivers without depression symptoms, those of caregivers with depression symptoms had lower TEQ scores (38.1 vs 41.5), higher CMAI scores (39.3 vs 36.3), lower AES scores (26.6 vs 31.5) and higher GDS scores (6.1 vs 4.9) (Table 2).

Table 2 Comparison of care-recipient characteristics between caregiver groups with or without anxiety and depression

Possible risk factors for caregiver’s anxiety and depression symptoms

After adjusting the possible risk factors (gender, age, education, presence of stroke, and diagnosis as well as the IQCODE, TEQ, CMAI, GDS, ZSAS and AES scores for care-recipients; and gender, age, education level, working status, experience caring for care-recipients with dementia, familiarity with the care-recipient and relationship with the care-recipient for caregivers), we found that possible risk factors for caregiver’s anxiety symptoms were having a male care-recipient (OR = 2.19, 95 % CI:1.07–4.48), a higher CAMI score (OR = 1.06, 95 % CI: 1.02–1.10), a higher GDS score (OR = 1.15, 95 % CI:1.05–1.27) and increased caregiver age (OR = 1.02, 95 % CI:1.00–1.05). The risk factors for caregiver’s depression symptoms were having a lower TEQ score (OR = 1.07, 95 % CI:1.02–1.11), a care-recipient with MCI(OR = 2.76, 95 % CI:1.11–6.88) or SCD(OR = 3.40, 95 % CI:1.16–10.01) compared with one with dementia, a higher GDS score (OR = 1.13, 95 % CI:1.03–1.24) and increased caregiver age (OR = 1.02, 95 % CI:1.00–1.05) (Table 3).

Table 3 Possible risk factors for caregiver’s anxiety and depression symptoms

Discussion

In our study, 26.5 % of caregivers had anxiety symptoms, and 22.4 % had depression symptoms. For caregivers of care-recipients with dementia, MCI or SCD, the rates of anxiety symptoms in were 28.8, 30.0 or 17.9 %, respectively; whereas the rates of depression symptoms were 20.9, 24.2 or 22.6 %, respectively. The risk factors for caregiver’s anxiety symptoms were higher CMAI scores, higher GDS scores, increased caregiver age and having a male care-recipient. The risk factors for caregiver’s depression symptoms were lower TEQ scores, higher GDS scores, increased caregiver age and caring for care-recipients with SCD or MCI.

The prevalence of depression symptoms among caregivers of care-recipients with SCD or MCI was higher than that among caregivers of care-recipients with dementia. The prevalence of anxiety and depression symptoms among caregivers of care-recipients with dementia was in accordance with that in previous studies [4, 6, 52]. The pooled depression rate of caregivers of care-recipients with MCI (CESD scores ≥ 16 or equivalent, total N = 929) was 23 % (11–24.6 % for individual studies) [12], which is in accordance with our results. One study suggested that dementia plays a significant role in caregiver’s depression among Latino families compared with cognitive impairment but not dementia (CIND) [53]. However, most studies have found that depression and anxiety symptoms among caregivers of care-recipients with dementia are not associated with level of cognitive impairment [5456]. Another study showed that cognitive function and dementia severity were not correlated with caregiver burden [57]. One possible explanation for our findings is that care-recipients with SCD might often complain about their own declining memory and refer to the effect of their declining memory on activities of daily living. These complaints draw the attention of caregivers and require support and care. When caregivers hear the complaint about declining memory from care-recipients who didn’t previously complain, and are unable to access the support that care-recipients need, caregivers might feel depressed. Another possible explanation is that prior to diagnosis, psychiatric symptoms are more stressful to caregivers because their etiology is unclear, leading to higher caregiver’s depression. After diagnosis, psychiatric symptoms are likely attributed to the process of MCI. With the care-recipient’ further cognitive decline, however, the caregivers become familiar with the disease, able to care for the care-recipients and able to accept the current situation. A third reason might be that care-recipients with mild or moderate dementia, not the severe dementia observed in our study, have relatively mild mental symptoms and do not become a heavy burden on their caregivers.

We found that care-recipient GDS scores were a risk factor for both anxiety and depression symptoms among caregivers; however, we did not find that care-recipient ZSAS or AES scores were associated with caregiver’s anxiety or depression symptoms. Most studies have found that depression and anxiety symptoms in caregivers of people with dementia are strongly associated with patients’ psychiatric symptoms, particularly, depression symptoms [55, 5862]. Furthermore, we found that older caregivers had higher risks of both anxiety and depression symptoms. In an Italian multicenter study of 419 elderly outpatients with dementia and their caregivers, increased caregiver age was a major risk factor for both depression and anxiety (BDDA) among caregivers [63]. However, another study of caregivers of people with cognitive impairment did not find that age was an important predictor of caregiver’s anxiety [6, 64]. This finding might be because the physical functions of older caregivers are worse; thus, they become anxious and depressed given the increased burden.

Our study showed that care-recipient CMAI scores were only related to caregiver’s anxiety symptoms. A study of 35 patient-caregiver pairs evaluated at two university-affiliated dementia clinics found highly significant correlations between patient agitation and caregiver burden (r = 0.59, p = 0.0002) as well as between depression and caregiver’s depression (r = 61, p = 0.0001) [65]. A Chinese study found a positively correlation between the agitation among patients with dementia in nursing homes and the stress of 40 nursing staff members [66]. The reason for this finding might be that in addition to the constant daily care they provide, nursing staff must also spend more energy and time preventing care-recipient' self-harm and harm to others. If these effects cannot be predicted or prevented, then it might lead to serious consequences, and make caregivers feel persistently anxious. Furthermore, our study also showed that caregivers of males were more likely to suffer from anxiety symptoms, unlike previous studies. A previous study [61] found that female caregivers were more likely to experience psychological distress. The LASER-AD study found that being a female caregiver predicted having an anxiety disorder [67]. Our result might be because males are the core members of Chinese families; however, they are more impulsive and harder to control. Caregivers must take on more responsibilities (e.g., physical or financial problems) than before, which might result in caregiver’s anxiety symptoms.

We also found that care-recipient TEQ scores were a risk factor for caregiver’s depression symptoms. Previous studies have not investigated the relationship between empathy and depression symptoms. One possible reason might be that cognitive impairment is difficult to treat with either behavioral or pharmacologic methods, leading to embarrassment among care-recipients, which might contribute to caregivers’ feelings of social isolation.

In our study, some characteristics of caregiver (i.e., gender, education level, the caregiver’s working status, experience in caring for care-recipients with dementia, familiarity with the care-recipient and their relationship with the care-recipient) were not associated with caregiver’s anxiety and depression symptoms. Having less education was significantly associated with depression of caregivers of care-recipients with MCI in two [68, 69] of three studies [6870]. Caregiver gender [7072] and relationship with care-recipients [69, 70] did not predict depression of caregivers of care-recipients with MCI. Having less dementia knowledge significantly predicted depression of caregivers of care-recipients with MCI [70]. Depression of caregivers of care-recipients with dementia or cognitive impairment without dementia was associated with whether the caregiver was the care-recipient’s spouse, and whether the care-recipient had dementia or CIND [73]. The reason may be that we studied the anxiety and depression symptoms among caregivers of care-recipients with subjective cognitive decline and cognitive impairment, not only with cognitive function impairment.

To our knowledge, this study is the first to report the prevalence of and risk factors for anxiety and depression symptoms among the caregivers of care-recipients with SCD. The first limitation of our study is that the cross-sectional design limits any conclusions in a causal or predictive direction. Future work should examine these relationships longitudinally to more fully characterize the direction of cause and effect. Second, we adjusted for as many risk factors as possible in the logistic regression model; however, we can’t exclude the possible influence of uncollected risk factors such as the specific care time of caregivers, alcohol drinking habits, disease history (e.g., like head injury, coronary heart disease, hypertension and diabetes), economic status, physical and psychological illness among caregivers, and drugs that affect mental health. Third, there are only care-recipients with mild or moderate dementia, not the severe dementia in our study, but care-recipients with the severe dementia may cause serious impacts on their caregivers.

Conclusions

Our study suggests that clinicians should be aware of high rates of anxiety and depression symptoms among caregivers of care-recipients with SCD or MCI. We should also attend to the risk factors for anxiety and depression symptoms among caregivers such as care-recipient depressions, empathy and agitation. Furthermore, many caregivers require more social support via training as well as physical and mental health care. Such programs should provide caregivers with support to address their burden and educate them learn about cognitive impairment.

Abbreviations

AES:

Apathy evaluation scale

AVLT:

Auditory verbal learning test

BDDA:

Burden, distress, depression and anxiety

BNT:

Boston naming test

CDR:

Clinical dementia rating scale

CESD:

Epidemiologic studies depression scale

CFT:

Rey-Osterrieth complex figure test

CI:

Confidence interval

CMAI:

Cohen-Mansfield agitation inventory

CWT:

Stroop color word test

EBPM:

Event-based prospective memory test

GDS:

Geriatric depression scale

HADS:

The hospital anxiety and depression scale

IQCODE:

Informant questionnaire on cognitive decline in the elderly

JLO:

Judgement of line orientation

MCI:

Mild cognitive impairment

MES:

Memory and executive screening

MMSE:

Mini mental state examination

MoCA:

Montreal cognitive assessment

OR:

Odds ratio

SCD:

Subjective cognitive decline

SD:

Standard deviation

SDMT:

Symbol digit modalities test

TBPM:

Time-based prospective memory test

TEQ:

Toronto empathy questionnaire

TEQ:

Toronto empathy questionnaire

TMT:

Trail making test

VFT:

Animal verbal fluency test

VOSP:

Visual object and space perception

WMT:

Word memory test

ZSAS:

Zung self-rating anxiety scale

References

  1. Burns A, Rabins P. Carer burden dementia. Int J Geriatr Psychiatry. 2000;15(1):S9–S13.

    Article  PubMed  Google Scholar 

  2. Clyburn LD, Stones MJ, Hadjistavropoulos T, Tuokko H. Predicting caregiver burden and depression in Alzheimer’s disease. J Gerontol B Psychol Sci Soc Sci. 2000;55(1):S2–S13.

    Article  CAS  PubMed  Google Scholar 

  3. Paradise M, McCade D, Hickie IB, Diamond K, Lewis SJ, Naismith SL. Caregiver burden in mild cognitive impairment. Aging Ment Health. 2015;19(1):72–8.

    Article  PubMed  Google Scholar 

  4. Cuijpers P. Depressive disorders in caregivers of dementia patients: a systematic review. Aging Ment Health. 2005;9(4):325–30.

    Article  CAS  PubMed  Google Scholar 

  5. Teri L. Behavioral treatment of depression in patients with dementia. Alzheimer Dis Assoc Disord. 1994;8(3):66–74.

    Article  PubMed  Google Scholar 

  6. Cooper C, Balamurali TB, Livingston G. A systematic review of the prevalence and covariates of anxiety in caregivers of people with dementia. Int Psychogeriatr. 2007;19(2):175–95.

    Article  PubMed  Google Scholar 

  7. Langa KM, Levine DA. The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014;312(23):2551–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Gauthier S, Reisberg B, Zaudig M, Petersen RC, Ritchie K, Broich K, et al. Mild cognitive impairment. Lancet. 2006;367(9518):1262–70.

    Article  PubMed  Google Scholar 

  9. Luck T, Luppa M, Briel S, Riedel-Heller SG. Incidence of mild cognitive impairment: a systematic review. Dement Geriatr Cogn Disord. 2010;29(2):164–75.

    Article  PubMed  Google Scholar 

  10. Petersen RC, Roberts RO, Knopman DS, Boeve BF, Geda YE, Ivnik RJ, et al. Mild cognitive impairment: ten years later. Arch Neurol. 2009;66(12):1447–55.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Yesavage JA, O’Hara R, Kraemer H, Noda A, Taylor JL, Ferris S, et al. Modeling the prevalence and incidence of Alzheimer’s disease and mild cognitive impairment. J Psychiatr Res. 2002;36(5):281–6.

    Article  PubMed  Google Scholar 

  12. Seeher K, Low LF, Reppermund S, Brodaty H. Predictors and outcomes for caregivers of people with mild cognitive impairment: a systematic literature review. Alzheimers Dement. 2013;9(3):346–55.

    Article  PubMed  Google Scholar 

  13. Reisberg B, Shulman MB, Torossian C, Leng L, Zhu W. Outcome over seven years of healthy adults with and without subjective cognitive impairment. Alzheimers Dement. 2010;6(1):11–24.

    Article  PubMed  Google Scholar 

  14. Jessen F, Wiese B, Bickel H, Eiffländer-Gorfer S, Fuchs A, Kaduszkiewicz H, et al. Prediction of dementia in primary care patients. PLoS One. 2011;6(2):e16852.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Amieva H, Le Goff M, Millet X, Orgogozo JM, Pérès K, Barberger-Gateau P, et al. Prodromal Alzheimer’s disease: successive emergence of the clinical symptoms. Ann Neurol. 2008;64(5):492–8.

    Article  PubMed  Google Scholar 

  16. Dufouil C, Fuhrer R, Alpérovitch A. Subjective cognitive complaints and cognitive decline: consequence or predictor? The epidemiology of vascular aging study. J Am Geriatr Soc. 2005;53(4):616–21.

    Article  PubMed  Google Scholar 

  17. Mitchell AJ, Beaumont H, Ferguson D, Yadegarfar M, Stubbs B. Risk of dementia and mild cognitive impairment in older people with subjective memory complaints: meta-analysis. Acta Psychiatr Scand. 2014;130(6):439–51.

    Article  CAS  PubMed  Google Scholar 

  18. Reisberg B, Gauthier S. Current evidence for subjective cognitive impairment (SCI) as the pre-mild cognitive impairment (MCI) stage of subsequently manifest Alzheimer’s disease. Int Psychogeriatr. 2008;20(1):1–16.

    PubMed  Google Scholar 

  19. Reisberg B, Prichep L, Mosconi L, John ER, Glodzik-Sobanska L, Boksay I, et al. The pre-mild cognitive impairment, subjective cognitive impairment stage of Alzheimer’s disease. Alzheimers Dement. 2008;4(1 Suppl 1):S98–S108.

    Article  PubMed  Google Scholar 

  20. Stewart R. Subjective cognitive impairment. Curr Opin Psychiatry. 2012;25(6):445–50.

    Article  PubMed  Google Scholar 

  21. Zhang MY, Katzman R, Salmon D, Jin H, Cai GJ, Wang ZY, et al. The prevalence of dementia and Alzheimer’s disease in Shanghai, China: impact of age, gender, and education. Ann Neurol. 1990;27(4):428–37.

    Article  CAS  PubMed  Google Scholar 

  22. Guo QH, Zhou B, Zhao QH, Wang B, Hong Z. Memory and Executive Screening (MES): a brief cognitive test for detecting mild cognitive impairment. BMC Neurol. 2012;12:119.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lu J, Li D, Li F, Zhou A, Wang F, Zuo X, et al. Montreal Cognitive Assessment in Detecting Cognitive Impairment in Chinese Elderly Individuals: A Population-Based Study. J Geriatr Psychiatry Neurol. 2011;24(4):184–90.

    Article  PubMed  Google Scholar 

  24. Guo Q, Hong Z, Lv C. Application of Rey-Osterrieth complex figure test in Chinese normal old people. Chin J Clin Psych. 2000;8(4):205–7.

    Google Scholar 

  25. Guo Q, Hong Z, Lv C, et al. Application of Stroop color-word test on Chinese elderly patients with mild cognitive impairment and mild Alzheimer’s dementia. Chin J Neuro Med. 2005;4(7):701–4.

    Google Scholar 

  26. Guo Q, Hong Z, Shi W, et al. Boston Naming Test in Chinese elderly patient with mild cognitive impairment and Alzheimer’s dementia. Chin Ment Health J. 2006;20(2):81–4.

    Google Scholar 

  27. Zhao Q, Lv Y, Zhou Y, Hong Z, Guo Q. Short-term delayed recall of auditory verbal learning test is equivalent to long-term delayed recall for identifying amnestic mild cognitive impairment. PLoS One. 2012;7(12):e51157.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Strauss E, Sherman E, Spreen O. A Compendium of Neuropsychological Tests. 3rd ed. Oxford University Press: New York; 2006. p. 617–27.

    Google Scholar 

  29. Livner A, Laukka EJ, Karlsson S, Bäckman L. Prospective and retrospective memory in Alzheimer’s disease and vascular dementia: Similar patterns of impairment. J Neurol Sci. 2009;283(1):235–9.

    Article  PubMed  Google Scholar 

  30. Raskin SA. Memory for intentions screening test: Psychometric properties and clinical evidence. Brain Impair. 2009;10(01):23–33.

    Article  Google Scholar 

  31. Zhao Q, Guo Q, Hong Z. Clustering and switching during a semantic verbal fluency test contribute to differential diagnosis of cognitive impairment. Neurosci Bull. 2013;29(1):75–82.

    Article  PubMed  Google Scholar 

  32. Zhao Q, Guo Q, Li F, Zhou Y, Wang B, Hong Z. The Shape Trail Test: application of a new variant of the Trail making test. PLoS One. 2013;8(2):e57333.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Benton AL, Hamsher K, Varney N, Spreen O. Contributions to Neuropsychological Assessment: A Clinical Manual. New York: Oxford; 1983.

    Google Scholar 

  34. Green P. Green’s Word Memory Test for Microsoft Windows: User’s manual. Edmonton: Green’s Publishing; 2003.

    Google Scholar 

  35. Warrington EK, James M. The Visual Object and Space Perception Battery. Bury St Edmunds: Thames Valley Test Company; 1991.

    Google Scholar 

  36. Juva K, Sulkava R, Erkinjuntti T, Ylikoski R, Valvanne J, Tilvis R. Usefulness of the Clinical Dementia Rating scale in screening for dementia. Int Psychogeriatr. 1995;7(1):17–24.

    Article  CAS  PubMed  Google Scholar 

  37. Sheikh JA, Yesavage JA. Geriatric Depression Scale (GDS): recent findings and development of a shorter version. In: Brink TL, editor. Clinical Gerontology: A Guide to Assessment and Intervention. New York: Howarth Press; 1986.

    Google Scholar 

  38. Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12(6):371–9.

    Article  CAS  PubMed  Google Scholar 

  39. Harrison JK, Fearon P, Noel-Storr AH, McShane R, Stott DJ, Quinn TJ. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within a secondary care setting. Cochrane Database Syst Rev. 2015;3:CD010772.

    Google Scholar 

  40. Spreng RN, McKinnon MC, Mar RA, Levine B. The Toronto Empathy Questionnaire: scale development and initial validation of a factor-analytic solution to multiple empathy measures. J Pers Assess. 2009;91(1):62–71.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Cohen-Mansfield J. Instruction Manual for the Cohen-Mansfield Agitation Inventory (CMAI) . RockvilleJ: The Research Institute of the Hebrew Home of Greater Washington; 1991.

    Google Scholar 

  42. Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the Apathy Evaluation Scale. Psychiatry Res. 1991;38(2):143–62.

    Article  CAS  PubMed  Google Scholar 

  43. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–70.

    Article  CAS  PubMed  Google Scholar 

  44. Snaith RP, Zigmond AS. The hospital anxiety and depression scale manual. Windsor: NFER-Nelson. 1994;11:12.

    Google Scholar 

  45. Chan CY, Tsang HH, Lau CS, Chung HY. Prevalence of depressive and anxiety disorders and validation of the Hospital Anxiety and Depression Scale as a screening tool in axial spondyloarthritis patients. Int J Rheum Dis. 2014. doi:10.1111/1756-185X.12456.

  46. Wong VT, Yu DK. Usefulness of the Hospital Anxiety and Depression Scale for screening for psychiatric morbidity in Chinese patients with Graves’ ophthalmopathy. East Asian Arch Psychiatry. 2013;23(1):6–12.

    CAS  PubMed  Google Scholar 

  47. Chan YF, Leung DY, Fong DY, Leung CM, Lee AM. Psychometric evaluation of the Hospital Anxiety and Depression Scale in a large community sample of adolescents in Hong Kong. Qual Life Res. 2010;19(6):865–73.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52(2):69–77.

    Article  PubMed  Google Scholar 

  49. Gough K, Hudson P. Psychometric properties of the Hospital Anxiety and Depression Scale in family caregivers of palliative care patients. J Pain Symptom Manage. 2009;37(5):797–806.

    Article  PubMed  Google Scholar 

  50. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington: American Psychiatric Association; 1994. p. 143–7.

    Google Scholar 

  51. Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med. 2004;256(3):183–94.

    Article  CAS  PubMed  Google Scholar 

  52. Alonso Babarro A, Garrido Barral A, Díaz Ponce A, Casquero Ruiz R, Riera PM. Profile and burden of care in caregivers of patients with dementia included in the ALOIS program. Aten Primaria. 2004;33(2):61–6.

    Article  CAS  PubMed  Google Scholar 

  53. Hinton L, Haan M, Geller S, Mungas D. Neuropsychiatric symptoms in Latino elders with dementia or cognitive impairment without dementia and factors that modify their association with caregiver depression. Gerontologist. 2003;43(5):669–77.

    Article  PubMed  Google Scholar 

  54. Eagles JM, Craig A, Rawlinson F, Restall DB, Beattie JA, Besson JA. The psychological well-being of supporters of the demented elderly. Br J Psychiatry. 1987;150:293–8.

    Article  CAS  PubMed  Google Scholar 

  55. Donaldson C, Tarrier N, Burns A. The impact of the symptoms of dementia on caregivers. Br J Psychiatry. 1997;170:62–8.

    Article  CAS  PubMed  Google Scholar 

  56. Deimling GT, Bass DM. Symptoms of mental impairment among elderly adults and their effects on family caregivers. J Gerontol. 1986;41(6):778–84.

    Article  CAS  PubMed  Google Scholar 

  57. Machnicki G, Allegri RF, Dillon C, Serrano CM, Taragano FE. Cognitive, functional and behavioral factors associated with the burden of caring for geriatric patients with cognitive impairment or depression: evidence from a South American sample. Int J Geriatr Psychiatry. 2009;24(4):382–9.

    Article  PubMed  Google Scholar 

  58. Baumgarten M, Battista RN, Infante-Rivard C, Hanley JA, Becker R, Gauthier S. The psychological and physical health of family members caring for an elderly person with dementia. J Clin Epidemiol. 1992;45(1):61–70.

    Article  CAS  PubMed  Google Scholar 

  59. Gallagher-Thompson D, Brooks 3rd JO, Bliwise D, Leader J, Yesavage JA. The relations among caregiver stress, “sundowning” symptoms, and cognitive decline in Alzheimer’s disease. J Am Geriatr Soc. 1992;40(8):807–10.

    Article  CAS  PubMed  Google Scholar 

  60. O’Connor DW, Pollitt PA, Roth M, Brook CP, Reiss BB. Problems reported by relatives in a community study of dementia. Br J Psychiatry. 1990;156:835–41.

    Article  PubMed  Google Scholar 

  61. Brodaty H, Luscombe G. Psychological morbidity in caregivers is associated with depression in patients with dementia. Alzheimer Dis Assoc Disord. 1998;12(2):62–70.

    Article  CAS  PubMed  Google Scholar 

  62. Haley WE, Levine EG, Brown SL, Bartolucci AA. Stress, appraisal, coping, and social support as predictors of adaptational outcome among dementia caregivers. Psychol Aging. 1987;2(4):323–30.

    Article  CAS  PubMed  Google Scholar 

  63. Rinaldi P, Spazzafumo L, Mastriforti R, Mattioli P, Marvardi M, Polidori MC, et al. Predictors of high level of burden and distress in caregivers of demented patients: results of an Italian multicenter study. Int J Geriatr Psychiatry. 2005;20(2):168–74.

    Article  CAS  PubMed  Google Scholar 

  64. Cooper C, Katona C, Orrell M, Livingston G. Coping strategies and anxiety in caregivers of people with Alzheimer’s disease: the LASER-AD study. J Affect Disord. 2006;90(1):15–20.

    Article  PubMed  Google Scholar 

  65. Victoroff J, Mack WJ, Nielson KA. Psychiatric complications of dementia: impact on caregivers. Dement Geriatr Cogn Disord. 1998;9(1):50–5.

    Article  CAS  PubMed  Google Scholar 

  66. Chen NE, Chen Y, Huang F, Zhang HJ. Study on correlation between agitated behavior of patients with dementia in nursing home and stress of nursing staff. Chin Nurs Res. 2012;26(29):2773–5.

    Google Scholar 

  67. Mahoney R, Regan C, Katona C, Livingston G. Anxiety and depression in family caregivers of people with Alzheimer disease: the LASER-AD study. Am J Geriatr Psychiatry. 2005;13(9):795–801.

    Article  PubMed  Google Scholar 

  68. Garand L, Dew MA, Eazor LR, DeKosky ST, Reynolds CF. Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment. Int J Geriatr Psychiatry. 2005;20:512–22.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Lu YFY, Austrom MG, Perkins SM, Bakas T, Farlow MR, He F, et al. Depressed mood in informal caregivers of individuals with mild cognitive impairment. Am J Alzheimer Dis Other Demen. 2007;22:273–85.

    Article  Google Scholar 

  70. Blieszner R, Roberto KA. Care partner responses to the onset of mild cognitive impairment. Gerontologist. 2010;50:11–22.

    Article  PubMed  Google Scholar 

  71. Bruce JM, McQuiggan M, Williams V, Westervelt H, Tremont G. Burden among spousal and child caregivers of patients with mild cognitive impairment. Dement Geriatr Cogn Disord. 2008;25:385–90.

    Article  PubMed  Google Scholar 

  72. Garand L, Dew MA, Urda B, Lingler JH, Dekosky ST, Reynolds CF. Marital quality in the context of mild cognitive impairment. West J Nurs Res. 2007;29:976–92.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Hinton L, Haan M, Geller S, et al. Neuropsychiatric symptoms in Latino elders with dementia or cognitive impairment without dementia and factors that modify their association with caregiver depression. Gerontologist. 2003;43(5):669–77.

    Article  PubMed  Google Scholar 

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Acknowledgement

We would like to thank all care-recipients and their caregivers for their participation.

Funding

This project was funded by Natural Science Foundation of China (Project Number: 81171019) and Beijing Municipal Commission of Science and Technology (Project Number: Z141107002514177).

Availability of data and materials

We can share our relevant raw data supporting our findings. If any scientist wish to use them for non-commercial purposes, without breaching participant confidentiality, he/her can contact us directly, and we will share our raw data freely with he/her.

Authors’ contributions

JL participated in the design of the study and subject recruitment and the data collection, edited the manuscript and read and approved the final manuscript. XL participated in the design of the study and the data collection and data input and data analysis, drafted the manuscript, edited the manuscript and read and approved the final manuscript. QG conceived of the study, participated in the design of the study and subject recruitment and its coordination, collected the data, made a diagnosis for cognitive function, edited the manuscript, and read and approved the final manuscript. FL participated in the design of the study and the data collection and its coordination, made a diagnosis for cognitive function, edited the manuscript and read and approved the final manuscript. DD, ZH and QZ all participated in the design of the study and the data collection, made a diagnosis for cognitive function, edited the manuscript and read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Huashan Hospital, Fudan University, Shanghai, China. All participants and/or their legal guardian provided their written informed consent to participate in the study.

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Correspondence to Jianfeng Luo or Fang Li.

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Liang, X., Guo, Q., Luo, J. et al. Anxiety and depression symptoms among caregivers of care-recipients with subjective cognitive decline and cognitive impairment. BMC Neurol 16, 191 (2016). https://doi.org/10.1186/s12883-016-0712-2

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