Fam Proc 29:245-254, 1990 Predictors of Depression in Caregivers of Dementia Patients: Boundary Ambiguity and Mastery PAULINE BOSS, Ph.D. a WAYNE CARON, M.A. a JOAN HORBAL, B.A. a JAMES MORTIMER, Ph.D. b a Family Social Science, University of Minnesota, 290 McNeal Hall, 1985 Buford Avenue, St. Paul MN 55108. b Veterans Administration Hospital, Minneapolis, MN. as psychologically absent, the less masterful and the more depressed she or he is. This study examined the role of two perceptual variables in predicting the development of depressive symptoms in caregivers. The first, boundary ambiguity, refers to whether the dementia patient is perceived as psychologically in or out of the family system. The second, an orientation toward mastery, is related to how persons manage various stressful situations, including caring for a dementia patient. This study included 70 patients and their caregivers. Stepwise regression and path analytic techniques were used to compare the impact of variables related to the illness per se and of variables related to caregivers' perceptions of their situations. Results indicate that both perceptual variables, boundary ambiguity, and mastery, are significantly related to a caregiver's depression level whereas severity of the patient's dementia is not. In sum, the more a caregiver perceives a mate as psychologically absent, the less masterful and the more depressed she or he is. Alzheimer's disease is a serious health problem in this country. As our population ages, the proportion of people afflicted with dementia and the proportion of families affected continue to rise. In 1980, approximately 1.9 million people were affected. Estimates for 1988 raise this figure to almost 3 million (27). For patients and for their families, the disease has severe consequences for health and functioning. We now know that Alzheimer's disease causes serious disruption to the internal cognitive organization of the person affected. But what is becoming increasingly apparent is that this disease also causes serious distress to people who are close to the patient. It is now clear that clinical management of Alzheimer's disease involves attending to caregivers as well as to patients (8, 28). The negative effects of the disease extend beyond even the caregiver and affect the internal organization of the entire family system (20). Management of this disease, therefore, means addressing the needs of all victims: caregiver and family as well as the patient. Family research to date has focused on the burdensome nature of caregiving (16, 29). However, the hypotheses of a direct link between how severely disabled the patient is and how the caregiver experiences the burden has not found support. Researchers thus have turned to a search for the correlates of burden in caregivers (24, 29). It was also our objective to investigate what influences a caregiver's assessment of the burden. If not the severity of the dementia, then what does determine impaired coping in caregivers? Zarit and colleagues (28) reported that the number of family visits to the caregiver was the best predictor of level of burden. In a later study, Fitting and colleagues (13) found that women were more burdened by caregiving than were men, and that lack of visitors and the perception that the patient was critical of the caregiver were associated with high burden. By contrast, a caregiver's previous experience caring for older people was reported to be associated with lower burden scores. Poulshock and Deimling (24) questioned the use of the concept "burden" given that objective measures of dementia severity were unrelated to caregiver outcomes. They demonstrated that subjective interpretations by the caregivers of patient functioning were critical to caregivers' levels of discomfort. Deimling and Bass (11) amplified this point by showing that caregivers who attribute a patient's behavior to the illness were less distressed than caregivers who attribute it to willfulness. Gilleard, Boyde, and Watt (15) reported that a caregiver's perceptions of the patient as "emotionally demanding" and "dependent" were associated with high strain, while perceptions of the patient as "disturbed" or "disabled" were associated with low strain. In summary, studies of caregiver burden have emphasized the importance of caregiver perception of the patient, but little attention has been paid to the family-systems dynamics that might produce differences in perceptions and attributions. In this study, two variables, boundary ambiguity and mastery, were used to measure how caregivers organize the perceptions of their situations. ______________________________________________________________________________________________________________ 1