Dementia caregiving is stressful for many reasons. Caregivers are watching the inevitable decline of a loved one, often their significant other. They are often elderly themselves and face their own declining health. Family caregivers shoulder the intense burden of daily care activities, ranging from taking over the care recipient’s finances to feeding and toileting. The constantly increasing level of care required over the course of a progressive illness like Alzheimer’s disease deprives caregivers of time for their own activities and opportunities for social support, and can even compromise their jobs and their abil-ity to meet obligations to other family members. Yet many caregivers also feel there are positive aspects of caregiving that tremendously benefit their lives⁷.

The ‘stress process’ model has guided our understanding of care-giving for almost 20 years⁹. This model describes how caregivers use resources (both internal and external) to respond to the demands of their caregiving situation and other life circumstances (e.g. job, spouse, children). This process takes place within a sociocultural con-text. Perceived stress is a function of the extent to which demands exceed resources and the requisite coping skills to manage these demands are no longer adequate to the tasks at hand.

One must also take into account such ‘individual difference’ variables as age, gender, ethnicity, relationship and socioeconomic status, which interact with objective stressors and resources and play important roles in determining which caregivers develop physical and/or emotional problems in response to their situations. For example, spousal caregivers are particularly susceptible to depression and stress¹⁰. Being female and being married to the care recipient tend to be related to lower levels of both physical health and psychological well-being¹¹. A caregiver’s age is also significant: younger caregivers and non-spouses are more likely to experience role strain, which is usually magnified by lack of resources and perceived intensity of caregiving-related stressors¹¹.

Cultural diversity is another important dimension that adds heuris-tic value to the stress process model. Many studies find that cultural differences affect multiple aspects of caregiving. Racial/ethnic groups vary greatly in how they perceive objective and subjective stressors, the knowledge they have and the use they make of resources, and the kinds of coping skills they prefer to employ to help them manage their situations^11–14 .ⁱ For example, Caucasian/white caregivers are

ⁱThere is great divergence in empirical findings on cultural differences, and to date there have been only a small number of studies on Asian-American and Hispanic caregivers. In order to give equal balance to each ethnic group and resolve hetero-geneous or conflicting results, we rely here on available meta-analyses and reviews rather than individual studies. Note also that the terms ‘Asian-American’ and ‘His-panic’ refer to very heterogeneous groups in terms of language, cultural heritage and socioeconomic status. These terms are used in this chapter because they are current designations used in the US Census; however, for clinical purposes, information about specific sub-groups is needed to work effectively – rather than relying on broad gen-eralizations that may or may not be accurate or apply to the individual caregiver in your office.

more likely to be married to the care recipient and report higher lev-els of caregiver stress, burden and depression than African-American caregivers¹⁴. They tend to use more formal support, such as attending support groups and receiving help from professionals, than non-white caregivers. However, Caucasian/white caregivers also tend to report lower levels of confidence and mastery and less positive appraisal of caregiving compared to ethnic minority caregivers^11,13,14.

African-American caregivers often report more role strain, such as more cognitive and physical impairment of the care recipient and a higher number of caregiving tasks, than white caregivers¹¹.Their use of religious coping and their sharing of caregiving responsibili-ties with extended family and non-family members seem to buffer the impact of objective stressors. They express lower subjective burden, higher levels of mastery and greater satisfaction, and fewer depres-sive symptoms than white or Asian caregivers^12,13.

Asian-American and Hispanic/Latino caregivers may have lan-guage limitations, strong beliefs in filial obligation and low levels of both acculturation and health literacy. Combined, these factors make caregiving more stressful. Such caregivers are often reluctant to admit their distress openly, relying instead on more indirect means of expression. For example, Chinese-American caregivers tend to present with a high level of somatic complaints; Mexican-American caregivers often present with depression and guilt¹³. Those who have limited knowledge of English for both reading and writing also have less accurate information about dementia and less access to the health-care system in general and use fewer formal support services than do their Caucasian/white counterparts¹¹.

While cultural beliefs and practices, such as strong family ties and religiosity, can buffer and protect caregivers from negative health outcomes of caregiving, other cultural premises such as filial obli-gation, the priority of family needs over individual needs, and face saving carry special hazards. Many ethnic minority caregivers regard it as shameful or a ‘loss of face’ to admit caregiving-related distress. They are likely to under-report care recipients’ behavioural and other problems, and to be reluctant to use formal services for elderly family members. Asian-Americans and Hispanics, in particular, may have low levels of acculturation, language barriers, and inadequate health literacy, which may lead to cultural isolation and inability to access services that are currently available in the US health-care system.

Current psychiatric practice emphasizes assessment and treatment of the patient with dementia¹⁵. We recommend a dyadic focus in which caregivers are also assessed and treated. Dementia family caregivers (across all racial and ethnic groups studied to date) are at risk of poor physical health and increased mortality, depression, anxiety, anger, frustration and feelings of grief and loss. A clinician should first assess a caregiver for serious difficulty in one or more areas; any diagnosable psychiatric disorders should be treated promptly with either pharmacotherapy or psychotherapy.

Existing guidelines suggest a variety of approaches for assess-ing the psychosocial and psychiatric status of the dementia family caregiver¹⁵. We suggest reviewing the Family Caregiver Alliance’s recommendations on domains to assess^16,17. An easily downloaded ‘kit’ of these resources, including actual measures and the ‘Care-givers Count Too!’ toolkit for practitioners¹⁸, is available free from its website. These provide materials needed to follow up problem areas with detailed assessment and begin directing caregivers towards treatment.

Key Domains to Assess