Alzheimer's disease is known as a family disease. Because the persistent anguish of seeing a loved one progressively deteriorate affects everyone, successful therapy will take into account the demands of the entire family. Caregivers are sometimes overlooked, disregarded, dismissed as inconsequential, or seen as an afterthought. The importance of caregiving cannot be overstated. Primary caregivers are just as vital as physicians and nursing personnel in the treatment of Alzheimer's geriatric patients (11). The successful treatment and rehabilitation of sick patients, particularly in cases of Alzheimer’s disease, depends largely on caregivers who bear the burden of day-to-day care of their loved ones. Therefore, this study aims to determine the effect of a psychological first aid program on stress levels and psychological well-being among caregivers of older adults with Alzheimer's disease.
The present study showed that the majority 83% of the caregivers were female, daughters 73%, living with their patients in the same house 67%, and they are looking after their Alzheimer's patients for more than 2 years, and there is someone else helping them in caring 6%. That was justified as in the Arab Muslim society; there are religious and spiritual beliefs that are connected to their family beliefs of honoring, respecting, and taking care of their parents. These beliefs endorse the meaning of familism and the motivation to become a caregiver. As well, according to the Egyptian culture, most of the families are extended families and everyone must look after each other. These results were consistent with studies done by Cody et al., 2021 who reported that the majority of informal caregivers were female and lived in the same household as their patients (11). Another study done on caregivers for Alzheimer's patients reported that the prevalent caregivers of the patients were wives or daughters who care for the patient at home (54). The present result also is consistent with that of the study done by Cody et al., 2021 who study the burdens of the caregivers of Alzheimer’s patients and reported that most caregivers had been providing care for 3–5 years, followed by 6 + years (11).
The present study found that almost half of the caregivers were not working, and more than one-third of them did not have enough income. In addition, about half of the studied caregivers of Alzheimer's patients take from 12 to 24 hours of caregiving daily. This can be explained by the fact that the burden of performing various tasks, such as feeding, protecting their patients, mobility, personal hygiene, giving medications affects all aspects of the caregiver’s life, and took most of the caregiver's time. That was consistent with a study done by Aguglia et al., 2004 who pointed out that the caregivers of Alzheimer's geriatric patients were obliged to decrease the working hours to look after their relatives (1). In the present study, about two-thirds of the studied caregivers have university or postgraduate education. That was consistent with the result of the study done by Cody et al., 2021 who found that the majority of years of caregiver formal education were college and postgraduate education (11). In addition Zahed, et al., 2020 who study 99 Alzheimer caregivers, and found that about one-third of them were highly educated and females (53).
The present study showed that more than half of the studied caregivers suffering from chronic illness and taking some types of medications. A study was done by Tulek et al., 2020 on caregiver burden, quality of life, and related factors in family caregivers of dementia patients in Turkey found that about 60% of the studied caregivers suffer from chronic illness (49). Also, another study was done by Mendez et al., (2021) reported that about 47% of the caregivers of patients with dementia suffer from hypertension and about 20% have diabetes mellitus (34).
Regarding the caregivers’ knowledge about Alzheimer’s disease, the present study showed that before the application of the study program, the level of knowledge about Alzheimer's was as low as the mean score was 13.02. The key explanation of this result is that most of the caregivers were unable to get adequate and reliable information because they simply did not know what to ask for, and whom to ask. That was also justified by a qualitative question asked by the authors in the present study about the caregivers' needs, most of them reported, “we need to know everything about Alzheimer's disease and how we can look after our relatives”. This finding is in the same line with that of a study done by Vara-García et al., (2021) who reported a lack of knowledge and information about Alzheimer's disease between caregivers and there is a need to increase their knowledge related to the identification of dementia symptoms and the progression of the disease through psycho-educational sessions for family caregivers (50).
After the application of the study program, there is a remarkable increase in the mean score of knowledge level about Alzheimer's from 13.02 to 27.43 with a highly statistically significant with a large effect size of 1.107. This could be attributed to the fact that the psychological first aid program was prepared based on the caregivers' needs and interests, so they complied with the program sessions. These results go with those of a study done by Tomar et al., 2019 who used dementia first aid program for the family caregivers of patients with Alzheimer's disease in Iran, and found a significant increase in the level of knowledge after the application of the program and that improvement was sustained for 6 months (48).
The level of stress experienced by the studied caregivers in the present study was moderate before applying PFA as the mean score of stress level was 27.5. The increase in the stress level among the studied caregiver can be justified by, the majority of them being female, married, and having their own family to look after them. The majority of them suffered from chronic diseases that need treatment. In addition, a long duration of caregiving during the day with little support may be a factor. Financial constraints may also affect. In addition, the majority of Alzheimer’s patients were more dependent on their caregivers in mobility and daily activities. They also suffered from chronic medical diseases and took medications with a long duration of diagnosed AD. All of these stressors and responsibilities make the term “sandwich generation” true for those caregivers (53). The result of perceived stress among caregivers of patients with Alzheimer’s was in the same line with that of a study done by Zahed et al., 2020 who reported that most of the caregivers suffer from a moderate level of stress, and the mean score was significantly higher in the female caregivers (53). Another study done by Anand et al., 2016 revealed that perceived stress among caregivers of patients suffering from Alzheimer's disease was three times increasing than stress among caregivers of patients with chronic diseases(55).
After the application of the psychological first aid program in the present study, a remarkable significant decrement in the mean score of the studied caregivers’ perceived stress was observed with a mean difference of 8.5 and an extremely large effect size of 3.12. The remarkable decrement in the stress level among the studied caregivers can be explained by, as the mean focus of the PFA program is to provide emotional and practical support to the caregivers at the time of stress-related caregiving. This is done by establishing a connection with oneself and other people surrounding with a compassionate nonjudgmental way to bring calm, comfort to self, feeling not alone, helping, assuring, and advising each other with exchanging their experience, and subsequently decreasing stress. In addition, the authors in the present study use stress-reduction techniques during and in-between session programs like; relaxation techniques, deep breathing exercises, imagination, and sublimating hold destructive feelings by using physical exercises.
The efficacy of the intervention was approved by a study done by Savundranayagam et al., 2011 uses a psycho-educational program called “powerful tools of caregivers” to decrease stress burden among spouses with disabled patients. They pointed out that the caregiver spouse who participated in the program reported a significantly lower stress burden than those who don’t participate (44). Another study was done by Martín-Carrasco et al., 2009 by using a psycho-educational intervention program to decrease the burden among caregivers of patients with Alzheimer's. They pointed out that the program successfully decreased the caregivers' stress not only for a short period but also for 6 months after the program was implemented (31). A cohort study was done by Lethin et al., 2017 found that caregiver stress burden, quality of life; neuropsychiatric symptoms in patients with dementia are associated with decreased caregivers’ psychological well-being. Eventually, all those factors mentioned in the previous study were included in the sessions of the present psychological first aid program (28).
Concerning the effect of the psychological first aid program on psychological wellbeing among caregivers of patients with Alzheimer's disease, the present study showed that there is a remarkable highly significant increase in the psychological wellbeing among caregivers after the application of the PFA program with a mean difference of 4.75 and large effect size 1.32. A study by Frias, Risco, & Zabalegui, 2020 contradicted the present study and found that applying psycho-educational intervention on the burden and emotional well-being among informal caregivers of people with dementia can lead to a slight insignificant improvement in the psychological wellbeing among them, because of low perceived social support (21).
Finally, most of the studies used to compare and discuss the present study results show the same efficiency of intervention in reducing stress, improving knowledge and psychological wellbeing among caregivers of Alzheimer's patients. Although, the differences in the methodological and interventional program names, the major concepts and skills were similar too close as they focus on enhancing knowledge competence about Alzheimer's disease and management of its progression and improving self-care besides other care.