“I Just Glove up and Do What Has to Be Done”: A Mixed-Methods Exploration of Dementia Care Challenges and Care Management Strategies

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the manuscript “I just glove up and do what has to be done”: A mixed-methods exploration of dementia care challenges and care management strategies. This is an excellent manuscript which was a joy to read and which provides significant insight into dementia care management strategies.

Highlights

Highlights are exceptionally well-written and clearly state the relevance and importance of the study.

Introduction

Clear, relevant, and important context and rationale. I understand the focus of the study is on dementia challenges but I wonder whether there may be a little more balance in the introduction with some inclusion of positively managed challenges and perhaps inclusion of a strengths based lens where possible. Your results certainly show some strengths based approaches being used by family care partners.

You provide a strong rationale for the mixed-methods approach to the study.

2. Materials and methods

Clear and detailed account of the methods.

3. Results

These are comprehensive, and insightful. The quotes and examples are particularly illustrative.

4. Discussion

A thorough contextualisation of the results. I wonder at teasing out more some of the implications for future research of the creative, loving, and supportive strategies that were demonstrated.

Author Response

Thank you for the opportunity to review the manuscript “I just glove up and do what has to be done”: A mixed-methods exploration of dementia care challenges and care management strategies. This is an excellent manuscript which was a joy to read and which provides significant insight into dementia care management strategies. 

 

Highlights 

Highlights are exceptionally well-written and clearly state the relevance and importance of the study. 

 

Introduction 

Clear, relevant, and important context and rationale. I understand the focus of the study is on dementia challenges but I wonder whether there may be a little more balance in the introduction with some inclusion of positively managed challenges and perhaps inclusion of a strengths based lens where possible. Your results certainly show some strengths based approaches being used by family care partners. 

 

Response: We thank the reviewer for this valuable suggestion to include more balance regarding strength-based approaches. We agree this better reflects our results showing care partners utilizing adaptive strategies. We have revised the introduction (page 2-3, lines 79-83) to acknowledge strength-based caregiving approaches. We now note how care partners mobilize individual strengths and adopt adaptive strategies such as diversion, teamwork, affection, emotional support, encouragement, and environmental modifications. We include additional references to support this. This addition follows our discussion of punitive strategies, presenting the full spectrum of care management approaches while maintaining focus on our study's aim to identify which strategies care partners employ for specific dementia symptoms. We also note that positive aspects such as active management and encouragement are included in the measures (e.g., section 2.7).  

 

 

You provide a strong rationale for the mixed-methods approach to the study. 

 

2. Materials and methods

Clear and detailed account of the methods. 

 

3. Results

These are comprehensive, and insightful. The quotes and examples are particularly illustrative. 

 

4. Discussion

A thorough contextualisation of the results. I wonder at teasing out more some of the implications for future research of the creative, loving, and supportive strategies that were demonstrated 

 

Response: We thank the reviewer for this suggestion to highlight implications of the creative, loving, and supportive strategies demonstrated in our findings. In response, we have added a sentence to the conclusion paragraph (Section 5, page 13, lines 503-506 explicitly noting that the strength-based approaches identified may be fruitful to incorporate in future behavioral interventions. 

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript presents a rigorous and thoughtfully designed mixed-methods study examining dementia care challenges and caregiver management strategies. The research question is clearly articulated, the introduction provides a strong overview of the literature and well-defined research gaps, and the convergent parallel mixed-methods approach is well justified. The methods section is particularly clear and transparent, especially with respect to qualitative coding decisions and integration of qualitative and quantitative data. The use of qualitative excerpts in the Results (Sections 3.1–3.2) effectively illustrates the lived experience of caregiving and strengthens the interpretation of quantitative findings. Overall, this is a high-quality study that makes a valuable contribution to the dementia caregiving and public health literature.

There are three areas that you might strengthen this very strong paper:

1. Representation of Caregiving Complexity in the Results

In Section 2.4, the authors clearly describe that care partners often reported multiple care challenges, but that only challenges with a discrete cognitive or behavioral response were included in the full qualitative analysis. While this analytic decision is clearly explained and methodologically reasonable, it is less clear how this acknowledged complexity is reflected in the Results. The presentation of findings by discrete categories (ADLs, BPSD, agitation, cognitive decline) is clear and accessible; however, caregiving situations are frequently characterized by overlapping and interacting challenges. The authors may wish to more explicitly address how often multiple challenges co-occurred and to reflect in the Discussion on how focusing primarily on “primary” challenges may shape interpretation of caregiving as a dynamic and multifaceted process.

2. Interpretation of Management Strategies and Bidirectionality

The manuscript appropriately notes that the relationship between dementia symptoms and management strategies, particularly for BPSD, may be bidirectional (Section 4.1). This is an important point that could be further developed. Specifically, it would be helpful to clarify whether management strategies such as criticism, rigidity, or disengagement are being conceptualized as relatively stable caregiver tendencies or as situational responses to acute or cumulative stress. Greater clarity on this distinction would strengthen interpretation of the findings and improve alignment between the qualitative descriptions of caregiving episodes and the quantitative assessment of management strategies.

3. Consideration of Caregiver Cognitive and Emotional Load

The findings related to the use of criticism and less adaptive management strategies in response to BPSD are compelling. The discussion could be strengthened by more explicitly considering caregiver cognitive and emotional load as a contributing factor to these responses. I often think of Smagula et al, [1] in caregiving and then Brene Brown[2] in leadership on the impact of cognitive load and capacity to respond adaptively.  Care partners managing frequent agitation, sleep disruption, and emotional strain may experience reduced capacity to engage in flexible or adaptive management strategies. Framing some observed responses as occurring under conditions of high cognitive or emotional load, rather than solely as maladaptive strategies—may provide a more balanced interpretation of the findings and has implications for intervention development and public health practice.

Minor Comments

1. In several sections of the Results, it may be helpful to briefly remind the reader when qualitative findings are based on a subset of participants due to frequency thresholds, to aid interpretation.
2. The Discussion could benefit from a short summary sentence at the end of Sections 4.1 or 4.2 to reinforce the key take-home messages before transitioning to implications.
3. Minor editorial review for consistency in terminology (e.g., “care partner” vs. “caregiver”) may improve clarity, although overall writing quality is strong.

Concluding Comments

In summary, this is a well-executed and clearly written study that offers meaningful insights into dementia caregiving challenges and management strategies. The suggested revisions primarily relate to interpretation and framing rather than study design or analytic rigor. Addressing these points would further strengthen the manuscript by enhancing alignment between the complexity acknowledged in the methods and the interpretation of the findings, and by situating caregiver responses within the broader context of caregiving demands and stress. I commend the authors for this important contribution and believe the manuscript will be of strong interest to the readership of the International Journal of Environmental Research and Public Health.

 

 

1. Smagula, S.F.; Stahl, S.T.; Santini, T.; Banihashemi, L.; Hall, M.H.; Ibrahim, T.S.; Reynolds, C.F., 3rd; Krafty, R.T.; Aizenstein, H.J.; Zhan, L. White Matter Integrity Underlying Depressive Symptoms in Dementia Caregivers. Am J Geriatr Psychiatry 2020, 28, 578–582, doi:10.1016/j.jagp.2019.11.010.
2. Brown, B. Strong ground: The lessons of daring leadership, the tenacity of paradoz, and the wisdom of the human spirit. ; Random House New York 2025.

 

Author Response

This manuscript presents a rigorous and thoughtfully designed mixed-methods study examining dementia care challenges and caregiver management strategies. The research question is clearly articulated, the introduction provides a strong overview of the literature and well-defined research gaps, and the convergent parallel mixed-methods approach is well justified. The methods section is particularly clear and transparent, especially with respect to qualitative coding decisions and integration of qualitative and quantitative data. The use of qualitative excerpts in the Results (Sections 3.1–3.2) effectively illustrates the lived experience of caregiving and strengthens the interpretation of quantitative findings. Overall, this is a high-quality study that makes a valuable contribution to the dementia caregiving and public health literature. 

There are three areas that you might strengthen this very strong paper: 

 

1. Representation of Caregiving Complexity in the Results 

In Section 2.4, the authors clearly describe that care partners often reported multiple care challenges, but that only challenges with a discrete cognitive or behavioral response were included in the full qualitative analysis. While this analytic decision is clearly explained and methodologically reasonable, it is less clear how this acknowledged complexity is reflected in the Results. The presentation of findings by discrete categories (ADLs, BPSD, agitation, cognitive decline) is clear and accessible; however, caregiving situations are frequently characterized by overlapping and interacting challenges. The authors may wish to more explicitly address how often multiple challenges co-occurred and to reflect in the Discussion on how focusing primarily on “primary” challenges may shape interpretation of caregiving as a dynamic and multifaceted process. 

Response: We thank the reviewer for their comment. We added context about secondary and multifaceted challenges in the discussion section on page 12.  

 

 

1. Interpretation of Management Strategies and Bidirectionality 

The manuscript appropriately notes that the relationship between dementia symptoms and management strategies, particularly for BPSD, may be bidirectional (Section 4.1). This is an important point that could be further developed. Specifically, it would be helpful to clarify whether management strategies such as criticism, rigidity, or disengagement are being conceptualized as relatively stable caregiver tendencies or as situational responses to acute or cumulative stress. Greater clarity on this distinction would strengthen interpretation of the findings and improve alignment between the qualitative descriptions of caregiving episodes and the quantitative assessment of management strategies. 

Response: We have added clarification to the Discussion (page 11, lines 410-412) explicitly framing management strategies as situational responses to specific dementia symptoms at a single time point, rather than as stable caregiver traits. We also added a sentence to the limitations/future directions paragraph (section 4.1) noting that longitudinal research is needed to examine the stability of care management approaches over the caregiving trajectory. 

 

 

 

1. Consideration of Caregiver Cognitive and Emotional Load 

The findings related to the use of criticism and less adaptive management strategies in response to BPSD are compelling. The discussion could be strengthened by more explicitly considering caregiver cognitive and emotional load as a contributing factor to these responses. I often think of Smagula et al, [1] in caregiving and then Brene Brown[2] in leadership on the impact of cognitive load and capacity to respond adaptively.  Care partners managing frequent agitation, sleep disruption, and emotional strain may experience reduced capacity to engage in flexible or adaptive management strategies. Framing some observed responses as occurring under conditions of high cognitive or emotional load, rather than solely as maladaptive strategies—may provide a more balanced interpretation of the findings and has implications for intervention development and public health practice. 

 

Response: We thank the reviewer for this suggestion. In response, we have expanded the Discussion (page 12, lines 419-420) to explicitly address how caregiver burden and cognitive load may contribute to these responses. This framing positions less adaptive strategies as occurring under conditions of high stress and reduced capacity, rather than solely as maladaptive choices, with important implications for intervention development. We added a few references to support this.  

 

 

Minor Comments 

1. In several sections of the Results, it may be helpful to briefly remind the reader when qualitative findings are based on a subset of participants due to frequency thresholds, to aid interpretation. 

Response: We appreciate this point and have added clarification in multiple sections of the qualitative results (pages 7-9) to remind readers when findings are based on participant subsets.  

 

 

1. The Discussion could benefit from a short summary sentence at the end of Sections 4.1 or 4.2 to reinforce the key take-home messages before transitioning to implications. 

Response: We added a summary sentence to the end of Section 4.1. The conclusion (section 5) also restates main take home messages.  

 

1. Minor editorial review for consistency in terminology (e.g., “care partner” vs. “caregiver”) may improve clarity, although overall writing quality is strong. 

Response: We checked for care partner and caregiver language for consistency. We use the term caregiving consistently to describe the caregiving practice but we used the preferred "care partner" when describing the individual.   

 

Concluding Comments 

In summary, this is a well-executed and clearly written study that offers meaningful insights into dementia caregiving challenges and management strategies. The suggested revisions primarily relate to interpretation and framing rather than study design or analytic rigor. Addressing these points would further strengthen the manuscript by enhancing alignment between the complexity acknowledged in the methods and the interpretation of the findings, and by situating caregiver responses within the broader context of caregiving demands and stress. I commend the authors for this important contribution and believe the manuscript will be of strong interest to the readership of the International Journal of Environmental Research and Public Health. 

  

  

1. Smagula, S.F.; Stahl, S.T.; Santini, T.; Banihashemi, L.; Hall, M.H.; Ibrahim, T.S.; Reynolds, C.F., 3rd; Krafty, R.T.; Aizenstein, H.J.; Zhan, L. White Matter Integrity Underlying Depressive Symptoms in Dementia Caregivers. Am J Geriatr Psychiatry 2020, 28, 578–582, doi:10.1016/j.jagp.2019.11.010. 

1. Brown, B. Strong ground: The lessons of daring leadership, the tenacity