Activities of Daily Living in Dementia Differentially Contribute to Factors of Caregiver Burden

Abstract

Background: Performance of daily activities (Activities of Daily Living [ADLs] and Instrumental ADLs [IADLs]) is key to independent functioning in dementia, and greater I/ADL dependence contributes to burden in caregivers. We investigated how domains of daily living activities predict previously defined factors of the Zarit Burden Interview (ZBI). Methods: Caregiver and care recipient data for 389 dyads were extracted from outpatient memory clinic records. Results: Four previously defined factors of the ZBI (‘Impact on Life’, ‘Guilt/Uncertainty’, ‘Embarrassment/Frustration’, ‘Overwhelm’) were used in regression analyses, which demonstrated that ADLs predicted Impact on Life and Embarrassment/Frustration while IADLs predicted only Embarrassment/Frustration. Conclusions: Areas of decline in daily performance may differentially contribute to facets of dementia caregiver burden, with ADLs potentially having greater impact than IADLs.

1. Introduction

Understanding performance of daily activities is key to determining levels of independence for individuals with dementia [1,2]; moreover, dependence in daily function is closely associated with burden in dementia caregivers [3]. Activities of Daily Living (ADLs) refer to basic tasks that must be completed for individuals to live independently (e.g., dressing, bathing, toileting, transfers, and ambulation) [4]. Instrumental Activities of Daily Living (IADLs) comprise more advanced tasks that contribute to the ability of an individual to complete higher-level tasks (e.g., feeding independence, telephone use ability, medication management, shopping, cooking, cleaning, transportation, and financial independence) [4]. Such activities are used for a multitude of purposes, with one of the key uses being to provide a metric for clinicians to evaluate patients and their ability to safely reside alone. Such findings may determine eligibility for services; for this reason, function regarding these activities is commonly queried in the assessment of persons with a diagnosis on the dementia spectrum (henceforth referred to as “care recipients” and “dementia”, respectively) [5]. Importantly, the divide between basic and complex activities allows for an individualized treatment plan. Because gradual loss of ability is associated with dementia, and assessment of independence can lead to revocation of certain freedoms [6,7], it is essential to understand these activities and their relationship to other clinical factors.

As rising rates of dementia [8] require greater numbers of dementia caregivers, it becomes increasingly important to understand the caregiver experience. Caregivers provide care throughout the course of dementia, with advanced disease stages being linked to diminished daily functioning capabilities and higher care needs [9,10]. Greater need to provide assistance with daily living activities for a dementia care recipient is in turn associated with caregiver burden, or the strain experienced when caring for an ill person [3].

Many caregivers are considered “informal”, “family”, or “unpaid” caregivers, providing care without any training prior to taking on this responsibility [11]. A form of caregiver burden is present in up to 50% of these informal dementia caregivers [12], developing in part because the care recipient shows increased dependence in daily activities described above [13]. Increased burden from caregiving is associated with negative social and health outcomes for caregivers and care recipients [14,15]. Caregiving has been associated with slower wound healing and general caregiver health decline, posited to be due to psychological stress associated with caregiving and a lack of free time for self-care [16,17]. Additionally, caregivers may experience factors such as financial strain [15] and social changes [18]. Moreover, time spent caregiving prevents caregivers from engaging in activities that they previously enjoyed [18]. Greater social isolation in this context increases risk of depression, and nearly half of caregivers will experience a form of either depression, anxiety, or a general increase in distress [19]. Indeed, caregivers may experience a range of physical, social, and psychological problems, underscoring the importance of understanding burden’s various presentations and contributors to its development.

Supporting the wide-ranging experiences of caregiver burden, models of burden vary in composition of identified factors making up the burden experience. The Zarit Burden Interview is a common measure used to assess caregiver burden due to its strong psychometric properties [20,21]. Some early models suggest two primary factors—role stress and personal stress [22]—though subsequent work suggests a more complex factor structure (e.g., uncertainty, direct impact of caregiving, and embarrassment and frustration) [23]. One recent model based on this measure suggests four factors of burden: Impact on Life, Guilt/Uncertainty, Embarrassment/Frustration, and Overwhelm [24]. Impact on Life includes themes such as declining social life, lack of control, stress, and decreased personal needs met. The Guilt/Uncertainty factor primarily incorporates feelings of inadequacy as a caregiver and fear of the future. Embarrassment/Frustration involves feelings of anger, embarrassment, and discomfort from caregiving. Finally, Overwhelm includes themes such as expectations of care and care recipient dependence. The emergence of these four factors suggests that power to predict presence of caregiver burden as an outcome might be greater if various aspects of caregiver strain are independently considered.

Research identifying potential mechanisms to improve prediction and understanding of dementia caregiver burden is much needed. Although other studies [25] have evaluated burden in relation to Activities of Daily Living, to our knowledge, no prior work has examined the contribution of care recipient dependence in daily activities to development of specific domains of burden. The identification of themes of burden may help clinicians identify caregiver needs, allowing for individualization of care. Given the ramifications of burden, effective methods of assessment are important. Although additional assessment of varied personal factors (e.g., personality, social support, time spent caregiving) may be ideal for burden prediction, for many clinics, this is not feasible due to time constraints and financial limitations [26,27]. As a result, clinics may need to rely primarily on brief and cost-effective assessments of daily activities conducted as part of clinical data gathering.

The goal of the current study was to explore how a care recipient’s dependence in domains of daily living activities might predict different facets of caregiver burden (with confirmation of the four-factor structure of the Zarit Burden Interview). We predicted that dependence in ADLs would predict more factors of burden relative to dependence in IADLs.

2. Research Design

2.1. Participants

Data from 1305 patients were extracted from the registry of an outpatient memory clinic located in Northeast Ohio, for consecutively enrolled patients between April 2017 to February 2022. This clinic serves primarily community-dwelling older adults. Inclusion criteria included a clinically supported patient diagnosis on the dementia spectrum following a comprehensive geriatric evaluation and completed assessments from an informal (i.e., family member or friend) caregiver. Exclusion criteria included missing data on primary variables of independence in daily functioning and burden (n = 690 excluded for missing daily functioning information and n = 226 removed for missing burden information; a comparison of retained and removed cases is detailed below). The final sample included 389 patients. See

Table 1. Demographics and descriptive statistics.

Factor	Total Sample
	N = 389
Caregiver Age (M/SD, Range)	62.41/13.01, 70
Caregiver Sex
Female	66.8%
Male	33.2%
Caregiver Education ≥ 12 years	97.4%
Caregiver–Care recipient Relationship
Child	49.4%
Spouse	38%
Other Family Member	10.5%
Friend	1%
Other	1%
Care Recipient Age (M/SD, Range)	77.69/7.02, 36
Care Recipient Sex
Female	60.9%
Male	39.1%
Care Recipient Race or ethnicity
White/Caucasian	92%
Black/African American	6.2%
Asian	1%
Hispanic/Latinx	0.5%
Other	0.3%
Care Recipient Education ≥ 12 years	83.1%
Zarit Burden Interview (ZBI; M/SD, Range)	27.96/17, 85
Activities of Daily Living (ADL; M/SD, Range)	7.07/1.63, 10
Instrumental Activities of Daily Living (IADL; M/SD, Range)	14.14/3.81, 14

Note. M indicates mean. SD indicates standard deviation.

for demographic information. This research aligns with the RECORD (observational routinely collected health data statement) [28].

2.2. Primary Measures

Independence in Daily Functions. Caregivers of dementia patients completed a clinical interview with a social worker, reporting the level of independence the care recipient had in a diverse set of activities. Activities rated include dressing, bathing, toileting, transfers and ambulation, feeding, telephone use ability, medication management, shopping, cooking, cleaning, transportation, and financial independence. The activities described above were then rated based on functional levels of “independent”, “aided”, or “dependent” by the social worker. Independent was rated as a 1, aided as a 2, and dependent as a 3.

Caregiver Burden. Burden was assessed in the caregiver using the Zarit Burden Interview (ZBI) [21]. This tool is a 22-item measure with a response scale ranging from 0 to 4 (0 = never to 4 = nearly always), with a higher score indicating greater caregiver burden. Psychometric properties for the measure include Cronbach’s alpha between 0.82 and 0.92 and test–retest reliability ranging from 0.88 to 0.89 [20,21]. Factors aligning with recent work [24] were utilized: (1) Impact on Life, consisting of loss of control, social life having suffered, insufficient time for self, lack of privacy, personal health having suffered, desire to leave care to someone else, feeling unable to continue providing care, stress caring for loved one, and not enough money; (2) Guilt/Uncertainty, including: feel I should be doing more, feel I could do a better job, uncertain about what to do, and afraid of what the future holds; (3) Embarrassment/Frustration, including embarrassed over behaviors, anger, uncomfortable having friends over, and caring affects other relationships; and finally, (4) Overwhelm, consisting of care recipient asks for more help than needed, care recipient expects care, and care recipient is dependent.

2.3. Secondary Measure

Dementia Severity. To control for dementia severity, which is related to both caregiver burden and care recipient daily functioning [29], a proxy measure of dementia severity was incorporated. Care recipients were administered either the Montreal Cognitive Assessment (MoCA) [30] or Mini-Mental State Exam (MMSE) [31]. Both measures have previously been used to estimate dementia severity in older adults [32,33,34]. Using normative data based on education and age [35,36], standardized T-scores were calculated based on a normative sample using the formula [raw score − population mean)/population standard deviation] * 10 + 50, allowing for direct comparison. These standardized T-scores were used as a single variable of dementia severity.

2.4. Procedure

Kent State University and Summa Health System Institutional Review Boards reviewed and approved procedures utilized in this study. The protocol was originally approved as Level I (exempt) by the KSU IRB on 14 July 2019 (#19-242). Summa Health Systems designated the study “Non-Human Subjects Research” on 13 September 2019 after reviewing the protocol. By completing the caregiver portion of the intake interview, caregivers self-identified. Medical records including the above measures and demographic information were extracted as part of the outpatient memory clinic’s routine clinical registry, and de-identified data were analyzed.

2.5. Statistical Power

For confirmatory factor analysis, a sample size of 200 is recommended [37], so data meets the criteria for factor analysis. Based on previous associations between burden and independence in daily activities (rs = −0.52) [25], G*Power 3.1 analyses with α = 0.05 and power (1 − β) = 0.8 suggested a minimum sample size of 74. The current study was thus sufficiently powered to detect significant results, even if lower-than-expected effects are present.

2.6. Statistical Analyses

Retained cases were compared to removed cases by means of independent samples T tests (continuous variables) and χ² tests (ordinal and nominal variables) to identify any significant differences between the samples. Variables were evaluated for normality, homoscedasticity, and multicollinearity to ensure they met criteria for parametric analyses. Univariate normality was assessed with criteria of kurtosis < 7 and skewness < 3 with 95% confidence intervals [38]. Variables were further evaluated for goodness-of-fit measures, with Kaiser–Meyer–Olkin (KMO) test and Bartlett’s Test of Sphericity for independence in daily functioning, Tucker–Lewis Index (TLI), Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and chi-square for ZBI. An exploratory factor analysis was conducted in SPSS version 28 [39] to evaluate the correctness of previously established divisions in Activities of Daily Living prior to their use in other analyses (see Supplemental Materials). On the basis of prior work suggesting four factors of burden (Zarit Burden Interview; ZBI: ‘Impact on Life’, ‘Guilt/Uncertainty’, ‘Embarrassment/Frustration’, ‘Overwhelm’), confirmatory factor analysis was conducted on the 22-item ZBI [24] in R Studio (R version 4.2.2) [40]; in keeping with previous work, the item “Do you feel strained?” was removed due to equal factor loading [24] as was an overall subjective burden rating.

A hierarchical multiple regression was then conducted between daily function factors and factors of the ZBI, controlling, when possible, for demographics (due to differences between retained and removed cases) and dementia severity (correlated with primary variables). Caregiver/care recipient relationship and care recipient sex were dummy-coded, with caregiver/care recipient child–parent relationship and female care recipients used as reference groups. In the first step of the regression, dementia severity, demographic factors of caregiver age, caregiver/care recipient relationship, care recipient sex, and care recipient education were entered as control variables. Care recipient race and living situation could not be included due to insufficient group sizes. Caregiver sex and education, as well as care recipient age, were considered but ultimately not included in analyses due to non-significant correlations with primary variables. Total scores for each factor of independence in daily functions were included in the second step of the regression with total ZBI. Remaining analyses included the same control variables in the first step of the regression. The second step of the regression included the identified factors of independence in daily functions to explore their prediction of each individual ZBI factor.

3. Results

Regression Analyses

Significant differences were found in caregiver age (p < 0.001), caregiver sex (p < 0.001), care recipient education (p = 0.02), caregiver/care recipient relationship, and combined ADL and IADL score (p = 0.01). There were no significant group differences between removed and retained cases in dementia severity (p = 0.37). Caregiver race and care recipient living situation were not evaluated due to limited group size. Due to limited group size, for the purposes of this analysis, caregiver relationship was examined across three categories: spouse, child, and other. Although the initial chi-square test between retained and removed cases appeared significant (χ² (1, N = 1305) = 7.76, p < 0.05), upon application of the Bonferroni correction, significant differences between groups disappeared. Due to an overall lack of differences in these demographic and clinical variables, it was deemed unlikely that removal of these cases would bias results. Variables found to have significant group differences were controlled for in analyses in addition to variables with significant correlations with primary variables (care recipient education, caregiver sex, caregiver age, dementia severity, and caregiver/care recipient relationship). We did not include variables without significant correlations, as that could unnecessarily limit power. Given the findings from an exploratory factor analysis of Activities of Daily Living (see Supplemental Materials, Table S1), ADLs will refer to dressing, bathing, toileting, transfers, and ambulation; IADLs refer to shopping, meal preparation, finances, housework, medications, transportation, and telephone use. Based on RMSEA (0.09) and SRMR (0.06), the confirmatory factor analysis of the four-factor structure was deemed acceptable (see

Table 2. Factor loadings from the Zarit Burden Interview (ZBI) confirmatory factor analysis.

ZBI Item	Impact on Life	Guilt/Uncertainty	Embarrassment/Frustration	Overwhelm
Lost control of life	0.79
Social life has suffered	0.81
Note enough time for yourself	0.81
Lack of privacy	0.72
Personal health has suffered	0.80
Leave care to someone else	0.74
Unable to care	0.68
Stressed caring for loved one	0.77
Not enough money	0.51
Should be doing more		0.78
Could do a better job		0.76
Uncertain about what to do		0.70
Afraid of what the future holds		0.61
Embarrassed over behaviors			0.61
Angry			0.74
Uncomfortable having friends over			0.72
Affects other relationships			0.75
Asks for more help than needed				0.50
Expects care				0.83
Loved one is dependent				0.72

Note. The items addressing overall burden and the experience of strain were removed.

) and thus retained for further analyses. However, a CFI value of 0.88 and a TLI value of 0.86 were found; these values should ideally be above 0.90. Chi-square demonstrated that the model was not the ideal fit (χ² = 714.75, df = 164, p < 0.001); while potentially impacted by sample size, the sample is considered adequate based on chi-square divided by degrees of freedom (χ²/df = 4.35) [41]. In support of retaining the current model, factor correlations range from 0.39 to 0.73, and all are below 0.85, the recommended cutoff for assessing if factors are measuring the same construct [42]. Regression analyses (see

Table 3. Regression model of ADL/IADL on ZBI Total and ZBI factors.

Predictors	b	SE	β	p	95% CI
Control Variables
Caregiver/Care Recipient Relationship (Spouse)	−0.89	0.71	−0.14	0.21	−2.29 to 0.51
Caregiver/Care Recipient Relationship (Other)	−0.84	0.76	−0.09	0.27	−2.34 to 0.51
Care recipient Sex (Male)	−0.50	0.49	−0.08	0.30	−1.36 to 0.46
Caregiver Age	0.04	0.03	0.15	0.14	−0.01 to 0.09
Dementia Severity	−0.00	0.01	−0.03	0.71	−0.02 to 0.01
Care Recipient Education	0.04	0.08	0.03	0.67	−0.12 to 0.19
Introducing ADL/IADL Factors to ZBI Total
Caregiver/Care Recipient Relationship (Spouse)	−1.99	1.63	−0.21	0.23	−5.23 to 1.26
Caregiver/Care Recipient Relationship (Other)	−2.75	1.75	−0.19	0.12	−6.23 to 0.73
Care recipient Sex (Male)	−1.09	1.06	−0.11	0.31	−3.21 to 1.02
Caregiver Age	0.08	0.06	0.24	0.16	−0.03 to 0.19
Dementia Severity	−0.00	0.01	−0.03	0.80	−0.03 to 0.02
Care Recipient Education	−0.00	0.17	−0.00	0.99	−0.33 to 0.33
ADL	−0.40	0.63	−0.11	0.52	−1.65 to 0.85
IADL	0.94	0.52	0.30	0.07	−0.10 to 1
Introducing ADL/IADL Factors to ZBI Impact on Life
Caregiver/Care Recipient Relationship (Spouse)	−0.51	0.19	−0.31	0.01 **	−0.88 to −0.14
Caregiver/Care Recipient Relationship (Other)	0.14	0.22	0.05	0.53	−0.30 to 0.57
Care recipient Sex (Male)	−0.04	0.13	−0.02	0.78	−0.29 to 0.22
Caregiver Age	0.01	0.01	0.15	0.16	0.00 to 0.02
Dementia Severity	−8.98 × 10−5	0.00	−0.00	0.96	0.00 to 0.00
Care Recipient Education	0.00	0.02	0.01	0.85	−0.04 to 0.04
ADL	0.45	0.08	0.64	<0.001 **	0.29 to 0.61
IADL	−0.04	0.07	0.06	0.60	−0.17 to 0.10
Introducing ADL/IADL Factors to ZBI Guilt/Uncertainty
Caregiver/Care Recipient Relationship (Spouse)	−0.49	0.32	−0.23	0.12	−1.13 to 0.14
Caregiver/Care Recipient Relationship (Other)	0.31	0.38	0.09	0.42	−0.45 to 1.07
Care Recipient Sex (Male)	0.18	0.22	0.08	0.41	−0.25 to 0.62
Caregiver Age	0.00	0.01	0.05	0.72	−0.02 to 0.03
Dementia Severity	−0.00	0.00	−0.06	0.54	−0.01 to 0.00
Care Recipient Education	−0.01	0.03	−0.04	0.72	−0.08 to 0.05
ADL	0.13	0.14	0.14	0.35	−0.14 to 0.39
IADL	0.16	0.11	0.21	0.16	−0.06 to 0.38
Introducing ADL/IADL Factors to ZBI Embarrassment/Frustration
Caregiver/Care Recipient Relationship (Spouse)	−0.34	0.29	−0.18	0.25	−0.93 to 0.24
Caregiver/Care Recipient Relationship (Other)	−0.18	0.34	−0.06	0.60	−0.86 to 0.50
Care Recipient Sex (Male)	−0.19	0.20	−0.11	0.32	−0.58 to 0.19
Caregiver Age	0.01	0.01	0.11	0.50	−0.01 to 0.03
Dementia Severity	−0.01	0.00	−0.23	0.03	−0.01 to 0.00
Care Recipient Education	−0.02	0.03	−0.08	0.46	−0.08 to 0.04
ADL	−0.29	0.12	−0.39	0.02 *	−0.53 to −0.06
IADL	0.25	00.10	0.40	0.01 *	0.05 to 0.45
Introducing ADL/IADL Factors to ZBI Overwhelm
Caregiver/Care Recipient Relationship (Spouse)	−0.10	0.31	−0.05	0.76	−0.72 to 0.53
Caregiver/Care Recipient Relationship (Other)	−0.03	0.36	−0.01	0.94	−0.74 to 0.68
Care Recipient Sex (Male)	−0.08	0.21	−0.04	0.71	−0.50 to 0.34
Caregiver Age	0.03	0.01	0.38	0.02 *	0.01 to 0.05
Dementia Severity	−0.00	0.00	−0.15	0.14	−0.01 to 0.00
Care Recipient Education	0.03	0.03	0.10	0.36	−0.03 to 0.09
ADL	0.05	0.12	0.06	0.80	−0.20 to 0.30
IADL	−0.03	0.10	−0.04	0.67	−0.23 to 0.18

Note. ZBI, Zarit Burden Interview; ADL, Activities of Daily Living; IADL, Instrumental Activities of Daily Living. Relationship was dummy-coded with child–parent relationship excluded. Sex was dummy-coded with female excluded. * p < 0.05; ** p < 0.01.

) demonstrated that ADLs predicted Impact on Life (β = 0.64, p ≤ 0.001; overall adjusted R² = 0.125) and Embarrassment/Frustration (β = −0.39, p = 0.02; overall adjusted R² = 0.051) while IADLs predicted Embarrassment/Frustration (β = 0.40, p = 0.01). Neither IADLs (β = 0.30, p = 0.07; overall adjusted R² = 0.085) nor ADLs (β = −0.11, p = 0.52) predicted total ZBI, Guilt/Uncertainty (IADLs β = 0.21, p = 0.16; ADLs β = 0.14, p = 0.35; overall adjusted R² = 0.039), or Overwhelm (IADLs β = −0.04, p = 0.67; ADLs β = 0.06, p = 0.80; overall adjusted R² = 0.118).

4. Conclusions

The present study explored how daily function in a dementia care recipient relates to different facets of burden in the informal caregiver, first examining the factor structure of the ZBI. Marginal fit was noted for the factor analysis, but internal reliability analyses suggest the scale is robust. Regression analyses showed that ADLs predicted Impact on Life and Embarrassment/Frustration, while I/ADLs predicted only Embarrassment/Frustration.

Findings suggested that specific areas of decline in daily performance may contribute differentially to domains of dementia caregiver burden, with ADLs predicting two aspects of burden (Impact on Life, Embarrassment/Frustration) versus IADLs predicting a single aspect of burden (Embarrassment/Frustration). Findings support what one might intuit—that burden is greater in caregivers with a care recipient who requires care for the most basic activities; however, because dementia severity was controlled for in analyses, severity of dementia alone does not account for these findings. Results might instead indicate that care recipients with higher dependency have a greater number of unmet needs [43] which in turn influences the caregiver’s life. More basic activities typically require near-constant attention from caregivers [44], and in a three-year longitudinal study [45], lower functional ability in the care recipient was associated with higher burden in the caregiver. Conversely, complex activities may only require occasional assistance and can often be arranged at a caregiver’s convenience (e.g., financial assistance, grocery delivery) compared to basic needs, which may require immediate attention (e.g., toileting, ambulation). Furthermore, given that IADLs comprise more complex activities, these caregivers could be newer to caregiving; early symptom presentations (particularly in public) could create greater embarrassment or frustration due to lower preparation for management of such symptoms. Interestingly, performance of daily activities predicted neither Guilt/Uncertainty nor Overwhelm, suggesting that Activities of Daily Living may serve as an efficacious predictor of some facets of burden, but that other factors should continue to be investigated to further improve prediction. A possible explanation for the lack of burden prediction in the two factors is that variables not accounted for, such as psychoeducation or self-efficacy, may protect against feelings of guilt and overwhelm. Psychoeducation has been associated with decreased feelings of burden, potentially preventing overwhelm [46,47]. Additionally, individual factors (e.g., self-efficacy) may allow caregivers to view providing assistance as a challenge rather than a straining event, further shielding them from overwhelm and guilt [48].

Several strengths are present in the current study. To our knowledge, no prior research has investigated the relationship between domains of daily living activities and those of burden. These findings help advance understanding of the complexity of burden and the heterogeneity of effects on the caregiver. This work may be of benefit to clinical understanding of the ways in which daily functioning of a dementia care recipient impacts the caregiver, highlighting primary areas of concern. Understanding these relationships could contribute to pre-emptive identification of at-risk caregivers, in turn avoiding costs associated with burden-related health issues [49]. Additionally, the accessibility of the measures utilized here lends to their usability in diverse clinical settings of wide-ranging socioeconomic status, making it an ideal early step in burden assessment. Because the current work was based upon routinely collected measures in a community-based memory clinic, the topics examined here represent factors that can be easily accessed by the clinician, readily identified, and simultaneously cost-effective.

Despite the strengths of the current research, limitations must be acknowledged. The sample utilized here was predominantly white and may not accurately represent effects of Activities of Daily Living on more diverse populations. Furthermore, this was a highly educated sample; education may impact the preparedness of caregivers for management of dementia-related symptoms. Another consideration is the possibility of bias in ADL and IADL assessment. In our sample, ADLs and IADLs are assessed by a social worker, though we acknowledge that this is performed on the basis of caregiver report. Although there is the possibility of bias in the caregiver reports, information about ADLs is generally collected in this manner in a clinic setting; thus, our data represent what naturally occurs in the environment of an outpatient memory clinic. Additionally, the nature of this retroactive record review study precludes determination of whether I/ADL deficits are related to dementia or another underlying medical concern (e.g., stroke). Such limitations should be used to inform next steps in this research.

In future work, due to the known benefits of psychoeducation [46,47] (or education surrounding the onset and progression of dementia), its effects should be investigated in conjunction with specific coping skills and support systems. Lower psychoeducation and support, for example, may result in broader burden, impacting necessary interventions. Individual difference factors (e.g., self-efficacy) should also be evaluated as they may account for differences in the caregiver experience across studies. Future research should also explore the influence of important demographic factors, such as race and living situation, as the current sample did not show adequate distributions to examine these variables. Furthermore, the efficacy of caregiver assessments in predicting other forms of caregiver distress should be considered as their addition may allow for a more comprehensive assessment [50] beyond initial burden identification. Finally, due to the impact of ADLs and IADLs on caregiver burden [3], as well as the natural decline in I/ADLs during dementia [3] suggesting a typical pattern of increased caregiver burden over time, a longitudinal study should be considered, as profiles of daily functioning and burden may shift throughout disease progression.

In conclusion, the present study suggests that basic and complex daily living activities may impact facets of burden differently. Findings contribute to the understanding of the impact of care recipient dependence on caregivers and provide accessible guidance for clinicians to aid in early burden detection.