Background

Caregiver burden of people with dementia (PwD) has been studied extensively in recent years. The
Zarit Burden Interview (ZBI) is a 22-item instrument commonly used to measure caregiving burden
in caregivers of PwD. The ZBI was initially conceptualised as a unidimensional model. However,
subsequent work, notably by Whitlatch and colleagues (1) have found that the ZBI consist of at least
2 factors: role strain and personal strain. Role strain refers to stress due to role conflict and overload
while personal strain refers to how the experience is personally stressful. Following Whitlatch and
colleages (1) work, researchers turned up another factor known under different names: self-criticism
(2), guilt (3), feelings of inadequacy (4,5), worry about caregiving performance (6) (WaP). This factor
consistently consists of items 20 and 21 of the ZBI (Table 1). The factor is of particular of interest and
importance as it appears to lie on a continuum (Figure 1). On the milder end of WaP, it can be a
motivating factor to improve on the caregiving task but can be potentially stressful if it progresses to
guilt on the more severe end.
In our previous work (6,7), we replicated the role and personal strain factors as well as the WaP
factor using exploratory factor analysis (EFA) in our local population. Our factor solution identified
two instead of one role strain factor. We also found that caregiver age was as significant predictor for
WaP.
Study objective
In our current study, we aim to validate the results from our previous work using confirmatory
factor analysis. Specifically, we want to 1) determine if our EFA results were superior to the 2 factor
model proposed by Whitlatch et al. (1), 2) determine if separating role strain into 2 factors is better
than keeping it as 1 factor and 3) explore in depth the relationship of WaP with the various patient
and caregiver characteristics.
Methods
A cross sectional design prospective design was adopted. Patients and caregivers were recruited
from the Memory Clinic at Tan Tock Seng Hospital (TTSH) between January 2010 to December 2011.
Descriptive statistics were used to describe sample characteristics. Confirmatory factor analysis was
used to compare the following factor models: 1 factor model (initial conception of ZBI), 2 factor
model (1), 3 factor model (1 role strain factor)(6) and 4 factor model (2 role strain factors)(6). Linear
regressions were used to determine the relationships between factors of ZBI with patient and
caregiver characteristics.
Results
Sample characteristics (n = 466 dyads)
*Figures reported are mean (SD) unless stated otherwise.
Background
Caregiver burden of people with dementia (PwD) has been studied extensively in recent years. The
Zarit Burden Interview (ZBI) is a 22-item instrument commonly used to measure caregiving burden
in caregivers of PwD. The ZBI was initially conceptualised as a unidimensional model. However,
subsequent work, notably by Whitlatch and colleagues (1) have found that the ZBI consist of at least
2 factors: role strain and personal strain. Role strain refers to stress due to role conflict and overload
while personal strain refers to how the experience is personally stressful. Following Whitlatch and
colleages (1) work, researchers turned up another factor known under different names: self-criticism
(2), guilt (3), feelings of inadequacy (4,5), worry about caregiving performance (6) (WaP). This factor
consistently consists of items 20 and 21 of the ZBI (Table 1). The factor is of particular of interest and
importance as it appears to lie on a continuum (Figure 1). On the milder end of WaP, it can be a
motivating factor to improve on the caregiving task but can be potentially stressful if it progresses to
guilt on the more severe end.
In our previous work (6,7), we replicated the role and personal strain factors as well as the WaP
factor using exploratory factor analysis (EFA) in our local population. Our factor solution identified
two instead of one role strain factor. We also found that caregiver age was as significant predictor for
WaP.
Study objective
In our current study, we aim to validate the results from our previous work using confirmatory
factor analysis. Specifically, we want to 1) determine if our EFA results were superior to the 2 factor
model proposed by Whitlatch et al. (1), 2) determine if separating role strain into 2 factors is better
than keeping it as 1 factor and 3) explore in depth the relationship of WaP with the various patient
and caregiver characteristics.
Methods
A cross sectional design prospective design was adopted. Patients and caregivers were recruited
from the Memory Clinic at Tan Tock Seng Hospital (TTSH) between January 2010 to December 2011.
Descriptive statistics were used to describe sample characteristics. Confirmatory factor analysis was
used to compare the following factor models: 1 factor model (initial conception of ZBI), 2 factor
model (1), 3 factor model (1 role strain factor)(6) and 4 factor model (2 role strain factors)(6). Linear
regressions were used to determine the relationships between factors of ZBI with patient and
caregiver characteristics.
Results
Sample characteristics (n = 466 dyads)
*Figures reported are mean (SD) unless stated otherwise.
Worry about caregiving performance:
A confirmatory analysis
1
Health Services and Outcomes Research, National Healthcare Group,
2
Cognition and Memory Disorders Service, Department of
Geriatric Medicine, Tan Tock Seng Hospital, Singapore,
3
Institute of Geriatrics and Active Ageing, Tan Tock Seng Hospital
Ruijie Li,
1
Mei Sian Chong,
2,3
Peng Chew Mark Chan,
2,3
Bee Gek Laura Tay,
2,3

Noorhazlina Binte Ali,
2,3
Bte Tengku Mohd K. Shariffah Mahanum,
2
Wee Shiong Lim
2,3
Confirmatory factor analysis
Table 5 shows the results of the confirmatory factor analysis (CFA). While the fit indices do not meet
the criteria to be considered a good fit, the is a trend of improving fit with more factors model. Of
note is that NNFI which is suppose to penalise for model complexity is the largest for the most
complex model (4 factor model). The 4 factor model is thus considered to be the best fitting model,
providing evidence that the presence of WaP improves model fit and also splitting role strain into 2
factors also improves model fit.
Regression
The regression results are presented in Table 6. WaP shows a distinctly different pattern of
relationship from the other factors in IADL, NPI-Q severity and distress. This provides additional
evidence that WaP is a unique factor. There is also some significance in the relationships between
caregiver and care recipient. Plotting out the caregiving burden across CDR stages by the different
relationships on a facet plot (Figure 2), we can see that WaP has a distinct trajectory for the different
relationships between care recipient and caregiver. This again provides evidence that WaP is a
distinct, unique factor.
Summary
In summary, our study provided evidence that WaP is a valid factor within ZBI. We also have
preliminary evidence that WaP is driven by the caregiver care recipient relationship.
References
1. Whitlatch CJ, Zarit SH, von Eye A. Efficacy of interventions with caregivers: a reanalysis. The Gerontologist. 1991 Feb;31(1):914.
2. Knight BG, Fox L, Chou C-P. Factor Structure of the Burden Interview. J Clin Geropsychology. 2000;6(4):24958.
3. Ankri J, Andrieu S, Beaufils B, Grand A, Henrard JC. Beyond the global score of the Zarit Burden Interview: useful dimensions for clinicians. Int J
Geriatr Psychiatry. 2005 Mar 1;20(3):25460.
4. Ko K-T, Yip P-K, Liu S-I, Huang C-R. Chinese version of the Zarit caregiver Burden Interview: a validation study. Am J Geriatr Psychiatry Off J Am
Assoc Geriatr Psychiatry. 2008 Jun;16(6):5138.
5. Lai DWL. Validation of the Zarit Burden Interview for Chinese Canadian Caregivers. Soc Work Res. 2007 Jan 3;31(1):4553.
6. Cheah WK, Han HC, Chong MS, Anthony PV, Lim WS. Multidimensionality of the Zarit Burden Interview across the severity spectrum of cognitive
impairment: an Asian perspective. Int Psychogeriatr. 2012 Jul 3;24(11):184654.
7. Lim WS, Cheah WK, Ali N, Han HC, Anthony PV, Chan M, et al. Worry about performance: a unique dimension of caregiver burden. Int
Psychogeriatr IPA. 2014 Apr;26(4):67786.
8. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Model
Multidiscip J. 1999;6(1):155.
Confirmatory factor analysis
Table 5 shows the results of the confirmatory factor analysis (CFA). While the fit indices do not meet
the criteria to be considered a good fit, the is a trend of improving fit with more factors model. Of
note is that NNFI which is suppose to penalise for model complexity is the largest for the most
complex model (4 factor model). The 4 factor model is thus considered to be the best fitting model,
providing evidence that the presence of WaP improves model fit and also splitting role strain into 2
factors also improves model fit.
Regression
The regression results are presented in Table 6. WaP shows a distinctly different pattern of
relationship from the other factors in IADL, NPI-Q severity and distress. This provides additional
evidence that WaP is a unique factor. There is also some significance in the relationships between
caregiver and care recipient. Plotting out the caregiving burden across CDR stages by the different
relationships on a facet plot (Figure 2), we can see that WaP has a distinct trajectory for the different
relationships between care recipient and caregiver. This again provides evidence that WaP is a
distinct, unique factor.
Summary
In summary, our study provided evidence that WaP is a valid factor within ZBI. We also have
preliminary evidence that WaP is driven by the caregiver care recipient relationship.
References
1. Whitlatch CJ, Zarit SH, von Eye A. Efficacy of interventions with caregivers: a reanalysis. The Gerontologist. 1991 Feb;31(1):914.
2. Knight BG, Fox L, Chou C-P. Factor Structure of the Burden Interview. J Clin Geropsychology. 2000;6(4):24958.
3. Ankri J, Andrieu S, Beaufils B, Grand A, Henrard JC. Beyond the global score of the Zarit Burden Interview: useful dimensions for clinicians. Int J
Geriatr Psychiatry. 2005 Mar 1;20(3):25460.
4. Ko K-T, Yip P-K, Liu S-I, Huang C-R. Chinese version of the Zarit caregiver Burden Interview: a validation study. Am J Geriatr Psychiatry Off J Am
Assoc Geriatr Psychiatry. 2008 Jun;16(6):5138.
5. Lai DWL. Validation of the Zarit Burden Interview for Chinese Canadian Caregivers. Soc Work Res. 2007 Jan 3;31(1):4553.
6. Cheah WK, Han HC, Chong MS, Anthony PV, Lim WS. Multidimensionality of the Zarit Burden Interview across the severity spectrum of cognitive
impairment: an Asian perspective. Int Psychogeriatr. 2012 Jul 3;24(11):184654.
7. Lim WS, Cheah WK, Ali N, Han HC, Anthony PV, Chan M, et al. Worry about performance: a unique dimension of caregiver burden. Int
Psychogeriatr IPA. 2014 Apr;26(4):67786.
8. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Model
Multidiscip J. 1999;6(1):155.
YIA-HSR-02
Item
20.
21.
Do you feel you should be doing more for your relative?
Do you feel you could do a better job in caring for your relative?
Questions
Table 1.
Figure 1. Figure 1.
Mild Severe
worries, feelings of
inadequacy
self-criticisms,
feelings of guilt
Age in years 53.8 (13.5)
Caregiver
Table 3.*
Female gender, n (%)
Education level in years
Relationship with patient, n (%)
Spouse
Adult children
Sibling
Others
287 (61.6)
11 (4.5)
124 (26.6)
286 (61.4)
48 (10.3)
8 (1.7)
Living with care recipient, n (%) 351 (75.3)
ZBI score (range 0 88) 24.9 (17.4)
Age in years 76.4 (7.4)
Care recipient
Table 2.*
Female gender, n (%)
Education level in years
Ethnic group, n (%)
Chinese
Malay
Indian
Others
275 (59.0)
4.9 (4.7)
417 (89.5)
14 (3.0)
6 (1.3)
29 (6.2)
CMMSE (range 0 28) 16.6 (6.1)
BADL (range 0 100) 92.9 (36.4)
IADL (range 0 23) 12.2 (5.9)
Distress (range 0 60) 5.9 (7.3)
Severity (range 0 36) 5.6 (5.0)
NPI-Q
Disease characteristics
Dementia types, n (%)
Alzheimers dementia
Vascular dementia
Mixed dementia
Mild cognitive impairment
217 (46.6)
79 (17.0)
58 (12.4)
26 (5.6)
Others 86 (18.5)
Global CDR score, n (%)
CDR 0.5 (mild cognitive impairment) 58 (12.4)
60 (12.9)
127 (27.3)
206 (44.2)
15 (3.2)
CDR 0.5 (very mild dementia)
CDR 1.0 (mild dementia)
CDR 2.0 (moderate dementia)
CDR 3.0 (severe dementia)
Table 4.*
BADL = Basic Activities of Daily Living; CDR = Clinical Dementia
Rating; CMMSE = Chinese Mini Mental Status Examination; IADL =
Instrumental Activities of Daily Living; NPI-Q = Neuropsychiatric
Inventory Questionnaire
Relationship with care-recipient (Reference: Adult child)
*p<.05; **p<.01; ***p<.001
Table 6.
Regression
Role strain
(Demands),
Role strain
(Control),
Personal
strain,
Worry about
performance,
Spouse -.097 -.132* -.114* -.185**
Sibling .061 .093* .077 -.056
Others -.061 .093 .077 -.056
Male -.001 .027 .010 -.029
Caregiver education -.046 -.105 -.071 .002
Yes .030 .017 .021 -.073
Caregiver gender (Reference: Female)
Living with care-recipient (Reference: No)
BADL (0 100) -.054 -.040 -.041 .059
IADL (0 23) -.201*** -.160** -.177*** .003
NPI-Q severity (0 36) .018 .057 .033 .190*
NPI-Q distress (0 60) .391*** .345*** .389*** -.001
CMMSE (0 28) -.036 -.023 -.030 -.065
Adjusted R
2
.293*** .267*** .291*** .083***
Recommended
+
+ Recommendations from Hu and Bentler (8)
RMSEA = Root Mean Square Error of Approximation; SRMR = Standardized Root Mean Square Residual; NNFI
= Non-normed Fit Index; CFI = Comparative Fit Index; AIC = Akaike Information Criterion
Table 5.
1 factor
2 factors
3 factors
4 factors
<.060
.108
<.080
.071
>.950
.781
-
1425
.120
.094
.090
.075
.062
.061
.771 1100
.831 1154
.847 1069
Confirmatory factor analysis fit indices
RMSEA SRMR NNFI AIC df CFI
- -
1337 209
134 1026
1060 206
203 969
>.950
.802
.800
.850
.865
Figure 2.
(n= 286) (n= 8) (n= 124)
Correspondence:
Li Ruijie, ruijie_li@nhg.com.sg