DISCUSSION

This study was conducted to identify the mediating effect of care activity and burden and the moderating effect of social support and social activity in the relationship between dementia patient state and caregiver depression. Hypotheses were tested with structural equation modeling and the tested results were compared with the findings from the precedent studies as follows:

1. Considerations on Direct Effect

The precedent studies have reported about the relationship between dementia patient state and depression that care situations like dementia elderly’s Activities of Daily Living (ADL) and Problem Behavior (BPSD) and family caregiver’s coping style and social support had an impact on family caregiver depression (Ma and Kim, 1995; Kim, 2002) and that the higher the dependence in dementia elderly’s activities of daily living and the worse the problem behavior, the higher the family caregiver’s depression or stress (Brodaty and Luscombe 1998; Meshefedjian et al., 1998). As can be seen in Jang(2013) or Hong(2016) who reported a similar relationship between dementia patient state and depression, caregiver depression is influenced by dementia patient state. Such a relationship was also drawn from this study.

As reported in many precedent studies on the relationship between burden and depression in dementia patient caregivers (Ryu, 2017, Hong, 2017, Park, 2015), the variables that had the biggest impact on depression were subjective health condition, care period, occupation, self-efficacy, quality of marital relationship before caring, and care burden prior to social support (Park, 2015), and the correlation between dementia patient caregiver’s care burden and depression is high, but both cannot be said as the same concept, and there are different opinions about the directivity, and unlike the care burden that individuals feel because they care for the dementia patients, depression is regarded as a psychological construct that is influenced by care situations including care burden and other different states and care burden is seen as a predictor of depression (Ryu, 2017).

Also, considering Pearlin(1990) and Tennstedt et al.(1989) arguing that care burden had an impact on depression, the same results could also be found in this study.

As can be seen in studies (Kwon et al., 2002) that patient state causes care activity and studies (Song et al. 2013; Bae et al, 2006) that patient state had an impact on care burden, such care activity or burden is associated with the symptoms that dementia patients show. The Ministry of Health and Welfare(2009) reported that among dementia patient’s declined cognitive function, deteriorated activities of daily living, and problem behavior, patient’s problem behavior had the biggest impact on dementia caregiver’s burden, and restlessness and aggressive behavior which are shown in the group of behavioral and psychological symptoms aggravates the relationship with caregiver and the aggravated relationship in turn causes more severe behavioral problems from the patients who are

cared, which is a vicious cycle (Rachel et al., 2005). In fact, dementia patient’s unregulated behavioral and psychological symptom like aggression is the cause why nursing facilities refuse them to admit, which aggravates caregiver burden. Song et al.(2013) stated that dementia severity is judged as declined cognitive disorder, behavioral and psychological symptoms, and activities of daily living, and depending on dementia severity, main caregiver’s time to take care of patients increases and care burden also increases. Compared with the findings from such precedent studies, this study is in the same context with such studies.

Precedent studies present various causes of care burden that dementia patient caregivers feel, but among which, care activity is emphasized. Song et al.(2013) maintained that in case of dementia severity, its severity increases main caregiver’s time to take care of patient and increases care burden, too. Lee et al.(2008) claimed that if the effort and time to take care of dementia elderly increases due to dementia elderly’s problem behavior and dependence, caregivers feel considerable care burden in physical, psychological, and economic aspects. Multiple precedent studies on care burden stated that care period has an impact on care burden and especially mentioned the relationship between role constriction and care period, as one of the care burden factors that dementia elderly caregivers feel strongly. Due to role constriction that threatens the existing ordinary lives, caregiver loses his self-esteem, which leads to anger at the patient and the burden from role constriction aggravates as the time to take care increases and care period cannot be separated in understanding the care burden. The more the care period, the care burden increases, and if one should take care of a patient all day long, care burden is great, and care

burden lessens if sharing the burden rather than if taking care of a patient alone, which shows a close relationship between care period and care burden (Kwon et al. 2015). When compared with the findings from this study based on the reports from such precedent studies, the explanations about the relationship between dementia patient caregiver’s care activity and care burden are in the same context.

However, Park et al.(2005) claimed that as caregivers have to be with dementia elderly all day long, they are socially isolated and their physical health is aggravated and at the same time, care burden increases and depression gets worse. Compared with Kim(2000) or Bae et al.(2018) who reported that caregiver’s activity has an impact on depression, this study shows a different context in that insignificant results were drawn in this study.

2. Considerations on Mediating Effect

As a result of analyzing the mediating effect of care activity and care burden that this study presented as core research hypotheses based on different research findings presented in precedent studies, it was found that the mediating effect of care activity between patient state and depression was not significant, but care burden showed a significant mediating effect in the relationship between dementia patient state and caregiver depression and the relationship between care activity and depression, which showed differentiation from the precedent studies. The moderating effect of social support did not appear in all routes between patient state, care activity, care burden, and depression, but the moderating effect of social activity

appeared significant in the impact of patient state on caregiving activity and the impact of patient state on care burden. This study result shows differentiation from the precedent studies.

3. Considerations on Moderating Effect

That the moderating effect of social support did not appear in this study well represents the care characteristics of dementia patients characterized by chronic stress (Lee, 2003) and is different from the usefulness of social support that appeared in the high level of stressful situations (Clyburn, 2000), which is noteworthy. This means that Korean caregivers use emotional coping styles a lot than American or Canadian family caregivers in stressful situations, which is explained by many scholars (Lee and Kim, 2000; Lee et al., 2002).

The role of social support needs to be analyzed by classifying to subject’s short-term stressful situation and constant stressful situation.

Also in judging the social support by subjective perception part, more structured and detailed testing needs to be attempted by developing definite tools and setting various research subjects and variables. Also as argued by Kim(2001) that low voluntary motivation acts as a care burden determinant, regarding the part that in the moderating effect of social activity, care activity increases more and care burden increases less in the group of high social activity frequency than in the group of low social activity frequency, the relationship between support motive and care activity needs to be examined more specifically.

The policy direction for dementia population is to create an environment

where patients can get along with their families or normal people rather than isolating them into a facility (Hong, 2017), while calling for the changes from disease treatment-centered medical paradigm to care in human correlations paradigm (Kim, 2010). Such direction is in the same context with the policy directions for dementia, for it was verified in this study that caregiver’s social activity has a moderating effect in increasing the caregiving activity and lowering the care burden.

Social participation activity acts positively in forming a recognition that one thinks oneself as valuable for the society, which plays a role in reducing the negative result like depression.

Social relationship is above all important as it helps keep self-identity and maintain living patterns (Atchley, 1999). But social relationship is formed by social participation activity, which consequentially contributes to keeping self-identify and maintaining living patterns. Therefore social participation activity acts positively in maintaining internal and external permanence, which influences reducing depression (Hooyman & Kiyak, 2008).

Based on the analytical results above, we could draw the following suggestions.

First, to reduce the depression of dementia patient caregivers, the caregivers will have to be supported and attended constantly and positively to improve patient state although dementia is an irreversible disease, for such support and attention has a significant impact on patient state and caregiver burden.

Second, given that care activity and care burden play a mediating role in

the relationship between dementia patient state and caregiver depression, the strategic plans for reducing caregiver depression need to be found from care activity and care burden. In other words, to ensure that caregivers involve in care activity more easily and subsequently reduce the care burden, specific support plans including training and direct service provision by care activity needs to be established.

Third, given that social activity has a positive moderating effect in the relationship between dementia patient state and caregiver’s activity or burden and depression, it is necessary to find the strategic plans for reducing the caregiver depression from their social activities. In other words, the structural devices that are effective and available should be established so that caregivers can involve in social activity constantly and stably.

Despite such findings, this study has limitations in generalizing the findings in that it did not target various dementia patient caregivers and did not consider various variables that could predict or cause caregiver depression.

The limitations of this study are as follows:

First, this study has limitations in that as it is based on CREDOS data, it could not use social support and social activity suitable for the intention of this study properly. That is to say, social support, used in this study contained three dimensions: care, moral support, and instrumental support, and social activity contained two dimensions: period and frequency. But the concepts social support and social activity can be more comprehensive and

accordingly measurement methods and scales can also vary. Despite the necessity of accurate measurement tools that can be explanatory of dementia patient caregiver’s social support and social activity specifically, this study could not help but use the social support and social activity questions provided by CREDOS. Therefore, it is considered that further studies need to develop the measurement tools that can predict social support and social activity for dementia elderly caregivers exactly. To this end, Delphi method which is based on the survey of experts, item fit analysis, and factorial analysis and reliability survey that can ensure the validity will have to be used.

Second, as this study is based on the CREDOS data, our analysis of dementia patient caregiver’s social activity was conducted centering on non-economic activities like religious gathering, social gathering, leisure, culture, and sports-related group meeting, reunion, hometown alumni, clan gathering, volunteer work, party meeting, civic group meeting, and interest group meeting. But based on the existing studies that economic activity based on labor reduces depression, there is a need to analyze the economic activity as well as non-economic activity.

Third, this study did not examine the mechanism between social activity and depression sufficiently. The existing studies present that social participation activity has an impact on depression through self-esteem, ego resiliency, and social integration. It is hoped that meaningful results can be drawn by conducting further studies that can reflect such mechanism sufficiently.

B. Conclusion and Suggestions

The findings from this study appeared as follows. In other words, the variables that had a significant impact on caregiver depression were dementia patient state and care burden. To look at the specific analytical results of these, it appeared that patient state had a positive (+) impact on depression and care burden had a positive (+) impact on depression. That is to say, it can be known that if patient state becomes worse, the caregiver depression gets bigger, and the more the care burden, the higher the depression becomes. But the impact of care activity on depression appeared not significant. This suggested that caregiver depression is unrelated to how much or how little the care activity is. And the variables that had a significant impact on care burden were dementia patient state and care activity, and it could be known that if the patient state becomes worse, the more the care burden become, and the more the care activity, the higher the care burden becomes. Also the impact of patient state on care activity appeared significant and it could be found that if the patient state becomes worse, the more the care activity becomes.

As a result of verifying the problems in the role of care activity and care burden in the relationship between dementia patient state and depression, identified in this study, it appeared that the mediating effect of care activity between patient state and depression is not significant, the mediating effect of care burden between patient state and depression is significant, and the mediating effect of care burden between care activity and depression is also significant.

As a result of verifying the problems in the role of social support and social activity in the relationship between dementia patient state, care activity, care burden, and depression that this study aimed to identify, it appeared that the moderating effect of social support in all routes between patient state, care activity, care burden, and depression was not significant.

Therefore, it could be found that the relationship between dementia patient state, caregiver activity or burden, and depression was unrelated to social support. And in the impact of patient state on care activity, the moderating effect of social activity appeared. In other words, it can be known that the impact of patient state on care activity was greater in group of high social activity. And in the impact of patient state on care burden, the moderating effect of social activity appeared. From this, it could be known that the impact of patient state on care burden was greater in group of low social activity.

Taken together, the structural relationship among the variables that had an impact on the depression of caregivers who took care of dementia elderly could be found. Therefore, to reduce the depression of family caregivers who take care of dementia elderly based on the findings from this study, the efforts to reduce the care burden should be preceded, and to achieve this, systematic support plans for caregivers to participate in social activity need to be established. Especially if the social activity becomes more, the care activity also becomes more. Given this, social activity participation can improve the quality of care. So customized program development related to caregiver’s social activity is required.

Based on the findings from this study, we proposed the followings for

further research.

First, the subjects of this study were those who were registered in CREDOS. These caregivers should be further investigated for continuous observation of patient state, care activity, care burden, depression, etc. The data obtained from such investigation will have to be provided for multiple researchers to establish the foundation for conducting various researches.

Second, the mediating effect of care burden and the moderating effect of social activity on caregiver depression were revealed. So to reduce the depression, systematic intervention program needs to be researched, developed and applied. Also the studies to verify the effects of reducing the caregiver depression by applying the intervention program should be conducted.

Third, this study looked at the moderating effect of social support and social activity with structural equation modeling by using the data investigated in the CARE study. For more accurate studies, measurement tools need to be developed and replication study is suggested.

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