Introduction: Despite a large literature on the stress process associated with caregiving for persons with dementia (PWDs), little attention has focused on how caregivers actually manage and provide care and how this may impact care outcomes. Criticism is one form of management caregivers may use to respond to the stresses of care by releasing frustration. It may also stem from the incorrect belief that the symptoms of dementia are within the control of the PWD. Stemming from work on family members of individuals with schizophrenia, a literature on expressed emotion (involving criticism, hostility, and emotional over-involvement) applied to caregivers for PWDs has shown that expressed emotion may have little effect on the course of dementia, but may have more to do with outcomes for caregivers themselves (Li & Murray, 2015; Tarrier et al., 2002; Vitaliano, Young, Russo, Romano, & Magana-Amato, 1993). Indeed prior research has found that constructs such as criticism, anger, and lower encouragement towards the PWD specifically have been associated with caregiver burden, a desire to institutionalize the PWD, and less experienced caregiving gains (Bakker et al., 2013; Davis et al., 2014; de Vugt et al., 2004; Hinrichsen & Niederehe, 1994; Hong, Luo, & Yap, 2013; Lim, Griva, Goh, Chionh, & Yap, 2011). Additionally, recent work found that caregivers, for PWDs, reporting high levels of distress utilized more acute care services such as emergency department visits (Maust et al., 2017). If criticism is a reflection of frustration related to care or a strategy utilized due to a lack of other adaptive management styles, it may follow that a caregiver would seek more services to assist in care provision. Ultimately, caregiver management styles, such as criticism, may be modifiable and through intervention prevent increased caregiver distress and unnecessary service utilization. In the current study, we consider criticism as a care management style that may be associated with a caregiver's mental health and service utilization.

Methods: Data are drawn from the baseline (pre-intervention) survey from the Advancing Caregiver Training (ACT) intervention study, a study designed to test a non-pharmacological approach for caregivers of PWDs to manage problem behaviors. The analytic sample included 256 informal caregivers living with an individual with diagnosed dementia or a Mini-Mental Status Examination score of less than 24, and who reported experiencing “upset” related to management of behavioral problems. Criticism was measured as a mean score on a four item subscale drawn from the Dementia Management Strategies Scale. In multiple linear regressions controlling for caregivers' demographics and PWDs' functional and cognitive impairment, we consider expressed criticism as a key predictor of caregiver burden, depressive symptoms, upset related to care recipient problem behaviors, desire to institutionalize the PWD, and level of frustration with care. Additionally, we considered criticism as a predictor of the number of services utilized in three categories: home-based, social, and health services.

Results: Caregivers on average were 66.6 years old, approximately 27% were African American, and half were caring for a spouse. On average, 10% of the sample used criticism as a management strategy “sometimes” or more frequently. Controlling for demographic characteristics and care recipient disability, greater use of criticism was associated with significantly more caregiver burden (β=.26, p<.001), upset over behavioral problems (β=.14, p<.05), and mean level of frustration with caregiving (β=.66, p<.001), but not depressive symptoms or a desire to institutionalize the care recipient. Criticism was also associated with significantly greater utilization of home-based (β=.14, p<.05) and social services (β=.15, p<.05), but not health care services.

Conclusions: Criticism appears to be a management strategy used by more burdened and frustrated caregivers providing care for PWDs, but does not appear to be associated with more objective measures such as caregiver depression and desire to institutionalize the care recipient. As analyses are not causal, it is unclear whether caregivers utilizing greater criticism may develop more burden, or whether burden leads to the use of criticism, and future work should consider this question. However, even accounting for the health and functional ability of the PWD, caregivers who displayed greater criticism were more likely to use social and home-based services, potentially reflecting a need for greater support among this group of caregivers. As criticism is not likely to have an adaptive impact on PWDs and is associated with negative outcomes for caregivers, behavioral interventions that can help burdened caregivers learn how to manage behavioral symptoms and other stressful aspects of care with positive, empirically validated strategies may be helpful.