Caring For Someone With Dementia

What Family Caregivers Need To Know About

Caring For Someone With Dementia

Dementia is a general term used to describe a group of symptoms affecting cognitive functions such as memory, thinking, and reasoning. It is not a specific disease itself but rather a syndrome caused by various underlying conditions or diseases. Dementia is characterized by a decline in cognitive abilities that is severe enough to interfere with a person's daily life and activities.

The most common cause of dementia is Alzheimer's disease, accounting for about 60-80% of cases. Other causes include vascular dementia, which occurs due to impaired blood flow to the brain, and Lewy body dementia, which is associated with abnormal protein deposits in the brain.

The symptoms of dementia can vary depending on the cause and stage of the disease, but they often include memory loss, difficulty with language and communication, impaired judgment, confusion, personality changes, and problems with performing familiar tasks. As the condition progresses, individuals with dementia may experience difficulties with self-care, mobility, and coordination.

Dementia is typically a progressive condition, meaning it worsens over time. However, the rate of progression can vary among individuals. Currently, there is no known cure for most types of dementia, but certain medications and interventions may help manage symptoms and slow down the progression of the disease. Supportive care, including creating a safe and supportive environment, providing emotional support, and assisting with daily activities, is crucial in improving the quality of life for individuals with dementia and their caregivers.

 There Are Many Types of Dementia

• Alzheimer’s Disease

• Vascular Dementia

• Lewy Body Dementia

• Parkinson’s Disease

• Krosakoff Syndrome

• Huntington’s Disease

• Frontotemporal Dementia

There are many challenges when caring for someone with dementia. Here are some tips to overcome these challenges.

 Communication

When communicating with someone who has dementia, it's important to remember that their cognitive abilities may be impaired, making it necessary to adjust your approach. Here are some tips to effectively communicate with someone who has dementia:

1. Maintain a calm and reassuring demeanor: Approach the person with a friendly and calm attitude. Speak in a gentle tone and use a relaxed body language. Your non-verbal cues can help create a positive and comfortable environment.

2. Use simple and concise language: Keep your sentences short and simple. Avoid using complex or ambiguous words that may confuse the person. Speak slowly and clearly, allowing them enough time to process what you're saying.

3. Be patient and allow extra time: People with dementia may take longer to understand and respond to conversations. Give them ample time to process the information and express themselves. Avoid rushing or interrupting them. Patience is key to effective communication.

4. Ask one question at a time: Present questions or information in a clear and straightforward manner. Asking multiple questions at once can overwhelm and confuse the person. Give them time to respond before moving on to the next topic.

5. Use visual aids and gestures: Visual aids, such as photographs or simple drawings, can help enhance understanding and memory. Pointing or using gestures can also assist in conveying your message. Visual cues often complement verbal communication effectively.

6. Maintain eye contact and show interest: Establishing eye contact helps to engage the person and shows that you are interested in what they have to say. Be attentive, actively listen, and respond with empathy. This can help build trust and create a positive connection.

7. Avoid correcting or arguing: It's common for people with dementia to have memory lapses or difficulties with reality. Correcting or arguing with them can lead to frustration and agitation. Instead, focus on the emotions behind their words and respond with empathy and understanding.

8. Use positive body language: Your body language should be warm, open, and inviting. Smile, nod, and use gentle touches if appropriate, as these can help convey a sense of comfort and reassurance.

9. Limit distractions: Choose a quiet and comfortable environment for your conversation, free from excessive noise or distractions. Minimize background distractions such as television or loud music, as they can interfere with communication.

10. Be flexible and adapt: Communication needs may vary from person to person, so be prepared to adapt your approach based on the individual's preferences and abilities. What works for one person with dementia may not work for another, so remain flexible and patient.

Remember, effective communication with someone with dementia requires understanding, empathy, and patience. By using these tips, you can help create a positive and meaningful connection with the person you're communicating with.

 Aggression

When dealing with aggression in a person with dementia, it's important to remember that their behavior is not intentional but rather a manifestation of the underlying condition. Here are some steps you can take to manage the situation:

1. Stay calm: It's crucial to remain calm and composed. Agitation can escalate if you respond with anger or frustration.

2. Ensure safety: Make sure that you and the person with dementia are safe. If necessary, remove any objects that may cause harm or create a potentially dangerous environment.

3. Identify triggers: Try to identify the factors that may be triggering the aggression. It could be pain, discomfort, fear, frustration, or an unmet need. Understanding the triggers can help you address the root cause of the aggression.

4. Redirect attention: Gently redirect the person's attention to something positive or engaging. This could involve changing the subject, introducing a favorite activity, or providing a sensory stimulus like calming music or a familiar object.

5. Validate emotions: Acknowledge the person's feelings without arguing or contradicting them. Use empathetic statements like, "I can see that you're upset. I'm here to help you."

6. Maintain structure and routine: A structured environment with consistent routines can help reduce confusion and anxiety, which may contribute to aggression. Stick to a regular schedule for meals, activities, and rest.

7. Modify the environment: Create a calm and soothing environment by minimizing noise, clutter, and excessive stimulation. Soft lighting, familiar objects, and comfortable seating can help create a more peaceful atmosphere.

8. Seek professional help: If aggression becomes a persistent problem or if you feel overwhelmed, it's important to seek guidance from healthcare professionals who specialize in dementia care. They can provide personalized strategies and may suggest medication if necessary.

Remember, each person with dementia is unique, so it may take some trial and error to find the most effective approaches to manage their aggression. Patience, empathy, and understanding are key to providing the best care possible.

 Confusion

If a person with dementia becomes confused, there are several strategies you can employ to help them:

1. Stay calm: It's important to remain calm and composed when interacting with someone who is confused. Your calm demeanor can help reduce their anxiety and agitation.

2. Reassure and comfort: Speak in a gentle and reassuring tone. Let the person know that they are safe and that you are there to help them. Use simple and clear language to convey your message.

3. Maintain a familiar environment: Keep the surroundings as familiar and predictable as possible. Avoid sudden changes or introducing unfamiliar objects or people that might add to their confusion.

4. Provide orientation cues: Remind the person of their location, time, and other relevant information. Use visual cues, such as calendars or clocks, to help them orient themselves.

5. Offer simple choices: Present limited and clear options when appropriate. For instance, if they are having trouble deciding what to wear, you can show them two outfits to choose from rather than overwhelming them with too many choices.

6. Break tasks into smaller steps: If the person is struggling with a task, break it down into smaller, manageable steps. Guide them through each step patiently and provide assistance when needed.

7. Use visual aids: Visual aids, such as written instructions or labeled objects, can be helpful in providing cues and reminders. For instance, you can place a sign on the bathroom door to indicate its location.

8. Maintain a routine: Establishing and sticking to a consistent daily routine can provide a sense of structure and familiarity, which may help reduce confusion and anxiety.

9. Involve familiar people: Encourage the involvement of family members, close friends, or caregivers who the person with dementia knows well. Familiar faces and voices can help provide comfort and reassurance.

10. Consult a healthcare professional: If confusion becomes a persistent or worsening issue, it's advisable to consult a healthcare professional specializing in dementia or geriatric care. They can provide a proper diagnosis, offer guidance, and suggest appropriate interventions.

Remember, each person with dementia is unique, so it's important to observe and understand their individual needs and preferences. By providing a supportive and understanding environment, you can help manage their confusion and improve their overall well-being.

 Agitation

When a person with dementia becomes agitated, it's important to respond calmly and try to identify and address the underlying cause of their distress. Here are some steps you can take to help manage agitation in someone with dementia:

1. Stay calm: It's important to remain calm yourself, as your demeanor can influence the person's emotional state. Speak in a soothing and reassuring tone.

2. Create a safe environment: Ensure that the immediate surroundings are safe and free from any potential hazards. Reduce noise and other stimuli that might be causing agitation, such as loud music or excessive activity.

3. Validate their feelings: Acknowledge the person's feelings and empathize with their frustration or anxiety, even if you don't fully understand the cause. Let them know you are there to help and support them.

4. Identify triggers: Try to identify any potential triggers for the agitation. It could be physical discomfort, hunger, thirst, fatigue, noise, or unfamiliar surroundings. Understanding the trigger can help you address the root cause.

5. Maintain a routine: People with dementia often benefit from having a regular routine. Familiarity and predictability can help reduce agitation. Stick to a consistent schedule for daily activities, meals, and rest.

6. Offer reassurance: Provide reassurance and comfort to the person with dementia. Use gentle touch, if appropriate, to convey care and support. Reassure them that they are safe and that you are there to help.

7. Redirect their attention: If the person is fixated on a particular topic or is upset about something, try to redirect their attention to a different activity or subject. Engage them in a calming activity they enjoy or reminisce about positive memories.

8. Use calming techniques: Techniques such as deep breathing exercises, gentle music, aromatherapy, or a comforting object can help promote relaxation. Experiment with different approaches to see what works best for the individual.

9. Consult a healthcare professional: If agitation becomes a persistent or escalating issue, it may be beneficial to seek guidance from a healthcare professional who specializes in dementia care. They can provide additional strategies and, if necessary, evaluate the person's medication regimen.

Remember, each person with dementia is unique, and what works for one individual may not work for another. It's important to be patient and understanding while trying different approaches to manage agitation

Snowflakes of Memories: A Caregiver's Tale

As I look out the windows of the sliders, the December wind escorts snowflakes that are falling onto autumn leaves. Layers of sparkling flakes hide Mother Nature's paintbrush strokes that turned greens into a kaleidoscope of brilliant hues. Another chapter in my Book of Life as a Caregiver has begun. 

This is the second December I am a Caregiver for a beloved elder in my position with Abundant Blessings. This is my 18th month of watching the sun rise over the lake at dawn, and enjoying the sunset's pink glow in the evening. I believe conversation is a healthy stimulant for not only her, but myself.  She enjoys when I reach into my childhood memories to share bits and pieces of my life. These tales may give her a better understanding of why I am the person I am today - or at least I like to think so. Lately, it's natural to focus on Christmas - "it's the most beautiful time of the year" - so the song sung by Andy Williams says.  I realize, however, that I am giving myself a gift, bringing what is hidden in my heart to the forefront.  While verbalizing about how Christmas was celebrated, I become the twelve year old who is now allowed to stay up "to help Santa trim the tree on Christmas Eve". That was the year my father whispered in my ear, "When the other kids are asleep, quietly come back downstairs". An hour after the eight of us had each opened the present that mysteriously had appeared under the undecorated tree, (a pair of new pjs to wear Christmas morning) and climbed the stairs to our bedrooms, I tiptoed down the stairs to see my father putting lights on the tree. Boxes of ornaments were on the couch and my stepmother was busy wrapping gifts on the dining room table. That was when I knew who Santa really was. Naïve? Maybe, but gloriously so! And oh how my heart is singing when I think about these times.

That magical night, my father placed the old foil Santa Claus face on top of the tree.  It had been the same Santa that graced his childhood tree. My main job was to put the tinsel on each branch -- one piece at a time. Now, this wasn't tinsel that was new and shiny, but hefty pieces of shimmering foil that had been wrapped around pieces of cardboard and used year after year. Dad was like the "tinsel police" - watching that I did the hanging just right and admonishing me if I didn't. After what seemed like hours, my tinsel job was finished. I then helped my stepmother wrap gifts, mostly in green or red tissue paper, with Christmas stickers holding the pieces together. In a family of ten, scotch tape was a rare commodity, only to be used very sparingly. Those little stickers of candy canes, elves or angels barely held up through the night to Christmas morning. 

On Christmas morning, my father would turn the tree lights on and have "the kids" come down the stairs in age order - youngest to oldest (me). I still see the joy on the faces of my sisters and brothers as they saw the now decorated Christmas tree and the orderly stacks of presents underneath. My Dad was there taking pictures with the old video camera. We'd sit on the floor and my stepmom would hand us each a present to open.  I remember all of this to be orderly and not the harried ripping of paper that one generally sees nowadays. We didn't have many gifts, but what we were given made us smile.  Money was always tight in our household. Both parents worked on the B&M Railroad in the neighboring town, and my father also held other jobs at the same time - Police Chief, Fire Chief, snowplower in the town trucks. I well remember the trees he would cut "way up north" and haul back for us to sell at my uncle's hardware store or in our side yard. My siblings and I gathered Princess Pine from the woods and made wreaths to sell. We shoveled walks and driveways till our feet and fingers seemed frozen. That was how we earned our Christmas money. 

As I share my childhood memories with this wonderful lady I am Caregiver for, she, in turn, talks about her childhood Christmases.  Her eyes light up, she laughs, and long forgotten names and places come out of that hiding deep in her mind. I listen with my ears, but it is my heart that is catching each memory she is reliving. There is no sadness, no tears of days long lost. There is only the gifts of sharing and caring. Laughter fills the air. Unlocking wonderful memories is like opening up the door of the past with the key of love. And so the night ends, and we watch the falling snow blanketing the lake. We both smile, lost in the peace of our yesterdays.

As we celebrate this wonderful time of year be sure to share your own Christmas memories and reminisce with those you love. What are some of your favorite Christmas memories?

Eight Reasons To Choose Homecare

by Vicki Salemi

As tough as it may be to enlist the help of a "stranger" when it comes to caring for your parents, sometimes it's for the best. For one thing, it will take the strain off of you, but your parent will also benefit from professional care in the comforts of home. Whether it's being attentive to special medical needs of assisting with personal care or homemaking, having a home health care professional will provide a variety of benefits to both the patient and the family. 

1 - Home care promotes healing.

"I know that our clients enjoy a much better quality of life which many families have said helped to extend the lives of their lived ones.," says Peter Ross, CEO and co-founder of Senior Helpers. "We focused on healing the mind, not just the body." Maxine Hochhauser, CEO of Visiting Nurse Regional Health Care System adds that in many circumstances the person rehabilitates better in the home. "They are in a familiar environment and are more comfortable. This is particularly true with individuals suffering from dementias." 

2 - Home care is safe.

"Many risks such as infection are eliminated or minimized when care is given at home," says Ross. Quality home care by professional caregivers can help prevent issues that may become very serious within the home. One example includes preventing falls in the home since seniors may be too weak or dizzy from medication since they fall when they're cleaning or bathing. 

3 - Home care allows for maximum amount of freedom for the individual.

Patients at home may be engaged with their typical daily activities as their health permits plus it allows patients to receive care in the least restrictive environment. "This is the most conducive to patient-centered care which allows individuals the most control over the care they'll receive and the manner in which they receive it," notes Hochhauser. "Plus, it allows individuals to remain in the community." 

4 - Home care gives them some control.

As baby boomers age the home care option gives them more control over the type of care they'll get to choose. Hochhauser explains, "They want more choices and want to be a more active participant in their own care. Home care allows them the most say in their care as they are in the least passive situation." 

5 - Home care is personalized.

According to Milca Pabon, RN, a home health care nurse with Adventist Home Health, "the best reason to choose home care is because the care that will be received in the home will be individualized to each patient according to their specific needs." Essentially home care is tailored to the needs of each patient as they receive one-on-one attention. 

6 - It eases burdens on the family.

Pabon explains, "With the length of stay in the hospital decreasing patients are going home earlier and many of them do not choose to go to a rehabilitation center to recover," explains Pabon. Rather, they want to go home to their own environment with their loved ones and have someone provide them with care they'll need to reach their maximum level of function. She continues, "Families are willing to have their loved ones with them, but may feel inadequate or unable to provide their loved ones with the help that they might need." 

7 - Home care is comfortable.

"Every study done has shown that people would prefer to stay in their home," says Constance Row, executive director of the American Academy of Home Care Physicians. There is familiarity and comfort of being in one's own environment surrounded by their loved ones. She notes, "It's a type of quality care that people would want for their senior relatives."

Source: http://www.seniorsforliving.com/content/article/eight-reasons-to-choose-home-care/18/

Questions to Ask When Hiring Homecare Services

Providing care for a loved one can be stressful. Hiring homecare services should help relieve stress, not add to it. We made the following list to help make hiring a homecare service easier. 

Things to consider:

1.  Reputation:  Ask around. Ask your hospital discharge planner about any agency you are considering.  Rehabs or Nursing homes will usually provide you a list of agencies to consider. Senior centers and government services such as Service Link in New Hampshire are also great place to get information. Ask specifically about more than one agency for comparison purposes. 

2. Check out their website: The agency’s website should be thorough, informative and professional.

3. Ask to have a free in-home assessment. Any reputable agency should be willing and able to provide an assessment of your loved one’s needs. This meeting should be one that is not only for admission purposes, but also to answer the family’s questions or concerns. The homecare representative should be willing and able to answer and help guide the family toward the options they have, without pressure. They should be willing to be a resource for you whether you use their services or not. 

Questions to ask an agency:

1. Is your agency licensed by the state?

The states of Maine and New Hampshire require homecare agencies to be state licensed. New Hampshire also requires a state license for independent caregivers. If your family is considering hiring privately for care for your loved one please read our article on this topic "Use Caution When Hiring Independent Caregivers".

2. Will you take care of all required payroll paperwork for my loved one’s caregiver? Are your caregivers all employed by the agency?

The states of Maine and New Hampshire consider you an employer if you independently hire someone to work in your home. There is a large amount of paperwork involved in being an employer. This paperwork covers such matters as taxes, Social Security, workers compensation, disability, and liability insurance. One benefit of hiring an agency is that the agency normally does this for you. Even so, it is good to ask, as some agencies do use independent contractors as caregivers.

3. What kind of training do you provide for your caregivers?

To expect experienced and trained caregivers to work in homecare should be the minimum. However, it is important to ask if the hiring agency is training the caregiver themselves in addition to any formal training or schooling which the caregiver has had. What do they require for continuing education? Abundant Blessings Homecare’s new hire training and continuing education exceeds the state requirements in every area. Our RN is continuously adding and improving our training. We believe providing the very best training and continuing education will assure that our caregivers are the very best caregivers!

4. Do you conduct drug testing on your caregivers?

The states of Maine and New Hampshire do not require drug testing for home healthcare workers. Many homes in which home healthcare services are provided contain controlled substances, therefore we believe drug testing should be a vital part of the hiring process for any home care agency.

5. What kind of background check do you conduct on your caregivers?

Having peace of mind that your loved ones are in good hands is vital when hiring homecare services. The state of NH requires that homecare agencies in New Hampshire conduct only a State of New Hampshire criminal background check, not a Federal background check. They also do not require a motor vehicle driving record check. At Abundant Blessings Homecare we believe that State, Federal and Motor vehicle record checks are all essential when hiring homecare for a loved one. We run all three checks on all our caregivers. These additional checks are an added expense during the hiring process but we feel they are essential for peace of mind for your family. It is possible for someone to have a criminal record in another state which would show up on a Federal check and yet their New Hampshire background check would return "clear". We also believe motor vehicle background checks are imperative because often times home healthcare workers provide transportation for their clients.

6. Are your employees insured and bonded? 

The state of New Hampshire requires insurance of homecare agencies, but not bonding. However, insurance does not cover theft; bonding does. Also, not all liability insurance is the same. You could ask the agency for a copy of their policy or ask what their liability insurance covers. 

7. If at any time my loved one needs more hours of care (eg: 24 hour a day), or if a caregiver should call in sick, do you have the staff for coverage? 

Any agency you hire should have enough staff to cover these situations should they arise.

8. What is your policy regarding sending a caregiver to my loved one’s home whom my loved one has never met?  

It is not safe for an elderly person to be answering the door to total strangers. An agency should have a policy in place regarding the meeting of new caregivers. Abundant Blessings Homecare never sends new caregivers to a home blindly; we always conduct a “meet and greet”.

9. What kind of supervision do you provide? 

Once a caregiver is placed in the home of your loved one, ongoing supervision of that caregiver needs to be provided. How often can you expect a Care Manager/Supervisor to be available? Your family is assigned a Care Manager who you will get to know and trust as your go to person. At Abundant Blessings Homecare our phone number is always answered 24/7 by a real person and if your Care Manager is off when you call, you will be connected with whomever is providing coverage. In addition, we conduct drop in visits just to see how things are going on a regular basis. 

10. What kind of service agreement is required? What are your minimum number of hours?

All agencies have different policies. Find out what is required to be sure it will work for the needs of your loved one.

11. What is your method for tracking a caregiver’s arrival and departure from a clients home?

The agency should have a system in place for this that works for you and your family.

12. What are your hours of operation, and how are phone calls handled during odd hours? 

Abundant Blessings Homecare is available by phone 24/7, and is always answered by a real person!

13. Do you provide a written plan of care which clearly describes any rates and fees?

The state of New Hampshire has requirements which must be on the plan of care. The plan of care should be thorough and well    explained to your family.

14. How soon can you start services?

Your family may need homecare right away, yet the homecare agency may be too busy or too small to handle a quick start. They may need time to schedule services. This is a very important question to ask.

Family Decision Time

Is the following story familiar to you?

You have been the family caregiver for your aging mom for some time now. She thinks she is entirely independent and doesn’t need help, you know better. You have been helping with laundry, cleaning, and even help her organize her medications. Although mom is in denial that she needs any help, you are at your limit; physically, emotionally, and your time is stretched to the max. You would like to get some Homecare help, but you dare not bring it up, yet.

Then Mom falls. She is hospitalized for a while, and after is moved to the rehab. The doctor gives a choice of either a nursing home or 24/7 homecare, and Mom gets angry. She insists she is not going to a nursing home and the thought of having strangers in her home invading her privacy is unsettling to her. 

The solutions to situations such as this will be unique to each individual family. You as the family caregiver can greatly relieve any anxiety mom may have by showing care, concern, and calming her. Let her know you are there for her. Tell her, “let’s just try this and see how it goes”.

There are many options and programs available for families in situations such as this. Following are some resources to get you started. 

Being a Family Caregiver - You’re Not Alone

More than 65 million people, 29% of the U.S. population, provide care for a chronically ill, disabled or aged family member or friend during any given year and spend an average of 20 hours per week providing care for their loved one.

The value of the services family caregivers provide for "free," when caring for older adults, is estimated to be $375 billion a year. That is almost twice as much as is actually spent on homecare and nursing home services combined ($158 billion).

In 43% of U.S. families, one sibling has the responsibility for providing most or all of the care for Mom or Dad, according to a survey of family caregivers. In only 2% of families in the U.S. the siblings split the caregiving responsibility equally.

The family caregiver is usually the adult child of senior parents who lives the closest. Between providing care, making decisions, and dealing with family members, the family caregiver has a stressful difficult job. This article is for the primary family caregiver, to help you in your role. Families come in all shapes and sizes, the situations are as varied as you can imagine. Many family siblings all have to work and have their own families, who will help? Many siblings may live a distance from Mom or Dad making being a part of caregiving difficult. If you are a family caregiver following are some tips.

The best advice is to plan ahead with your siblings and parents before care is needed. Discuss all possible situations and what Mom and Dad want. If it is too late to plan ahead, don’t worry. There are many resources available to help you. It is never too late to plan. Even if you have been caring for your Mom for many years, if you haven’t taken these steps, it is not too late.

Research – discover senior options in your area. This could be from senior centers programs, to assisted living options, to homecare services. There are family caregiver respite programs and senior day out services. Below is a list of resources to help you learn what options are available.

Have a family meeting – all siblings and parents should be at this meeting. Some may have to participate via telephone speakerphone, or skype, but  it is best to have everyone in the immediate family involved. If you are planning ahead, your parent(s) may be in their 70’s and may be mostly independent. This is the best time to make decisions and hear what they want. Planning ahead is less stressful and can be more productive. However, if you are in the midst of having to make imminent decisions a family meeting is still important. There are many things to discuss and consider at a family meeting such as; who has the power of attorney? If no one knows, or if this isn’t planned ahead, you may want to call an elder law attorney to help. An elder law attorney can help with many areas of senior planning and options. When the other family members they see what is involved in caregiving they may be able or willing to contribute something. Open caring communication is key at this stage.

Get outside help – Some families have trouble agreeing on what is best for Mom or Dad. If this is the case get a social worker, or care manager to join the family meeting. To have an unbiased third party helps more often than not.

Don’t neglect your needs – many family caregivers are overworked and stressed. The job of caring both for Mom and for your own needs can be overwhelming. Schedule time for yourself. Homecare agencies may be able to help with short term respite so you can have a day off, or take a vacation. There are many caregiver support groups available where family caregivers meet to encourage one another, share ideas, and what programs are available. Do not try to do this alone and do not forget your own needs.

Give your Mom or dad as much independence as possible. You may need to take the car keys away at some point, if so, find an alternative means for them to get around.  Make sure they feel they are making their own decisions. Every senior has care needs are at different levels. Do your best to help them feel as capable and independent as possible.

1. Caregiving in the United States; National Alliance for Caregiving in collaboration with AARP; November 2009

2. Evercare Survey of the Economic Downturn and Its Impact on Family Caregiving; National Alliance for Caregiving and Evercare. March 2009 Page 2

3. Study conducted by The Boomer Project, included 711 adults in the U.S. and 383 in Canada ages 35-64 with living siblings or stepsiblings, who said they either currently provide care for a parent or older relative, or did provide care in the past 18 months.