Spousal Caregiving for Partners With Dementia

Abstract

Spousal caregiving allows stressed couples to continue living in the community rather than seeking institutional solutions. Dr. Toni Calasanti has postulated that there are gender differences in the care work styles and coping strategies used by spousal caregivers dealing with dementia. While caregiving husbands tend to adopt task-oriented (masculine) approaches, caregiving wives are more likely to take an emotionally focused (feminine) orientation. These differences result in the need for varied interventions. Male caregivers tend toward a managerial approach, whereas female caregivers generally adopt a relational approach. This distinction was examined in the course of a literature review through the deductive process. It was determined that the core thesis of such a gender-based view of care work as a tiered entity threaded with masculinity/femininity remains quite plausible in contrast to models based on self-perceived gender identity of caregivers that require more exploration. Recommendations for future investigations are offered as new questions arise.

Keywords

Alzheimer’s dementia gender caregiving spouse

The number of older adults with Alzheimer’s disease and related disorders (ADRD) is expected to rise rapidly in the next few decades, accelerated by the baby boomers (born in 1946-1964) who have just begun to reach age 65. It is projected that the number of older Americans with Alzheimer’s disease will increase to 13.2 million by 2050 from the present prevalence figure of 5.1 million (National Alzheimer’s Project Act, http://aspe.hhs.gov/dalcp/napa). Distinct from the care for older adults with physical illness or impairments, the care work for those with dementia involves particular caregiving styles and coping strategies due to the emergence of erratic problem behaviors, which requires constant vigilance and results in heightened caregiver burden, stress, and strain.

This study focuses on older spouses providing care at home, as spousal caregivers are likely to become more predominant with the greater longevity of marital partners and the preference to age in place (American Association of Retired Persons, 2012; Keenan, 2010). For this topic, Calasanti’s (2003) funded project report “Gender Differences in Informal Care Work for Persons With Alzheimer’s Disease”¹ was examined along with her subsequent published articles. The goal was to determine whether the topical construct, built on the feminist perspective and found to be innovative in the stress-coping paradigm, could be assumed to be a hypothesis, and whether the proposition could be corroborated by finding congruence in similar studies and ultimately lead to confirmation of the theorem. Naturally, this process calls for a deductive path as opposed to the inductive approaches common in qualitative data analyses in which researchers begin broadly with an area of study and allows the theory to emerge from the data. In contrast, deductive analysis sets out to test whether data are consistent with the prior assumptions, theories, or hypotheses identified or constructed by an investigator (Thomas, 2006). Also, Cooper and Hedges (2009) stipulated that the primary foci and goals of “research synthesis” (the term they prefer to “systematic review”) is to hold each work up against a criterion and find it more or less acceptable. The criterion can include issues related to “the logical rigor, completeness or breadth of explanation if theories are involved” (p. 5). Now, we assume Calasanti’s concept of femininity/masculinity in dementia care work as the “criterion” that will be tested for its ability to explicate caregiving styles, even in the “spousal” situation of cohabitation or same-gender partnership.

For this literature review, the following inclusion criteria were adopted: (a) research participants are husbands/wives or men/women in partnered caregiving relationships; (b) gender differences in caring and coping are investigated singularly (either men or women) or as a coupled unit; and (c) the literature was published after the year 2003 (assuming that Calasanti’s funded project had already comprehensively incorporated related articles from earlier research). The literature search was conducted by examining standard databases (MEDLINE/PubMed, EMBASE, PsycINFO, CINAHL), cross references, and other e-journals available via the university library system using searches with keywords such as Alzheimer’s disease, dementia, care, caregiving, spouse, gender, men, women, husband, wife, coping, or stress, and appropriately applying the operators OR and AND when needed. The search yielded, in addition to 4 more articles written by Calasanti (and colleagues), 12 studies by others comprising 7 qualitative observations, 3 quantitative analyses, and 2 systematic reviews as summarized in Table 1.

Table 1.

Summary of Literature Review on Spousal Caregiving in Relation to Calasanti’s Original Study.

No.	Year	Author	Design	Thesis/findings	Comment	Calasanti’s cited
Qualitative
1	2007	Hellstrom, Nolan, and Lundh	20 couples (12 men and 8 women with dementia)	The “couplehood” as reciprocity, affection, and appreciation in the marital relationship was maintained in caregiving.	Gender differences in the couplehood were not elaborated.	No
2	2007	Russell	30 older men caring for wives with ADRD	Caregiving husbands remain to wield managerial skills in care for their ill wife, but were discontented with the invisibility of their hard work.	Calasanti elaborated male caregivers’ managerial, dominant, and task-oriented care styles.	No
3	2007	Ribeiro, Paul, and Nigerian	53 older men caring for wives with ADRD (27) and other illness (26)	Male caregivers try to maintain their masculine image and roles, and consider their care work a marital duty to be honored publicly.	The article echoes Calasanti’s emphasis on masculinity in husbands’ approaches to care work.	Yes
4	2008	Ribeiro and Paul	Same as above	Older husbands who care for wives with dementia tend to emphasize more positive aspects of their care work than those who care for wives with physical disabilities.	This study is an affirmation of the above research from a different perspective.	Yes
5	2009	Hayes, Boylstein, and Zimmerman	28 elderly caregivers to partners with ADRD (13 men and 15 women)	Male caregivers continue to assume their roles as the husband whereas female caregivers were aware of a lack of marital reciprocity in the new relationship.	The authors view care work in terms of marital reciprocity, whereas Calasanti focuses on gendered care along the masculinity/femininity dimension.	No
6	2010	O’Shaughnessy, Lee, and Lintern	7 spouse caregivers for partners with dementia (5 wives and 2 husbands)	The experience of spouse caregivers changes as the disease progress in terms of gender identity, responsibility, future uncertainty, and coping with stress.	The observation has an inkling of Calasanti’s notion of logical or emotional coping in terms of masculinity/femininity.	No
7	2010	Walters, Oyebode, and Riley	6 elderly wives caring for husbands with dementia	Caregiving wives who embrace a sense of continuity tend to have positive adjustments to their relational changes; however, individual concepts of continuity are elastic along the continuum of continuity/discontinuity.	The notion of relational changes depending on the progression on the disease was often discussed in Calasanti’s earlier articles. Husband caregivers’ conceptions of continuity were not explored.	No (continued)
Quantitative
8	2007	Ducharme et al.	323 older caregiving husbands to wives with deficits in Activities of Daily Living or ADRD—analyzed by hierarchical and logistic regressions	Husband caregivers’ health is associated with stressors due to role overload/captivity, and inversely with self-efficacy. Their intention to end in-home care is related to role captivity and relational deprivation.	Research on wife caregivers’ situations is necessary for generalization. The notion of feminine traits among husbands is in opposition to Calasanti’s conception of traditional femininity/masculinity.	No
9	2008	Simonelli et al.	100 older adults living with dementia (33 men and 67 women)—compared with a control group	The perception of burden by spouse caregivers is higher in women than men. The higher the burden, the lower the affective and sexual satisfaction of caregivers.	The finding of stronger sexual desire in male caregivers, in contrast to female caregivers who are more concerned about attending to the affected partners’ care needs, was mentioned by Calasanti and others.	No
10	2010	Baker, Robertson, and Connelly	70 male caregivers for wives with dementia—analyzed using hierarchical regression	Role strain, personal strain, and gain are closely associated with gender role conflict rather than gender identity. Husband caregivers want public kudos for their hard work.	The notion of the underlying cause of role strain (i.e., lack of self-efficacy), personal strain (i.e., belief in masculinity), and wanting public kudos echoes Calasanti’s observations.	No
Systematic review
11	2008	Baker and Robertson	9 articles were focused specifically on male caregivers from 93 studies, 1950-2007	Only 2 studies using multivariate analysis attempted to explain the mediating factors between strain/burden and coping in men’s care work for ADRD, but none of the articles assessed the functions of coping in terms of gender identity and role. (It seems that their article above, 2010, is an attempt to address this omission in the literature.)	Although Calasanti and colleagues’ research adopted qualitative approaches, their observations were based on conclusions about gender role/identity.	No
12	2009	Braun, Scholz, and Bailey	5 articles using data collected directly from care-receivers in the literature on dyadic relationships	The perspectives of both caregivers and care-receivers grappling with dementia will facilitate a better comprehension of caregivers’ stress, and thus lead to more effective strategies for enhancing their well-being.	Calasanti did not explore specifically this issue; however, her model of femininity/masculinity may be applied to this little-known territory by examining care work as a dyadic world of dementia caregiving.	No

Note. ADRD = Alzheimer’s disease and related disorders.

Calasanti’s Conceptual Framework of Spousal Caregiving

Background

The stress-coping paradigm has included some evolving foci in the theorization or conceptualization of spousal caregiving, especially in terms of problem- and emotion-focused coping strategies, over the last 30 years. For example, tracing back, first the issue in the general population was laid out by Pearlin and Schooler (1978), Folkman and Lazarus (1980), and Billings and Moos (1984). Then, caregiving in the general population was described by Stone, Cafferata, and Sangl (1987); Kramer (1997b); and Pinquart and Sorensen (2006a). Next, gender differences in general caregiving were considered by Zarit, Todd, and Zarit (1986) and Miller and Cafasso (1992), followed by Almberg, Grafstrom, and Wimblad (1997) then Kramer and Vitaliano (1994), with both of the latter studies specifically targeting dementia care. The focus was then further narrowed specifically to spousal caregiving as examined by Kramer (1997a), Rose, Strauss, Nuendorfer, Smyth, and Stuckey (1997), and Thompson et al. (2004). Finally, deliberation related to spousal caregiving for persons with dementia from a feminist point of view, opened a new chapter in this field. Calasanti’s theme is innovative in the sense that her view of masculinity/femininity in connection with problem- and emotion-focused coping strategies provides a unique tool for better understanding the situations confronting spousal caregivers. By implication, this could eventually lead to transcending the biological bond and the production of indistinct gender roles crossing the traditional division of labor in marriage.

Calasanti’s Conceptualization in the Original Research

Calasanti began her inquiry with the following questions: (a) How does gender influence the way care is perceived, provided, and experienced? (b) What are the differential sources of caregiving stress? (c) Given that there are gender-different care styles, does this influence how caregiving husbands and wives try to cope with the distress? and (d) How can interventional assistance be provided when needed in gender-appropriate ways? To explore these questions, Calasanti used a qualitative, constructivist approach using semi-structured interviews, supplemented by participant observation during support group meetings in Virginia. The sample consisted of 13 wives and 8 husbands caring for their spouses with Alzheimer’s disease. The investigation allowed her to conclude that the basis of differences in care work lies on a gender repertoire, that is, a gender-based set of skills, resources, and expectations, that defines oneself as a “man” (not a nurturer) or a “woman” (not a forceful being). Therefore, some perceived sources of stress differ for men and women, and their coping strategies vary accordingly. These differences, in turn, entail different interventions. These research findings are summarized in Table 2.

Table 2.

The Epitome of Gender Differences in Care Work in Calasanti’s Research.

Care work	Husbands	Wives
Caregiving style
Approaches to care	Logical/Instrumental Task-oriented (problem-solving, managerial)	Emotional/Relational Person-oriented (nurturing)
Source of stress
Aggressive/disruptive/non-compliance behaviors	Men encounter more often than women.	Women encounter less than men.
Violence	Men worry less than women (Perception of men being stronger than women).	Women worry very much—leads to institutionalization of care recipient.
Concern for partner’s feelings	Not mentioned.	Worried about applying coercion.
Incontinence	Men handle it less negatively than women—deemed a task.	Women see it as very distressing—leads to institutionalization. “The husband is not a child.”
Dealing with strain
Attitude	Men tend to act in a harsh manner to get tasks done—feel less guilty—content with kudos related to accomplishments.	Women feel threatened and fearful—especially of violence—and consider institutionalization.
Coping strategies
Minimizing disruption	Maintain outdoor activities or travel as often as possible.	Try to keep lifestyles as before.
Emotional distancing	Simply try to cope with situations—even through coercion—remain stoical.	Try not to use coercion due to concern for partner’s feelings—thus unable to distance from emotions.
Talking to others	Less likely—prefer sons as confidants.	More likely—prefer daughters as confidants.
Spirituality/churches	Not mentioned.	Women more likely to talk about than men.
Drinking/medication	As a last resort, men tend to take alcohol/antidepressants to cope.	Not mentioned.
External help
Formal services	Depending on income, men tend to use adult day care or other assistance.	Women tend to feel guilty to using even if they are affordable.
Support groups	Try to seek information or advice—likely to share their care work successes and enjoy kudos.	Try to obtain emotional support and comfort by sharing their experiences.

Calasanti’s Subsequent Articles

Calasanti and colleagues published four articles using the original research data with different emphases as summarized in Table 3.

Table 3.

Summary of Literature Review on Calasanti’s Subsequent Articles Published.

No.	Year	Author(s)	Thesis/findings	Comment
1	2006	Calasanti	There are similarities and differences in spousal care work between men and women. Both consider caregiving a marriage commitment, but differ in style which stems from gender-based skills and resources.	This article is an extended version of the original study.
2	2006	Calasanti and Bowen	Care work involves not only assuming the pre-morbid tasks shared by the couple but also maintaining ill partners’ gender identity.	This article is another explication of the original article with emphasis on gender-specific situations in the care work.
3	2007	Calasanti and King	Men’s approaches to care for their wives are rooted in masculinity; hence, husbands’ experiences in care work and coping strategies are different from wives’ dealings with dementia.	This article discusses observations only of husband caregivers from the original study.
4	2010	Calasanti	There exist gender inequalities in relation to old age. Especially, the care work for spouses with Alzheimer’s disease is dictated by gender repertoires that define gender identities.	This overarching article about gender relations in aging affirms her beliefs about gender differences even in care work.

The first article describes similarities and differences in care work between caregiving husbands and wives. Similarities were observed in the extent of care work performed, the motivations derived from marital commitments, knowledge of who the partner is, and perceived social isolation. Differences were found in the approaches to care. Men typically view it as various tasks to be accomplished, whereas women deem it as nurturance. In the second article, Calasanti and colleague explored crossing the gender boundaries of day-to-day care work and examined the gender identities of affected partners in terms of masculinity/femininity. The third article, focused only on caregiving husbands, demonstrated that men’s approaches to care work are rooted in masculinity, and this in turn influences their coping strategies. Finally, Calasanti argued that gender repertoires, forged historically on the basis of inequality in our society, have distinctively dictated the spousal work of caring for older partners with ADRD.

The Core of Calasanti’s Work

In her original research and the subsequent articles, Calasanti explicated spousal ADRD caregiving in terms of three tiers, which are serially interlocked. The first tier embodies care-work styles, then the second encompasses sources of stressors and coping strategies, and the third incorporates interventions for assistance. These tiers are threaded with the elements of masculinity/femininity, forming a systemic structure in which the preceding element (gendered style) sets the stage for the next element (different coping strategies) and results in the final element (the pertinent intervention). It can be summarized as follows: Male caregivers, typically characterized as being masculine, view caregiving as a task to be resolved in the same way they performed tasks in their careers. As a consequence, the source of stress lies primarily in their perception of whether the care is provided adequately or not. To cope with the strain, they try either to avoid emotional entanglements or to bear the disruptions stoically. Hence, husbands want to gather information about task-oriented care experiences and enjoy kudos during support group meetings related to their successful achievements.

In contrast, female caregivers, who have traditionally devoted their life to nurturing and homemaking (i.e., feminine roles), view caregiving as a disturbed situational change, which is upending their marital relationships, while they remain obliged to be domestic caretakers. Thus, the stresses have dual sources, that is, nurturing the “stranger” and solely maintaining the internal and external household. Given the nature of nurturance in abnormal circumstances and the unfamiliarity of certain required tasks, caregiving wives’ care work triggers emotional reactions such as anger, worry, and/or depression as intimate reciprocal relationships diminish. They are now forced to determine, as a way of coping with the dire situation, how to live out their compromised conjugal life which must be led, either negatively with the fear of their husbands’ disruptive behaviors or positively with empathy for their mates. Because of their emotion-based approach to care work, caregiving women prefer to share their experiences among sympathetic caregivers and seek solace from support groups.

Three Serially Interlocked Tiers

Calasanti’s view of the three-tiered care work is examined deductively in close comparison with the literature listed in Table 1. The articles were gleaned through their inclusion of the dimension of masculinity/femininity, described either explicitly or implicitly.

Commonalities in Care Work

Before proceeding to laying out our investigation of gender differences in this regard, it is worthwhile to mention that Calasanti (2006) noticed similarities in care work, common to both parties (i.e., caregivers and care-receivers) regardless of their gender. A recent study by Hellstrom, Nolan, and Lundh (2007) may elucidate more of this mutually caring relationship which results as a consequence of fulfilling marital commitments. They identified three broad phases: (a) sustaining the couplehood that connotes “we,” (b) maintaining involvement actively by both caregivers and care-receivers, and (c) moving on toward a new beginning through the stages of “hand over,” “let go,” and “take over” marital responsibilities as the disease progresses. These examinations revealed that, after all, caregiving is not a wholly negative experience, even as the positive relationship becomes compromised by the progressively debilitating disease. Thus, the couple’s unfolding experience can be understood in a “nurturative relational context” (Hellstrom, Nolan, & Lundh, 2005) where both parties try to sustain reciprocity, affection, and appreciation in their marital relationship.

However, some questions arise: (a) How shall the couple navigate through the phases when the cognitive impairment of the care-receiver is getting more severe? (b) Can the balanced nurturative relational context be applied only during the earliest stage? and (c) Will caregiving wives adopt the same path or tools as caregiving husbands when facing and controlling problematic situations? Simply put, gender-neutral observations of dyadic care ignore the inner operation of care work embedded in gendered repertoires. Therefore, addressing these questions calls for reverting to discussions of gendered operational differences in care work.

Care Work Styles

Ribeiro, Paul, and Nigerian (2007) studied only husbands’ approaches to care work. They found that male caregivers were unwilling to abandon their masculine image and stoically retained certain characteristics of the traditional manly role. One participant provided an assertive display of masculinity as he claimed there was no problem because “a man must know how to do everything.” It seems that the feeling of being in charge reinforces men’s traditional role of authority, and hence their masculinity. The public visibility of men’s roles and gendered social relationships were found to be important in maintaining their masculinity. Some participants bragged about their good deeds, fully expecting that their male friends and neighbors would appreciate the difficulties of care work and view the care as a marital duty to be honored. In this context, public visibility in a social location mirrors the managerial roles in the workplace, where accomplishing a multitude of tasks is highlighted, appreciated, acknowledged, and sometimes rewarded by colleagues and others. Using the same data, Ribeiro and Paul (2008) found that older husbands’ attitudes toward the care for their impaired wives (half of whom were dealing with ADRD) was generally positive. Interestingly, this positive action was found to be greater than that of those tending to partners with physical ailments. This positivity was ascribed to a good pre-morbid relationship built on a lifelong determination to maintain marital vows. The authors concluded that those confident caregivers naturally wanted to show off their successful care work in public. Thus, the main thesis of this article is similar to the conclusions reached by Calasanti and King (2007). Both observed the masculinity displayed in husbands’ care work as a way of tackling tasks and demonstrating a muscular strength symbolizing authority, as well as an accompanying desire for social visibility of these efforts. Citing Calasanti and Bowen (2006), the authors emphasized the importance of such gendered caregiving within the late-life marriage disrupted by dementia.

Russell (2007) also exclusively researched male caregivers’ perspectives on caring for wives with ADRD, and observed that the majority of respondents, who had been in market-economy employment where public recognition was common, complained about the transition into in-home caregiving situations where “Nobody sees what we’re doing,” and consequently, even family members were not providing appreciation, let alone rewards. Nonetheless, the use of management skills, a display of masculinity, prevailed to overcome the unheroic, toiling tasks of dementia care. Thus, husband faced both struggles and success in their caregiving experiences. They struggled to cope with isolation from the public arena and the invisibility of their care work, but they nevertheless experienced the successes in accomplishing difficult caregiving tasks through a meaningful combination of management skills and nurturing behaviors stemming from affective spousal commitments. It should be noted that Russell crosses the gendered line of caregiving style—asserting that for effective care, the managerial skill should be joined by nurturance. In other words, male caregivers should adopt both masculine and feminine approaches, but the author did not explain how this would manifest itself in different ways of caregiving or elaborate on what male nurturance would look like. In this regard, a question may be raised as to whether this two-pronged caregiving approach can be applied to female caregivers as well. If female caregivers used the same style, could similar outcomes be expected? To put it another way, unless someone investigates female caregivers, using the same method and tools as Russell used in the case of males, and finds similar results, Russell’s tenet related to the gender-neutral aspects of care work may not hold up. This is a corollary to the question (c) posed above in the section on gender commonalities. Noteworthily, according to Walters, Oyebode, and Riley (2010) who observed only female caregivers, wives tried to hold on to their gender identity as women in supporting their compromised husbands, even when caring was likened to comforting a “baby” with the accompanied feelings of guilt, loss, or social isolation. Remarkably, there was no mention of any sort of managerial aspect in their care.

Thus, Ribeiro et al. (2007), as well as Russell (2007) in part, maintain that managerial skills are an essential part of the care work, which benefit both caregivers and care-receivers. Given that the participants studied were all male, their findings are perfectly congruent with Calasanti’s notion of masculinity in terms of the approach taken by caregiving husbands. That is to say, this masculinity is known to be embedded in their gender identity, manifested in their gender role, and ultimately translated into the power of performing their care work.

In a different vein, Hayes, Boylstein, and Zimmerman (2009) found that male and female caregivers differed in the perceptions of self-identity or the identity of care-receivers. Caregiving men had a tendency to preserve their identity as the husband and the supporter of the household, and thus continued caring for their ill wives as they always had done. There was an inclination however to treat her as lacking the same “womanhood” as was previously possessed. By contrast, caregiving wives tended to see their compromised husbands as being childlike, rather gender-neutral, adults incapable of performing marital roles. As such, their care work was thought of as lacking marital intimacy and reciprocity along with the additional burden of taking on the husbands’ previous work. Thus, this article also confirms that there are gender differences in dementia care work, as clarified by Calasanti and Bowen (2006) who maintained that in crossing gender boundaries “women may have greater difficulty than men in performing some personal care tasks, perhaps because of the way wife caregivers violate women’s sense of their husbands’ masculinity” (p. 262). Hayes et al. (2009) construe intimacy within interpersonal reciprocal relationships as requiring awareness of the social “other” based on self-identities as husbands or wives along with pertinent social meanings, but now such marital intimacy is transmuted into the dementia care relationship and no longer carries affection and reciprocity. Yet, it was found that caregiving wives tended to want emotional intimacy in terms of companionate love and reciprocal role expectations, contrasting with caregiving husbands who primarily sought physical intimacy. When the ordinary intimacy and expectancy in marital relations are lost, the reaction is different between genders. According to O’Shaughnessy, Lee, and Lintern (2010) who focused on changes in relationships due to dementia care, a husband saw his caring role as a challenge to carry on in positive ways, whereas some wives expressed a resigned, fatalistic acceptance of their situation that was often fraught with anger, resentment, and fear. Borrowing Calasanti’s terms, the reaction was rational for males in contrast to the more emotional approach observed in some females.

With regard to the reactions taken by caregiving wives, Walters et al. (2010) presented caregivers’ viewpoints in terms of continuity and discontinuity as influenced by the pre-morbid relationships couples used to have. It was found that the perception of gender identity toward husbands with dementia was of prime importance. The perception of ill partners as the “same person or different” (associated with continuity or discontinuity, respectively) dictated relational changes in the marital relationship, which was based either on love/affection (continuity) or on protection/care (discontinuity). That, in turn, engendered different emotional responses to behaviors, either empathy (continuity) or guilt (discontinuity), exerting an impact differently on day-to-day life that was either durable (continuity) or not (discontinuity). It seemed however that the individual conception of continuity was elastic and dependent on personality differences but independent of the degree of change itself along the dimension. In line with Atchley (1989), who construes continuity in terms of internal and external structures obtained through adaptive choices during the life course, Walters et al. (2010) assert that maintaining continuity should be regarded as an adaptive response attempt to adjust positively to the relational changes caused by the disease. But a question arises about the process female caregivers may experience, beyond the initial recognition of disabled husbands as the same persons, as they determine how to sustain the sense of such continuity. That is, shall the path be of a rational (masculine) or an emotional (feminine) orientation? As mentioned previously, caregiving husbands were found to have a greater tendency to retain the same gender identity throughout than were caregiving wives in the first place (Hayes et al., 2009).

It should be noted, other than the continuity themes, that Walters et al.’s (2010) observations of women’s likening caregiving to comforting a baby, diminished marital reciprocity and taking on spousal responsibilities are clearly apparent, if not seminal with Calasanti and colleagues. A distinction emerges however, as Calasanti maintains that relational changes fluctuate with progression of the disease, we deduce that the importance of continuity in coping is independent of disease severity (Walters et al., 2010). For those researchers, it seems that continuity is also independent of the relational changes that occur, and the ability to cope is similarly unaffected. Clearly, this is a supposition that deserves further exploration.

Regarding the question of how to make caregivers turn to the positive aspects of caregiving for spouses with dementia, some clue may be found in an exploratory study by Nimrod and Kleiber (2007) who proposed an innovation theory of successful aging, which attempted to integrate the classical Continuity (Atchley, 1989) and Activity (Havighurst, 1963) theories. Their innovation theory states that there can be innovation activities after retirement. Either a sense of self, that is, Self-Preservation Innovation (internal continuity) is preserved or the transition allows one to strike out in entirely new direction, that is, Self-Reinvention Innovation (e.g., newly found self-efficacy not related to the past). Both eventually may lead to challenging the persons’ well-being in later life as individuals strive to find personal meaningfulness and a sense of purpose. In connection with Walters et al.’s (2010) view of continuity (i.e., the emphasis on the same person, love over care, and empathy over guilt), the self-preservation innovation theorem predicts that the positive effects of continuity in dementia care work can be made more apparent by encouraging some innovation activities inherent in the self of caregivers, and possibly in the self of care-receivers as well. Nimrod and Kleiber (2007) observed that self-preservation innovation activities were triggered by imposed (situational) causes such as a need to take care of someone along with extrinsic motivations (expected benefits) such as fulfillment of filial obligations. For our review, the trigger is seen as the care work needed amid the spousal situational changes, and the motivation is to seek the positive aspects of caregiving through innovation activities based on the internal continuity defined by Walters et al. (2010) with a sense of renewal and determination. However, the question of how to trigger motivation is a separate task to be addressed along with the question of whether there is a gender difference in actualizing such motivation amid disturbance.

In short, if the continuity–discontinuity dimension can relate the differential care styles to career (managerial), gender role (instrumental), or motivation (logical), then caregiving husbands are more likely to wield these attributes in the care work than are caregiving wives who are usually depicted in terms of discontinuity with a disposition toward experiencing diminishing marital intimacy/reciprocity (emotional) or a confused perception of gender identities in the dyads (relational). For Calasanti and colleagues, these gendered qualities are believed to be examinable through the lens of masculinity/femininity, which in turn would systemically affect coping strategies.

Stress and Coping

It is widely known that care work styles are closely associated with stress and coping. For example, the task-oriented, problem-solving approaches are said to alleviate strain (e.g., Calasanti & King, 2007; Russell, 2007). Thanks to well-developed instruments which have enabled researchers to quantify the multi-faceted stressors resulting from dementia care, three quantitative studies yielded persuasive evidence related to gender differences in this regard.

Ducharme et al. (2007) found that the psychological distress of husbands caring for wives with functional/cognitive impairments was closely associated with such stressors as role overload, role captivity, disruptive behaviors, and so on, defined in the model established by Pearlin, Mullan, Semple, and Skaff (1990). But it was found to be conversely related to the self-efficacy of caregivers. That is, husbands who were more competent in performing care work were less likely to suffer from stress. Although the authors attempted to examine the influence of self-perceived gender identity by controlling for the masculinity/femininity traits of husbands in their regression analyses, this contextual variable did not contribute in a statistically significant way to the prediction of either psychological distress, self-perceived health, or the intention to cease home caregiving. Furthermore, the presence of feminine traits as defined by Bem (1974, 1981) did not correlate with either primary objective stressors or subjective stressors, suggesting that these stressors appear gender neutral. In this regard, Calasanti’s dichotomous view of distress between husband and wife caregivers is not supported by these data. But this may be a consequence of sampling bias because the data were collected only from male participants. The authors noted that slightly more than half of the caregiving husbands in the study defined themselves as having feminine traits, and commented that this observation was uncharacteristic of the age cohort sampled. It is tempting to speculate what would result from a test if the authors replicated their analyses with a sample of female caregivers only. This might either confirm their finding that stressors are unrelated to gender identity or to the contrary, affirm Calasanti’s thesis related to gender-specific (not necessarily in biologic terms) sources of stress and coping strategies.

Another quantitative analysis performed by Baker, Robertson, and Connelly (2010) also explored male caregivers’ strains and gains in dementia care as it related them to gender identity in terms of gender role conflict (O’Neil, Helms, Gable, David, & Wrightsman, 1986). As with Ducharme et al.’s (2007) research results described previously, self-perceived gender identity did not appear important in male caregivers’ appraisals of strains or gains. Yet, gender role conflict gained explanatory power for the outcomes; the higher the level of gender role conflict the male caregiver held, the less likely he was to report his role strain (demands of care work). But males with higher levels of gender role conflict were more likely to mention their personal strain (i.e., self-doubt about being an adequate caregiver). In other words, male caregivers are less concerned about the number of tasks to be performed, but more concerned about their ability to deal with the care situation (displaying a managerial aspect of care work). Beneath the construct of gender role conflict lie the traditional beliefs in masculinity/femininity (or gender stereotype), as represented in the study by the subscale variable restrictive affectionate behavior between men, which gauges discomfort about being personally revealing or emotionally connected to other men. This type of same-gender dysphoric orientation may actually be an expression of typical masculinity that stems from gender role conflict. Another subscale variable of gender role conflict measures the respondents’ self-perception of success/power/competition (SPC), which was found to be positively associated with caregiving gain. Traditionally, SPC is conceived of as pertaining more to the masculine domain. Thus, Baker et al.’s (2010) conception of gender role conflict together with Ducharme et al.’s (2007) self-efficacy construct may translate into Calasanti’s notion of masculinity in terms of managerial, task-oriented approaches to care work and of coping strategies contrived accordingly.

It is often mentioned in the stress management literature that physical affection or sexual activity can be a stress reliever. Even amid stressful dementia care work, sexuality remains a positive part of life with the ill partner. Many caregivers find it to be a support, a reassurance, and a means of coping with their partner’s illness as observed by Simonelli et al. (2008). They conducted research on sexual intimacy and marital satisfaction in relation to the subjective perception of burden by spousal caregivers of those with Alzheimer’s and found that the higher the burden the less affective/sexual satisfaction was derived. Furthermore, the perceived burden was higher in women than in men, and it was related to disease severity. Nonetheless, there was a gender difference in sexual attitude. Generally, male caregivers had stronger sexual desire and a higher tendency toward unilateral contact, contrasting with female caregivers who tried to suppress sexual desire and considered it immoral, given their partner’s mental deterioration. These gendered behaviors were also observed by Hayes et al. (2009), who saw sexual restraint among female caregivers as a consequence of a lack of marital intimacy and reciprocity. Whatever the motive, this poses questions as to whether such suppression, regardless of gender, could constitute a stressor in spousal relationships, and whether the stronger suppression contributed to heavier burden in women. A further question might be whether such gendered reactions to sexual desires can be translated in masculinity/femininity terms. For example, there are implications from an anthropocentric point of view that affectionless unilateral actions are usually committed by males, whereas consensus with affection is a prelude to female actions.

Interventions

Most articles presented in this review offered some suggestions on interventions based on their research findings but these were stated in general terms, and tended to focus on the importance of providing psychological support/services that are sensitively tailored to the needs of caregivers. There is some research, however, about the effect of interventions in terms of depression and well-being of caregivers for dementia in relation to gender.

The meta-analysis with 127 intervention studies by Pinquart and Sorensen (2006b) found that, in the case of gender, more women than men showed improvements in depression as well as knowledge and ability. The authors see the results of these interventions as a relative reflection of their earlier findings (Pinquart & Sorensen, 2006a), which showed that female caregivers were more depressed than males in the first place, and that gender difference in the perception of positive well-being was small. They contend that men are less likely to show a decline in depression because they are less likely to admit negative feelings regardless of the intervention. We view this as an act of stoicism that can be considered a masculine trait.

Another literature review conducted by Etters, Goodall, and Harrison (2007) echoes Pinquart and Sorensen’s (2006b) conclusion that psychoeducational interventions (which are more structured and intensive than others) backed by active participation from caregivers are the most effective. Etters et al. (2007) found evidence that individually developed multi-component interventions which include a diversity of services decrease burden, improve quality of life, and enable caregivers to provide in-home care for a longer period of time prior to institutionalization. By contrast, Schoenmakers, Buntinx, and DeLepeleire (2010) found in their meta-analysis that psychosocial interventions, which teach caregivers cognitive, behavioral, or social strategies in handling problematic situations to help improve their well-being, had almost negligible effects on depression. Despite these outcomes, multidisciplinary care management interventions contributed to a sizable decrease in depression, although the effect was not statistically significant. Interestingly, respite care was found to be responsible for an increase in burden, contrary to popular belief. However, the authors urge that in spite of small benefits from formal support, professional care providers should keep in mind that these interventions are indispensable in dementia homecare, because family caregivers appreciate them nonetheless. Although these researchers did not specifically examine the interventions in terms of gender differences, they emphasized the significant effects of individualized services or case management, which should take gender identities of caregivers as well as care-receivers into account for suitable care decisions.

With respect to institutionalization, de Vugt et al. (2005) found that caregiver distress stemming from behavior problems is a predictor of nursing home placement, but the decision is dependent on the caregiver’s perception of the problems rather than the problem behaviors per se. This point reminds us of Calasanti’s observation that the motivations for institutionalization (e.g., violence, incontinence) are different between wives and husbands with respect to whether or not the problems are faced with an orientation toward masculine strengths and mindfulness of the job-to-be-done. Rose et al. (1997) proposed a screening tool which examines the personality dimension of distress in conjunction with the problem- or emotion-focused coping strategy adopted. This allows professionals to determine the most effective way of integrating services into the overall care plan.

More specific conclusions may be drawn about the likely institutionalization of spousal partners with dementia. Ducharme et al. (2007) used husbands’ intentions to curtail home care as the dependent variable in a logistic regression analysis and found robust odds ratios (OR) for the variables role captivity (i.e., being trapped; OR = 8.3; 95% confidence interval [CI] = [1.98, 34.39]) and relational deprivation (i.e., loss of marital relations; OR = 5.1, 95%, CI = [1.32, 19.45]). Caregiving husbands who had high levels of role captivity were 8 times more likely to indicate their wives would end up in long-term care in the coming year. This result was moderated by frequent use of formal services (OR = 1.6, 95%, CI = [1.11, 2.29]). Now a question arises: Is the tendency for institutionalization due to social isolation and affectless marriage limited to male caregivers? This is particularly important, given Calasanti’s observation that female caregivers are more sensitive to instances of violence and incontinence when contemplating decisions related to their husbands’ institutionalization. Thus, appropriate services or programs that tie in with caregivers’ gender characteristics (such as the masculine/feminine orientation) are called for to prevent or, at least, delay institution-alization especially in the case of Alzheimer’s care.

Finally, in this connection, it is important to consider the public visibility of male caregiving (now recognized socially as a man’s legitimate work). This has allowed positive-minded husbands to consider caregiving as a source of self-esteem and self-worth, thereby strengthening their coping strategies (Ribeiro & Paul, 2008). Interventions should be considered as they relate not only to the physical provision of health care but also in terms of the mental benefits that can be afforded (relief from stress and strain through the public arena). Indeed, some researchers, including Calasanti, have emphasized the utility of support group meetings as they provide a forum for caregivers to discuss their experiences and share sympathy/empathy, kudos, and useful information. This is why Calasanti recommends in her final project report that facilitators should consider the gender composition of their group and select themes or proceedings that are most suitable.

Systematic Reviews

Of several systematic review articles in the dementia-related caregiving literature published most recently, only two studies were found that explored either gender-specific differences or their relevance in spousal caregiving. Baker and Robertson (2008) focused on the literature concerning the coping strategies of men who were caring for partners with ADRD. Among the dominant findings in their male-only review are (a) caregivers reporting high levels of distress were more likely to use an emotion-focused strategy (specifically, wistfulness), whereas those at lower levels adopted problem-solving strategies (acceptance and instrumental coping), confirming the gendered differences in coping; (b) the majority of men reported a marital commitment and involvement in the care work akin to women, echoing the similarities indicated by Calasanti as well as Hellstrom et al. (2007); and (c) male caregivers were found to be more concerned about how they were viewed by others, perceiving their failure in proper care as being weak and losing control. This latter observation represents an expression of masculinity as observed by Calasanti and other researchers (e.g., Baker et al., 2010; Ribeiro et al., 2007).

However, Baker and Robertson (2008) found that, of the few studies exploring gender as a mediator of coping and burden, the focus had been mainly on (biological) sex differences, rather than gender identity. They concluded that if men are to be compared with women, treating gender as a source of individual differences is preferable to confusing it with the biological category of sex. The finding that caregiving husbands willingly apply both emotion-focused and problem-focused approaches in coping exemplifies this nuance distinguishing gender and sex. It also suggests the need to transcend the construct of femininity/masculinity, which has been commonly attributed simply to women and men. It should be noted that this literature review was conducted prior to 2008 and, therefore, could not include subsequently published articles (some of which have been reviewed in this article) that studied gendered care work and coping. It seems that their awareness of the paucity of gender-specific research resulted in their later publication (Baker et al., 2010), as discussed previously in this article as one of the quantitative studies.

Braun, Scholz, and Bailey (2009) raised the fundamental question of whether a one-sided narration of dementia caregiving, as much of the literature in this field has considered, can really reflect spousal relations after the onset of ADRD. Their premise begins with the notion that the best understanding of care work can be achieved through dyadic perspectives of the caregiver and care-receiver. They believe that capturing genuine caring and coping experiences depends on the extent to which information is collected directly from both partners. The authors found and reviewed five such studies, and provided a synthesis of how the participants perceived their spousal relationships after the onset of the disease as follows: (a) care recipients report higher levels of marital satisfaction including sexual activity than caregivers do; (b) some aspects of communication between the pair remain intact; (c) the couples overcome the adversity arising from problem behaviors by sharing the difficulty together; and (d) pleasurable activities enjoyed together enhance caregivers’ well-being. These encouraging attitudes and behaviors should be quite propitious for alleviating stress and strain to both parties. Although the terms used in their review are different from those described by Hellstrom et al. (2007), the tone taken when referring to the existence of positive attitudes in dementia care work is very similar in both. But this raises the question of whether or not the positive dyad can be achieved or sustained without fluctuation when (a) the couple has the same personality, that is, either feminine or masculine; (b) they possess different personalities, that is, one is feminine and the other is masculine; or (c) the ill partner becomes gender-neutral. Thus, gender differences in the initiation of positive actions/behaviors, along with impact of disease severity on the relationships, remain to be revealed in future research.

Conclusion

This deductive study started by presenting Calasanti’s proposition that the spousal care work for partners with ADRD is a systemic entity consisting of care styles, coping, and interventions, all of which are threaded in tiers with the construct of masculinity/femininity. Although there are some commonalities in care work shared by both caregivers and care-receivers (e.g., Hellstrom et al., 2007) or are seen jointly among caregiving husbands and wives (e.g., Russell, 2007, in part), the distinction along the gendered line is immediately apparent. The viability of Calasanti’s proposition in terms of such a distinction has been examined by comparison across similar studies.

First, regarding care styles, Calasanti’s view of care approaches taken by caregiving husbands in contradistinction to caregiving wives is echoed in two studies (Ribeiro et al., 2007; Russell, 2007), which conducted male-only observations. However, in the study about identity changes in marital relationships involving dementia care (Hayes et al., 2009), it is found that caregiving husbands tend to preserve their gender identity/role as male and treat their ill wife as before, whereas wife caregivers are likely to see their incapable husband as being gender-neutral. The continuity of gender identities are considered to bring about positive effects in spousal relationships even in distressful circumstances (Walters et al., 2010). Extending the continuity theory, Nimrod and Kleiber (2007) see that self-preservation innovation activities, which are revamped attempts to continue to live a beneficial and meaningful life in retirement, can be triggered by the recognition of situational changes and the necessity for pertinent care work. Overall, as with Calasanti’s study, most male caregivers are found to be managerial in tackling tasks/problems, logical in preserving self-identity/role, and proactive in pursuing innovative activities. In contrast, many female caregivers tend to get emotionally fraught with negative attributes when facing stressful care work. These contrasting gendered characteristics of care work styles were first termed masculine versus feminine by Calasanti.

Second, Calasanti’s notion of interlocking relationships between care work styles and coping strategies is corroborated by Baker and Robertson’s (2008) systematic literature review. Here, we see that the elements of masculinity/femininity permeate most coping strategies in accordance with the gendered care work.

Third, there are gender differences in responding to interventions. The stoic behavior observed by Pinquart and Sorensen (2006a, 2006b), along with feelings of being in charge, reinforces men’s traditional roles of authority. We have also shown how the public visibility of men’s role amid gendered social relations illuminated by Ribeiro et al. (2007) as well as Baker and Robertson (2008) is supported by Calasanti’s contention that support group meetings as a venue for caregivers of both genders to relieve stress and strain can be as effective as more traditional health care interventions. Regarding institutionalization, de Vugt et al.’s (2005) observation is consistent with Calasanti’s assertion of gender differences related to different reactions toward patients’ problem behaviors. Caregiving husbands approached the situation as a “job-to-be-done” (managerial), whereas caregiving wives considered it the loss of their partner’s identity (relational). As for in-home care, many health professionals ascribe benefits to individualized programs or case management (Etters et al., 2007; Schoenmakers et al., 2010). Yet these approaches may be more effective if the programs consider the caregiver’s coping attitude (problem- or emotion-oriented) as it is sifted through the “distress screen” suggested by Rose et al. (1997).

Thus, Calasanti’s proposition of masculinity/femininity permeating throughout the care work for spouses with ADRD is affirmed to be quite plausible. Yet, because Calasanti’s study was based on the biological dyad as male and female, this theorem should be tested for validity with respect to self-perceived gender identity. Male caregivers with feminine traits may use nurturance-oriented care and emotionally charged coping mechanisms, whereas female caregivers who apply managerial approaches may excel in actuating problem-solving coping strategies. Initially, Baker and Robertson (2008) raised this self-perceived, gender-identity-based care theorem as an issue to be addressed in future research. Also, Ducharme et al. (2007) found that even though more than half of husband caregivers in their male-only research had feminine traits, there was no significant effect on the outcomes. In addition, Walters et al. (2010) observed that none of their caregiving wives ever assumed a masculine approach to managing problems. Thus, to further establish a gender-identity-based care work theory, it seems that quantitative research should be conducted not only on male and female caregivers separately but also on participants of both genders placed in the same analyses. This would be particularly advantageous in terms of validity if the methods and instruments used are consistent with the studies that have already contributed to the literature. Also, future studies should take into account that women are now much more engaged in managerial occupations: Will this cohort of female professionals continue to wield their managerial skills in their care work for ill husbands? Interestingly, Paun (2003) found in her research on older women’s caregiving experiences with dementia that most participants reported no difficulty taking on new roles because they had a sense of being in control over the situation. Could this seemingly episodic case become more of a norm in women’s care work in the near future? To further the gender identity theories it would be helpful to examine whether spousal care dynamics in terms of masculinity/femininity among same-sex marriages are comparable with those observed in heterosexual couples. In fact, this question was also raised by Calasanti (2010) who speculated that coupled gay men may both develop similar workplace skills and identities, and declared, “How such gender repertoires influence care work remains unknown but is an important area for future research” (p. 728). In short, Calasanti’s theorem of masculinity/femininity, pertaining to biological identity, as opposed to self-perceived gender identity, is sustained.

As the elements of masculinity/femininity become well-defined and measurable specifically in relation to dementia care work, Calasanti’s theory could extend into a broader field where the care work situations of same-sex marriages as well as other patterns of couplehood may parallel those of heterosexual couples. In this case, the construct of self-perceived gender identity could be better fit for analysis. If found, the broader theory could also be used to examine the following cases. Recently, Noel-Miller (2011) found a distinct caregiving pattern that distinguished older cohabiting heterosexual couples from married couples. Cohabitors with a deficit in activities of daily living were much less likely to receive care from partners than their married counterparts were. This finding may reflect “cohabitors’ diminished commitment to caregiving obligations inherent to the institution of marriage” (p. 350). Furthermore, there were no gender effects on the pattern of partnered care in the case of cohabitation, whereas married husbands tended to rely more on spousal care than wives did. Of course, factors such as the length of marriage or cohabitation, as well as the time since diagnosis, must be considered when making such comparisons. Koren (2010) found a difference in motivation to provide care between those in second couplehood and those in lifelong marriage. The former were prompted by an urge related to “I want to” (will), whereas the latter was dictated by “I have to” (obligation). A rapid rise of cohabitation trends these days has been noted by many researchers including Calasanti and Kiecolt (2007). We wonder if these distinct partnered-caregiving patterns in cohabitation would be observed when the disability entails an illness such as Alzheimer’s disease as opposed to a more generalized functional limitation. Finally and equally important, cultural considerations should be a focus for future studies. In cultures where male-dominant, female-repressive marital relationships, sometimes along with large families, are prevalent, spousal care work may not be comprehensively ascribed by the masculinity/femininity dimension. Rather, the partners, especially if male, may simply pass the work along as a filial obligation to adult children, or opt for institutionalization if it is available and affordable. In this case, the care work is not abandoned, but rather the number of responsible parties is expanded and burden is shared, however unequal. The resulting triangular tension of care work would not be immediately ascertained, so questions along these lines remain inadequately explored in the literature.

Returning to Braun et al.’s (2009) view of capturing dyadic perspectives to better understand ever increasingly strained spousal relationships, perhaps a general theory of care work can be developed by using the field theory (e.g., Lewin, 1951) in terms of gender differences that would relate Calasanti’s masculinity/femininity model to Baker et al.’s (2010) analytics based on the self-perception of gender role conflict shared by caregivers and care-receivers. A concrete matrix composed of three arrays (i.e., care styles, coping, and interventions) in terms of masculinity/femininity, as they apply to qualitative data reflecting the experiences of both caregivers and care-receivers and quantitative measurement using Pearlin et al.’s (1990) constructs or other appropriate indices, would certainly advance understanding of the dynamics involved in spousal caregiving.

There are limitations in this study. The participants in all of the qualitative research (including Calasanti’s) are pre-baby-boomers. In addition, the majority of participants in these studies are of European origin. As a consequence, the findings are restricted culturally and racially. Throughout the presented studies, the mention by caregivers of marital commitments in the context of care work is predominantly apparent regardless of gender. The intensity and endurance of conjugal vows, however, might vary in culture and race from generation to generation.

To sum up, Calasanti’s construct of masculinity/femininity, based initially on the attributes of husbands and wives, could become a viable foundation for examining ADRD-related care work, when further developed, regardless of whether it is viewed from the distinction between men and women or from self-perceived gender identity. Yet, the latter approach needs more exploration to determine if there are differing dynamics in the caregiving/receiving situation due to changing social mores in couplehood such as cohabitation or same-sex marriage. Of equal importance is the impact of women’s pre-morbid careers as managing professionals, now that this has become so prevalent in modern society.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

Sung-chull Hong, PhD is a Research Associate at the Virginia Center on Aging (School of Allied Health Professions) at Virginia Commonwealth University (VCU). With a background in architecture (AIA) and planning (AICP), his primary research concern ia aging in place.

Constance L. Coogle, PhD is the Associate Director for Research in the Virginia Center on Aging. She adminstrers the Alzheimer’s and Related Diseases Research Award Fund and is also Director of Evaluation for the Virginia Geriatric Education Center. She has a joint appointment as an Associate Professor of Gerontology, as well as an affiliate appointment in the Department of Psychology at VCU.

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