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doi:10.1111/psyg.12365 PSYCHOGERIATRICS 2019; 19: 65–72

ORIGINAL ARTICLE

The hidden patient: chronic physical morbidity, psychological

distress, and quality of life in caregivers of older adults
Rajeswari SAMBASIVAM ,* Jianlin LIU,* Janhavi A. VAINGANKAR, Hui L. ONG, Min-En TAN,
Restria FAUZIANA, Louisa PICCO, Siow Ann CHONG and Mythily SUBRAMANIAM

Research Division, Institute of Mental Health, Sin- Abstract

gapore, Singapore
Aim: Increasing demands for care provision to older adults require good
Correspondence: Ms Rajeswari Sambasivam BSc
Psychology, Research Division, Institute of Mental physical and mental health among caregivers. Few studies have examined
Health, Buangkok Green Medical Park, 10 Buangkok the health status and correlates of quality of life among caregivers of older
View, Singapore 539747. adults. The present study therefore sought to examine the prevalence of
Email: [email protected] chronic physical conditions, psychological distress, and correlates of physi-
 Both authors contributed equally to the cal and mental quality of life among caregivers of older adults (≥60 years) in
manuscript Singapore.
Disclosure statement: None.
Methods: Participants were 285 informal caregivers who were providing
Centre Grant Programme of The National Medical
Research Council NMRC/CG/004/2013
care to an older relative. Participants were recruited at the Institute of Men-
tal Health, Singapore, and they completed self-report measures on chronic
Received 21 March 2018; revision received 20 June 2018;
accepted 18 July 2018. physical morbidity, psychological distress, and physical and mental quality
of life. Multiple regression models were constructed to examine correlates
of physical and mental quality of life.
Results: More than half of the caregivers had at least one chronic physical
condition (58.6%) and psychological distress (52.6%). Chronic physical
morbidity, psychological distress, and secondary education status were
associated with lower physical quality of life. Psychological distress, youn-
ger age, primary education status, and more time spent caregiving were
associated with lower mental quality of life.
Conclusion: Poor physical and mental health among caregivers may impair
their ability to provide adequate care to older adults with progressive medi-
cal needs. It is important for medical practitioners not to neglect the physi-
Key words: caregivers, chronic disease, mental cal and mental health of caregivers through continued assessment of
health, quality of life. chronic physical morbidity, psychological distress, and quality of life.

Its population is ageing rapidly, and the number of

INTRODUCTION
citizens aged 65 and above is expected to reach a
Demographic ageing is a shift in the age structure of
a country’s population towards older ages (age total of 900 000 by 2030, which is more than 25% of
65 and above) that is usually characterized by an the overall population.3
increase in the population’s mean and median ages, One consequence of an ageing population is the
a decline in the birth rate, and a rise in the proportion need for informal caregivers for older adults. An infor-
of older adults.1 According to a World Bank report, mal caregiver is an unpaid or paid person, usually a
countries in South-East Asia are undergoing a faster family member or a friend, who provides assistance
rate of ageing compared to other regions.2 Singapore with activities of daily living to an individual with ailing
is a multi-ethnic country located at the southern tip physical and/or mental health. The task of caring for
of the Malay Peninsula in South-East Asia. It has a an older adult with chronic health conditions requires
resident population of 3.9 million people comprising the caregiver to have good physical and mental
those of Chinese, Malay, Indian and other ethnicities. health because of the considerable physical and

© 2018 The Authors 65

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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which per-
mits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifica-
tions or adaptations are made.
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R. Sambasivam et al.

emotional demands involved in caregiving, which evaluate correlates of physical and mental quality of
often includes assisting the older adult with personal life among a sample of caregivers caring for older
hygiene, ensuring that medical needs are met, and adults (≥60 years) in Singapore.
dealing with the uncertain prognosis on a daily
basis.4–6
Caregivers are gradually increasing in age, placing METHOD
them at an increased risk of developing chronic con- Sample population and procedure
ditions, which has several implications.4,6,7 For
The present study used a cross-sectional design with
instance, caregivers diagnosed with chronic illnesses
convenience sampling to obtain a sample of
such as diabetes must maintain their blood sugar
285 informal caregivers (mean age  SD: 47.23
level by making sure to take their medication and eat
 10.87 years; range: 21–65 years) who were provid-
well-balanced meals on time, and they must go for
ing care to older adults. Participants were either
regular medical check-ups, which can be time-
referred by medical doctors at the Institute of Mental
consuming and emotionally draining. Caring for their
Health (n = 106), which is the only tertiary psychiatric
own health needs in turn reduces the amount of
institute in Singapore, or had given prior consent to
physical and psychological resources that caregivers
be re-contacted from an existing research database
can provide to older adults under their care. Quality
(n = 179) that had been part of an earlier population-
of life is defined as a person’s insight of his or her
based survey that examined the prevalence of
position in life in the context of the culture and value
dementia in Singapore.12 Sample size estimation was
systems in which they live and in relation to one’s
conducted, and it was found that a sample size of
own goals, expectations, standards, and concerns. It
285 was adequate to achieve a precision level of 3%
comprises various domains such as the person’s
at 80% power while accounting for 20% of
physical, psychological and social well-being, per-
missing data.
sonal beliefs, level of independence, and environ-
The inclusion criteria for the sample were as fol-
mental relationships.8 Burton et al. examined the
lows: (i) informal caregiver or family member living
hazards of caregiving and found that increased care-
with at least one older adult aged 60 years and
giving activity escalates the possibility of a fatigued
above and involved in or organized their care;
caregiver, putting the caregiver at a higher risk of
(ii) aged 21–65 years old; (iii) Chinese, Malay, or
declining physical and mental health.9 Other studies
Indian ethnicity; (iv) the ability to read, write, and
have also observed that poor sleep and increased
speak English fluently; and (v) a Singapore citizen or
fatigue have negative effects on caregivers’ physical
permanent resident. Older adults were referred to
and mental health by exacerbating physical and psy-
those aged 60 years and above, and some had been
chological morbidity, and reducing quality of life.10
diagnosed with chronic conditions, such as demen-
Although some studies have recognized the benefits
tia. Caregivers who had placed their older relatives in
of caregiving,11 most studies have reported a high
a nursing home at the time of recruitment were
prevalence of psychological distress, depression,
excluded. Participants provided written informed
and anxiety.5–7 Such detrimental effects on care-
consent, and ethics approval was obtained from the
givers’ health status adversely affect the quality of
Domain Specific Review Board of the National
care that they provide.
Healthcare Group, Singapore (ref no. 2014/00887).
Therefore, it is hoped that the findings of the pre-
sent study will provide additional insight on the prev-
alence of physical and psychological morbidity, as Measures
well as factors associated with caregivers’ physical Psychological distress
and mental quality of life. Such findings are neces- The General Health Questionnaire (GHQ-12) is a self-
sary to better inform holistic interventions that aim to report instrument that has been designed for use in
improve both physical and psychological health of clinical settings to assess psychological distress.13
caregivers of older adults. The present study thus The 12 items assess the level of psychological dis-
sought to examine the prevalence of chronic physical tress (e.g. ‘Have you recently been feeling unhappy
conditions and psychological distress and to and depressed?’) over the past few weeks with a

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Physical and mental health of caregivers

4-point Likert-type scale (e.g. range: 0 (better than Statistical Analyses

usual)–3 (much worse than usual)). The total score, The means and standard deviations were calculated
which was obtained by summing up the individual for continuous variables, while frequencies and per-
scores of the 12 items, ranges from 0 to 36. Higher centages were calculated for categorical variables.
scores indicate greater psychological distress. In Multiple regression models were constructed to
addition, a cut-off score of more than 11 on the examine the correlates of physical (PCS) and mental
GHQ-12 indicates possible clinical caseness of (MCS) quality of life. Correlates examined in the
depression and anxiety disorders.14 The GHQ-12 models included age, gender, ethnicity, education,
demonstrated good reliability for assessing the level marital status, employment status, caregivers’ rela-
of psychological distress (α = 0.87). tionship to the older adult, total time spent caregiv-
ing, chronic physical condition of caregivers and care
Physical and mental quality of life recipients, and psychological distress. Data were
The 36-item Short-Form Health Survey (SF-36) analyzed with SPSS version 23.0 (SPSS Inc., Chi-
covers eight health domains: (i) physical functioning; cago, IL, USA), with statistical significance level set
at 0.05 for all procedures.
(ii) physical role functioning; (iii) bodily pain;
(iv) general health; (v) vitality; (vi) social functioning;
(vii) emotional role functioning; and (viii) mental
health.15 This widely validated self-report measure is RESULTS
often used as a measure of health-related quality of Sociodemographic and clinical characteristics
life.15 The SF-36 further looks at the level of physical The sociodemographic and clinical characteristics of
quality of life (physical component summary (PCS)) the overall sample are summarized in Table 1. The
and mental quality of life (mental component sum- mean age of the caregivers was 47.23  10.87 years,
mary (MCS)) by working out the mean average of the and the majority were women (64.6%), of Chinese
physically relevant items and the emotionally relevant ethnicity (56.1%), married (60.7%), employed
items.16 Higher scores on the PCS and MCS indicate (75.8%), and had completed pre-tertiary education
better physical and mental quality of life, respectively. (36.6%). In addition, more than half (85.6%) of the
The PCS and MCS showed good reliability indexes caregivers were providing care to an immediate fam-
for the levels of physical (α = 0.79) and mental ily member.
(α = 0.85) quality of life, respectively. More than half (58.6%) of the caregivers had at
least one chronic physical condition. Frequencies
Sociodemographic characteristics and chronic and percentages of each chronic physical condition
are presented in Table 1. The most prevalent chronic
conditions checklist
physical condition was hyperlipidaemia (26.3%), fol-
Demographic information included the caregivers’
lowed by hypertension (22.1%) and back injuries
age, gender, marital status, ethnicity, education,
(11.6%). The overall prevalence of psychological dis-
employment, relationship to the older adult, and total
tress was 52.6% among this sample of caregivers.
time spent caregiving. To determine the number and
We had also assessed the overall level of psychologi-
type of chronic health conditions, participants were
cal distress (mean  SD: 11.03  5.29) as well as
asked to check a list of history of health problems
physical (PCS) (mean  SD: 52.36  7.11) and men-
that included arthritis, asthma, back injuries, diabe-
tal (MCS) (mean  SD: 49.51  9.50) quality of life.
tes, hyperlipidaemia, hypertension, migraine, thyroid
disease, mood disorder, anxiety disorders, and
schizophrenia spectrum disorders. The total time Correlates of quality of life among caregivers of
spent on caregiving was calculated based on the older adults
time spent per day (i.e. no time, 1–2 h, 3–5 h, or 6 h Tables 2 and 3 present two separate multiple regres-
or more) assisting or engaging with the older adult in sion models that examined the correlates of physical
eight areas of care (communicating, using transport, (PCS) and mental (MCS) quality of life among care-
dressing, eating, grooming, supervision, toileting, and givers. In the first model, which examined the corre-
bathing). lates of PCS, participants without any chronic

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R. Sambasivam et al.

Table 1 Characteristics of the overall sample significantly lower levels of physical quality of life
Total than those who had obtained tertiary education
(N = 285) (β = −3.22, 95%CI: −5.31–−1.14, P = 0.003). In the
Variable Frequency %
second model, which examined the correlates of
Age (mean  SD: 47.23  10.87 years) MCS, participants without psychological distress
21–39 75 26.3
40–65 210 73.7 (β = 8.88, 95%CI: 6.85–10.91, P < 0.001) and who
Gender were older (β = −4.80, 95%CI: −5.64–−0.23,
Male 101 35.4 P < 0.001) had significantly higher levels of mental
Female 184 64.6
Marital status
quality of life. Participants who had primary educa-
Single/other (separated/divorced/ 112 39.3 tion status had significantly lower mental quality of
widowed) life than those who had obtained tertiary education
Married 173 60.7
(β = −5.89, 95%CI −11.72–−0.06, P = 0.05). Partici-
Ethnicity
Chinese 160 56.1 pants whose care recipients needed care occasion-
Malay 38 13.4 ally also had a significantly lower level of mental
Indian 87 30.5 quality of life (β = −2.93, 95%CI −5.64–−0.23,
Education
Primary or below 9 3.2 P = 0.03) than participants whose care recipients did
Secondary 76 26.8 not need any care.
Pre-tertiary 104 36.6
Tertiary and above 95 33.4
Employment
Unemployed 69 24.2 DISCUSSION
Employed 216 75.8 Extending from previous research on chronic physi-
Caregiver’s relationship to older adult
cal morbidity and psychological distress in
Child 224 78.6
Spouse 18 6.3 caregivers,6,7 the present study aimed to examine
Other 43 15.1 the prevalence of chronic physical morbidity and psy-
Total time spent on caregiving (mean  SD: 3.60  3.93 h) chological distress and to evaluate correlates of qual-
Psychological distress caseness
Psychologically distressed 150 52.6 ity of life in caregivers of older adults in Singapore.
Not distressed 135 47.4 More than half (58.6%) of the caregivers reported
Chronic physical condition diagnosis at least one chronic physical condition, which is
At least one diagnosis 167 58.6
No diagnosis 118 41.4
lower than the prevalence rate (81.5%) reported in a
Chronic physical condition types† study of informal caregivers of older adults in the
Arthritis 19 6.7 USA.17 The caregiver sample in the study by Wang
Asthma 19 6.7
et al. had a higher mean age  SD (65.4  12.6
Back injuries 33 11.6
Diabetes 25 8.8 years) than the present study (47.23  10.87 years),
Hyperlipidaemia 75 26.3 which could account for the higher prevalence rate of
Hypertension 63 22.1 chronic physical conditions in the US study.17
Migraine 15 5.3
Thyroid disease 10 3.5 Although the present study had a lower mean age,
Total Scores Mean SD the majority (73.7%) of caregivers were within the
Psychological distress (GHQ-12) 11.03 5.29 40–65 age range. One in four Singaporeans above
Physical quality of life (PCS) 52.36 7.11
Mental quality of life (MCS) 49.51 9.50
the age of 40 has been diagnosed with at least one
†
chronic physical condition, and the risk of being diag-
Exact percentages based on the total sample were used for each chronic
physical condition type. GHQ-12, General Health Questionnaire; MCS, nosed with a chronic physical condition increases
SF-36 mental component summary; PCS, SF-36 physical component sum- with age.18 The caregivers with at least one chronic
mary; SF-36, 36-item Short Form Health Survey.
physical condition in the present study had a lower
physical quality of life than those without any chronic
physical conditions (β = 3.27, 95%CI: 1.58–4.95, physical conditions. The most prevalent chronic con-
P < 0.001) or psychological distress (β = 2.08, 95% ditions were hyperlipidaemia, hypertension, and back
CI: 0.43–3.73, P = 0.014) had significantly higher injuries. Chronic conditions, such as hypertension
levels of physical quality of life. Participants who had and back injuries, are reported to have a significant
obtained secondary education status had negative impact on quality of life,19,20 and caregivers

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Physical and mental health of caregivers

Table 2 Multiple regression model for correlates of physical quality of life (physical component summary)
β 95%CI P-value
Age −0.04 −2.03 1.96 −0.97
Gender (male) 0.74 −0.94 2.42 0.30
Ethnicity (non-Chinese) −1.41 −3.07 0.25 0.10
Marital status (single/other) −1.03 −2.73 0.68 0.24
Employment status (unemployed) −0.89 −2.78 0.10 0.35
Education (primary) −3.72 0.8.5 1.03 0.12
Education (secondary) −3.22 −5.31 −1.14 0.01*
Education (pre-university) −0.82 −2.79 1.14 0.41
Education (tertiary) Ref.
Relationship (child) 1.61 −1.98 5.19 0.34
Relationship (other) 2.43 −1.54 6.39 0.23
Relationship (spouse) Ref.
Time spent caregiving (no time) 0.39 −2.17 2.92 0.97
Time spent caregiving (1–2 h) −0.27 −2.71 2.18 0.83
Time spent caregiving (3–5 h) −1.17 −3.48 1.13 0.32
Time spent caregiving (>6 h) Ref.
Chronic physical condition caregiver (no) 3.27 1.58 4.95 0.001**
Chronic physical condition care recipient (no) 1.11 −1.95 4.17 0.29
Extent of care needed (Needs care much of the time) −1.96 −4.30 0.39 0.10
Extent of care needed (Needs care occasionally) 0.10 −2.11 2.30 0.93
Extent of care needed (Does not need care) Ref.
Psychological distress (no) 2.08 0.43 3.73 0.01*

* P < 0.01. ** P ≤ 0.001. CI, confidence interval.

with back injuries were likely to have had difficulties mental health conditions are likely to result in poorer
in their mobility, which may hinder their ability to pro- physical and emotional outcomes among
vide day-to-day care for themselves and those older caregivers.6
adults under their care. Other chronic conditions like The present study found that 52.6% of the care-
diabetes were also reported to be associated with givers had psychological distress. This is similar to
emotional distress, and comorbid physical and previously reported prevalence rates (51–55%) of

Table 3 Multiple regression model for correlates of mental quality of life (mental component summary)
β 95%CI P-value
Age (21–39 years) −4.80 −7.25 −2.35 0.001***
Gender (male) 0.53 −1.53 2.60 0.61
Ethnicity (non-Chinese) 0.70 −1.34 2.73 0.50
Marital status (single/other) −0.46 −2.55 1.64 0.67
Employment status (unemployed) −0.08 −2.23 2.40 0.94
Education (primary) −5.89 −11.72 −0.06 0.05*
Education (secondary) −1.99 −4.55 0.58 0.13
Education (pre-university) 0.35 −2.06 2.76 0.77
Education (tertiary) Ref.
Relationship (child) −0.65 −5.05 3.75 0.77
Relationship (other) 1.95 −2.93 6.82 0.43
Relationship (spouse) Ref.
Time spent caregiving (no time) 1.66 −1.50 4.78 0.30
Time spent caregiving (1–2 h) 0.42 −2.59 3.42 0.79
Time spent caregiving (3–5 h) 0.50 −2.34 3.34 0.73
Time spent caregiving (>6 h) Ref.
Chronic physical condition caregiver (no) 0.54 −1.53 2.61 0.61
Chronic physical condition care recipient (no) 1.01 −2.75 4.76 0.60
Extent of care needed (Needs care much of the time) −1.07 −3.95 1.81 0.47
Extent of care needed (Needs care occasionally) −2.93 −5.64 −0.23 0.03*
Extent of care needed (Does not need care) Ref.
Psychological distress (no) 8.88 6.85 10.91 0.001***

* P < 0.05. ** P < 0.01. *** P ≤ 0.001. CI, confidence interval.

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R. Sambasivam et al.

psychological distress in caregivers.21 As suggested review conducted by Farina et al. reports that when
by Hudson et al., caregivers experience multiple neg- care recipients demand more care from their care-
ative physical, emotional, social, and financial givers, the quality of life of the latter is negatively
stressors due to the increased demands of caregiv- affected.28
ing, leading to overwhelming stress and psychologi- The present study’s findings on psychological dis-
cal distress.21 tress and mental quality of life are supported by pre-
The findings of this study corroborate previous vious studies,6,7 which showed that higher levels of
research on the distinct properties of the PCS and psychological distress are associated with poorer
MCS because of different factors found to be associ- mental quality of life among caregivers. Importantly,
ated with these.22,23 First, the present study more time spent dealing with daily challenges associ-
observed that lower education level, the presence of ated with caregiving may in turn result in persistent
chronic physical conditions, and the presence of psy- psychological distress with deleterious effects on
chological distress were associated with a lower mental quality of life among caregivers.29 Recogniz-
physical quality of life. A higher education status ing these factors is critical as they help to address
could result in a greater availability of economic the caregivers’ issues more effectively.
resources, which in turn may have a positive influ-
ence on physical quality of life. While there have been Study limitations
positive findings on the influence of education on The present study adopted a cross-sectional design
quality of life in other populations,24,25 past research to assess the physical and mental health of care-
has not examined the influence of education status givers. This did not allow for the interpretation of
on physical quality of life among caregivers of older causal relationships such as whether greater psycho-
adults. Next, the presence of chronic physical condi- logical distress reduced quality of life. Future longitu-
tions and psychological distress may suggest lan- dinal research should examine potential changes
guishing physical and mental health among between correlates of physical and mental quality of
caregivers. In addition to the burden of caring for an life over time. Latent growth models may also be
older adult, caregivers are likely to experience multi- constructed to examine the trajectories of quality of
ple daily stressors that may result in a lower physical life. This will enable researchers to understand the
quality of life.4,6,7 risk and protective factors that influence physical and
Younger age, lower education level, psychological mental quality of life over time. Study inclusion was
distress, and care recipients who needed occasional limited to caregivers who were able to read and
care were associated with a lower mental quality of understand the English questionnaire in the study.
life. Previous research found that older age was This limits generalizability for caregivers with low
associated with a lower mental quality of life among education or those educated in other languages such
caregivers, which was contradictory to the present as Chinese, Malay, or Tamil. The additional use of
study findings.26,27 However, samples of caregivers convenience sampling may have introduced bias into
in previous studies were older (mean range: 60.36– the present study, but this was necessary to achieve
65.7 years) than in the present study (mean an adequate sample size of caregivers who were pro-
age: 47.23 years). In addition, these studies were viding care to older adults.
focused on caregivers of stroke patients who may The GHQ-12 and the SF-36 (MCS) contain similar
have faced different challenges and experienced a items, and this may have an implication from a con-
differential impact on mental quality of life compared ceptual perspective because of the possibility of
to caregivers of older adults.26,27 Further research measuring a single construct. From a statistical per-
that examines age differences and mental quality of spective, highly correlated constructs may also
life among caregivers of older adults may clarify this increase the risk of multicollinearity, and this may
discrepancy; specifically, research may consider have an implication on the interpretation of our find-
exploring differences in mental quality of life between ings. A multicollinearity test was performed for all
younger (mean: 40 years) and older caregivers predictors, and the test revealed acceptable values
(mean: 60 years) of older adults while adjusting for (close to 1) and low variance inflation factor values. In
other potential confounding variables. A systematic addition, bivariate correlations were performed that

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Physical and mental health of caregivers

showed that the GHQ-12 was significantly and nega- reduction of psychological distress, improved physi-
tively correlated with the SF-36 (MCS) score cal and mental quality of life, and the ability to pro-
(r = −0.76). The inverse relationship may suggest the vide better care to older adults in need.
presence of two distinct constructs (psychological
distress and quality of life). However, it should be
noted that both the GHQ-12 and SF-36 are self-
report measures, and future studies should consider ACKNOWLEDGMENTS
the use of structured clinical interviews to corrobo- This work was supported by the Centre Grant Pro-
rate information obtained from self-report measures. gramme (grant no. NMRC/CG/004/2013). The funding
Although the GHQ-12 was able to detect psycho- source had no role in the study design, data collec-
logical distress within the present sample, it is limited tion, analyses, data interpretation, or publication of
in identifying the prevalence and symptomatology of the manuscript. The authors would like to thank all
specific, underlying psychiatric disorders among research staff and participants for assisting and par-
caregivers. Future research should consider the use ticipating in this study.
of clinician assessment tools to corroborate screen-
ing results on the GHQ-12, as they are able to pro-
vide more information on the prevalence and REFERENCES
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