The costs of family caregiving: implications for geriatric oncology

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1 Critical Reviews in Oncology/Hematology 48 (2003) The costs of family caregiving: implications for geriatric oncology William E. Haley Department of Gerontology, SOC 107, University of South Florida, Tampa, FL 33620, USA Accepted 30 April 2003 Contents 1. Introduction Background on family caregiving Cancer caregiving nature and extent of caregiving roles Costs of cancer caregiving major domains Mental health Physical health Social and economic costs Sustained costs of caregiving after bereavement Sustained costs of caregiving after cancer survivorship Benefits of caregiving Factors affecting caregiver response Interventions to minimize the costs of caregiving Implications for research and clinical practice Reviewers References Biography Abstract Older adults with cancer receive considerable care from their family members. The article reviews the types of stressors family members face while caregiving, and what is known about the psychological, physical health, social, and economic costs of caregiving. The benefits experienced by caregivers, and sustained effects on families after bereavement or cancer survivorship are also reviewed. Interventions that are promising in decreasing the costs of caregiving, and implications for research and clinical practice are discussed Elsevier Ireland Ltd. All rights reserved. Keywords: Family caregiving; Stress and coping; Elderly 1. Introduction While the patient with cancer is understandably the focus of most efforts in cancer treatment, the effects of cancer on family members also deserves considerable attention. Par- Tel.: ; fax: address: (W.E. Haley). ticularly for older patients, family members often assume a caregiving role that includes help with the cancer treatment regimen, psychological support of the patient, and direct assistance with impairments in the patient s activities of daily living. The caregiving role can be highly stressful and can lead to considerable psychological, social, economic, and health costs for the family caregiver. This presentation will review what is known about the effects of the stress of caregiving on family members, factors that affect response to /$ see front matter 2003 Elsevier Ireland Ltd. All rights reserved. doi: /j.critrevonc

2 152 W.E. Haley / Critical Reviews in Oncology/Hematology 48 (2003) caregiving, interventions to assist caregivers, and implications for clinical practice and policy. 2. Background on family caregiving Family caregiving is increasingly recognized as a common and important activity. There are no precise estimates of total caregiving activities by family members across all ages and conditions, but the available findings make it clear that such caregiving is common and substantial. Estimates on the extent of caregiving for older adults in the United States vary depending on the age groups included and the extent of care provided. For example, from 5.8 to 7 million Americans provide assistance for a person over age 65 with an impairment in activities of daily living, while up to 52 million caregivers provide assistance to someone aged >20 years who is ill or disabled [1]. Most researchers distinguish between normative or usual caregiving assistance provided to relatively health individuals, and extraordinary caregiving provided in response to serious illness and/or disability [2]. In addition, most caregiving by family members is considered informal or unpaid, in contrast to formal caregiving, which is provided by professionals for pay. While caregiving for disabled or ill individuals can occur across the life span, the majority of caregiving efforts are for older adults, since older individuals have greatly increased rates of disability [3]. Given the projected growth of the older adults population in the United States, the need for family caregiving is expected to soar in the coming decades [3]. The motivation for informal caregiving is primarily voluntary and related to bonds of attachment between family members, but can also be affected by cultural norms about family obligations, or feelings of guilt and obligation [4]. Families commonly prefer to care for disabled relatives themselves when they have the capacity to do so, which saves substantial expenses in formal care such as nursing home care. Older adults are usually highly motivated to remain in their homes even with illness and disability. Families also experience pressures to provide caregiving due to the limits of community services, and the high financial burden associated with hospital and nursing home care. These changes have resulted in more families, particularly spouses and adult daughters, assuming the role of caregivers. Most previous research on caregiving has focused either on caregiving for patients with Alzheimer s disease and other dementias a particularly demanding and stressful form of care or more broadly to caregiving for frail elders who may vary considerably in the extent of caregiving they need. In an analysis of data from the National Caregiving study, it was found that 36.8% of the dementia caregivers and 51.8% of the non-dementia caregivers provided care for 8 h a week or less [5]. At the other extreme, 16.1% of the dementia caregivers reported providing constant care versus 10.9% of the non-dementia caregivers. While the present review will emphasize what is known about informal caregiving for older individuals with cancer, relevant information from other areas of caregiving research will also be noted. The evidence base concerning the effects of cancer caregiving has not addressed a number of important issues, and many older adults present with multiple conditions that may affect caregiving, including dementia, so pertinent research that might guide clinical practice and research specific to cancer caregiving merits consideration. 3. Cancer caregiving nature and extent of caregiving roles Family caregivers provide much of the care for older adults with cancer. This care can vary from minimal assistance through total care of highly debilitated patients, and may be related not only to cancer but also to multiple comorbidities in older patients. Family members are often involved in stressful decision making throughout the course of cancer care, including decisions about whether to use hospice or other palliative care programs and proxy decision making about end-of-life issues [6]. Caregiving may also involve very difficult and stressful activities including witnessing or managing incontinence, pain, dyspnea, anorexia, cognitive impairment, and death. The duration of caregiving may be very brief or extend over many years, and may include survivorship issues. In many situations, caregiving ends with the death of a spouse or other close relative, and the subsequent stress of bereavement. It is difficult to make general statements about the requirements of cancer caregiving because of the diversity of cancer in later life and the diversity of impairments experienced by older patients. For family caregivers of some cancer patients minimal assistance with activities of daily living and emotional support for the older adult who is facing the illness are the daily requirements. In contrast, families of patients with end-stage lung cancer may provide extensive assistance with medical care and activities of daily living. Adding to the complexity of making generalizations about the extent of caregiving provided in cancer is that older adults may have premorbid or comorbid conditions, such as dementia, along with the cancer. In such circumstances of caregiving for multiple comorbid conditions caregiving may be extremely stressful. A recent publication by Hayman et al. [7] estimates that current treatment for cancer in older adults is associated with a 31% increase in the likelihood of receiving informal caregiving compared with older adults without cancer, and a 45% increase in hours of informal caregiving per week. In this national sample older adults receiving current cancer treatment reported receiving on average 10 h per week of care [7], of which less than 1/3 was specific to their cancer. Because this figure includes all elderly individuals with cancer, it underestimates the extent of caregiving that might be provided for more serious illness. In contrast, a recent study

3 W.E. Haley / Critical Reviews in Oncology/Hematology 48 (2003) of spousal caregivers of hospice patients with lung cancer reported that wives spent an average of 127 h per week in the caregiving role, and husbands reported an average of 105 h per week [8]. Older cancer patients may face a number of stressors that are extremely difficult, but have not been systematically characterized. Many of these occur because cancer patients may be undergoing aggressive treatment regimens aimed at palliative care, cure, or the remission of cancer. For example, depending on the type of cancer, family caregivers may coordinate and witness complex medical regimens, such as chemotherapy, radiation, or infusion therapy in an ambulatory or home setting. Family caregivers may assist the patient in coping with treatment-related side effects, such as nausea and vomiting. These diverse stressors need to be more systematically studied in order to understand the role that primary stressors may have upon caregivers mental and physical health outcomes. Existing research suggests that assisting with self-care tasks, managing patient symptoms [9] and the treatment regime [10], and witnessing the suffering of the relative with cancer [11] are major stressors identified by cancer caregivers. Greater psychosocial problems may arise when cancer metastasizes [12]. Terminal care provides other unique stressors. Family caregivers must deal not only with difficult in-home care tasks, but also coping with sensitive aspects of the death of their relative, including closing the eyes upon death or dealing with material expelled upon death [13]. Finally, caregiving can also lead to secondary stressors that are indirectly caused by caregiving. These can include role strain (e.g. problems in maintaining employment or roles as spouse and parent), strains on finances, family conflict, and intrapsychic strains, such as feelings of guilt or changes in the caregiver s self-concept [14]. These spillover effects may be important but not addressed by the healthcare team because they seem external to the task of care for the patient with cancer. Existing research suggests that finances, managing the household, alterations in roles, employment changes, disrupted schedule, and lack of family support [9,13,15] are secondary stressors identified as problems by cancer caregivers. Cancer causes changes in the family s identity, roles, and daily functioning. The effect of such changes may be profound and long lasting, regardless of the outcome of the disease [16]. Many caregivers experience negative effects from the stress of caregiving, depending on the nature of caregiving, extent of care provided, the duration of care, and the coping resources of the family. These can be hidden costs of care that are borne by family members, such as negative effects on psychological, social, or physical health functioning [17]. Since caregivers may experience adverse effects, attention to caregiving issues is important in understanding how this major, unpaid segment of our health care and long-term care system works and what we can do to minimize the burdens of caregiving. The effects of cancer caregiving on major domains, including mental and physical health, and economic and social well-being, will now be reviewed. 4. Costs of cancer caregiving major domains 4.1. Mental health Most of the research on the mental health risks of family caregiving has been conducted within the context of dementia. Across a large number of studies, there is strong evidence that dementia caregiving leads to an increased risk for both depressive disorders and depressive symptoms compared with population norms and appropriate control groups [18,19]. Up to 30% of dementia caregivers experience a depressive disorder, and up to 55% report clinically significant depressive symptoms on self-report instruments [18,19]. The few studies that have attempted to assess the mental health impact of caregiving for relatives with cancer have not always detected marked negative effects, although these studies have often included caregiving for patients requiring minimal levels of caregiving assistance. In Sales et al. s review [12], several researchers indicate that most family members do not develop clinically problematic levels of emotional distress when coping with the demands of cancer. However, Mor et al. [20] reported rates of depression in cancer caregivers that are somewhat higher than population norms, but are lower than rates found in dementia caregivers. One recent study comparing dementia caregivers and lung cancer caregivers in hospice found that cancer caregivers reported the same levels of depression as dementia caregivers, but female caregivers reported higher levels of depression than male caregivers [8]. Haley et al. also found that both lung cancer and dementia caregivers reported lower life satisfaction and higher levels of depression than non-caregiving controls and normative data [8]. It is of note that this project focused on caregivers of patients who were severely impaired and terminally ill, thus exposing both groups of caregivers to very high levels of stress Physical health Negative physical health effects of caregiving have been widely documented in studies of dementia caregiving, and in broader studies of caregiving stress, but have not been widely studied specifically in response to cancer caregiving. A recent review [19] which examined studies that have used sophisticated approaches to measure the effects of caregiving on physical health found that intensive caregiving can lead to lowered immune system functioning [21], altered response to influenza vaccination [22], and slower wound healing [23]. This review also found that caregiving can lead to increased blood pressure [24] and altered lipid profiles [25]. One recent study found evidence that caregivers who feel highly stressed in their roles showed a 63% increase in mortality over a 4-year period compared with non-caregivers

4 154 W.E. Haley / Critical Reviews in Oncology/Hematology 48 (2003) or caregivers who do not report being highly stressed [26]. Thus, caregiving can clearly put family members at risk for health problems. A recent project examining self-reported health in both lung cancer and dementia caregivers reported lower perceived health among spouse caregivers than carefully matched non-caregiving controls [8]. It is of note that this project focused on caregivers of patients who were severely impaired and terminally ill, thus exposing both groups of caregivers to very high levels of stress Social and economic costs In the broader literature on family caregiving, caregiving has been noted to put families at risk for social isolation, decreased levels of social activities, and to lead to substantial economic costs for families [19,27]. There is also a related literature documenting the social and economic costs of terminal illness, including but not specific to cancer [28,29]. Research on cancer caregiving and its social and economic impact have been surprisingly sparse [30]. Most of the research has focused on examining the impact of cancer on the patient s supportive network instead of examining effects on the caregiver s social support. The few studies available suggest that family caregivers of cancer patients experience a lack of perceived support from family members and the medical staff [10,30,31]. One recent study found that cancer caregivers with a low level of daily emotional support were more depressed over time [32]. A study that attended to the social consequences of caregiving found that over half of cancer caregivers report disruption of their daily routines, with over half of the caregivers also reported reduced socializing with neighbors, friends, and others due to the demands of caregiving [20]. Decreased social activities can also produce a sense of interpersonal loss for the caregiver, and lead to loss of intimacy and affection, increased symptoms of depression, and increased feelings of resentment [33]. Using a national data set, Hayman et al. [7] have recently reported a detailed study of the economic impact of informal caregiving for older cancer patients. They estimate that informal caregiving costs specifically for older adults with cancer (above and beyond caregiving for other conditions they may have) are about US$ 1200 per patient per year, totaling over US$ 1 billion annually in the United States. It is of note that total yearly costs of informal caregiving for older adults with cancer treatment in the previous year were about 10 h of caregiving per week, estimated at US$ 4200 per year [7]. These results are noteworthy in that management of the elderly cancer patient will require attention to both cancer-specific and more general caregiving needs of the patient Sustained costs of caregiving after bereavement Since caregiving is highly stressful, its end via death of the family member may lead to relief from the daily strains of caregiving. It may also lead to sustained distress related to problems that started while caregiving (e.g. loss of roles), and new problems brought on by the stress of bereavement. The available research suggests that some caregivers, particularly those who experience very high stress while caregiving, do not show increases in depression after the death of their relative and may even show improvements in certain aspects of their health [34]. However, other caregivers have long-term depression that is sustained even years after highly stressful caregiving ends [35]. The depletion of caregivers resources, alterations in their social supports and activities, and the lingering reminders of caregiving and loss may make the bereavement process more difficult for some caregivers. Little research has focused on sustained effects of caregiving during bereavement, and the present reviewer has identified no studies specific to cancer on this topic. In one longitudinal project, Robinson-Whelan et al. [35] found that, even at 3 years after the death of a relative with dementia, caregivers as a group reported levels of depression as high as when they had active caregiving responsibilities and far in excess of non-caregiving controls. Of interest is that two factors were found to be particularly predictive of continued distress: low levels of social support and high levels of rumination (repetitive thinking) about the caregiving situation [35]. In a longitudinal study of bereavement after hospice care, Nolen-Hoeksema and Davis [36] found that bereaved former caregivers with a ruminative coping style, who tend to focus excessively on their own emotional reactions to a trauma, coped more poorly during bereavement. Schulz et al. [34] found that highly stressed caregivers showed stable levels of depression after bereavement, while unstrained caregivers report increased depression after loss. Future research should examine subgroups of caregivers who may be at greatest risk, versus those who are particularly resilient to the stress of bereavement. The limited evidence on this topic specific to cancer suggests that cancer caregiving may also lead to such troublesome problems for bereaved caregivers [37]. It appears likely that caregivers who become socially isolated or depressed after lengthy and extensive caregiving duties may have similar problems in resolving their grief and resuming an active life. There is a need for more research on the long-term effects of caregiving on bereaved caregivers, including not only effects on psychological well-being, but also on physical health and mortality, given the extensive literature demonstrating that bereavement leads to excess mortality, especially for men [38]. Some studies suggest some improvements in caregiver well-being after death of the relative and cessation of caregiving responsibilities, including decreases in role strain, increases in the sense of mastery, and increased levels of social engagement [39]. Thus, clinicians should be sensitive to the balance of loss and relief that can be simultaneously experienced when bereavement follows extensive caregiving.

5 W.E. Haley / Critical Reviews in Oncology/Hematology 48 (2003) Sustained costs of caregiving after cancer survivorship Having cancer has the potential for negative long-term psychosocial and physical sequellae although generally cancer survivors quality of life increases with greater time elapsed since treatment [40,41]. Such problems are heightened in cancers with high probability of metastasis or recurrence. While younger cancer survivors have generally been found to attain maximum physical and psychological functioning approximately 1 year after primary treatment [42], there are reasons to be concerned that older adult cancer survivors may face additional problems that complicate their recovery from cancer. Older patients may have multiple other comorbid diseases and/or functional impairments that can affect their recovery. At present, little is known about the implications of cancer survivorship for the family member. However, it is likely that the family caregiver will be at risk for sustained problems to the extent to which the older cancer patient experiences psychological distress, functional impairment, or fear of recurrence. This is an area that merits greater attention as more older adults survive cancer Benefits of caregiving While caregiving can lead to serious negative consequences, recent work has also examined positive outcomes of caregiving, including improvement on measures of the caregiver s level of mastery, satisfaction, and other perceived benefits of caregiving. Some caregivers do report benefits from the caregiving experience. For example, one study of men who survived testicular cancer found that the men and their wives experienced improvements in a number of dimensions of marital outcomes, including increased intimacy, as a result of the experience of coping with cancer [43]. One recent study found that caregivers may sustain their quality of life by deriving self-esteem from caregiving [15]. Another recent project [8] also found that many spouses also report experiencing benefits from caregiving. Some of the gains that are reported by caregivers include giving back to someone who has cared for them, satisfaction of knowing that their relative is getting excellent care, sense of personal growth, and gaining meaning and purpose in one s life. Some caregivers also feel that they are passing on a tradition of care and that by modeling caregiving their children will be more likely care for them if this is necessary. This sense of satisfaction and well-being can have important benefits for caregivers well after caregiving has ended [44]. It is important for future research on caregiving to pay greater attention to the balance between costs and benefits of caregiving. 5. Factors affecting caregiver response Spousal caregivers may be especially vulnerable because of their own age, health, and willingness to sacrifice themselves for the care of their partner. The average number of hours spent in the caregiving role per week by a spouse is substantially greater than for an adult child, and spouses are shown to provide this care for a much longer period of time [45]. Spousal caregivers are often in poorer health than non-caregivers, yet they have no greater number of social supporters to assist them in their caregiving roles [46]. Spousal caregivers report more fatigue, less energy, and more sleep difficulty than non-spousal caregivers [47]. Race and ethnicity are increasingly recognized as important in caregiving because of diverse cultural values and supports. Few studies have addressed racial/ethnic diversity in cancer caregivers, but in studies of dementia care, African American caregivers are shown to have higher levels of mastery related to caregiving and lower depression than White caregivers in a number of different studies [48]. Research indicates that while adult children are a major source of care for both older Whites and African Americans, African Americans are more likely to be cared for by a member of their extended family than Whites [48]. Some ethnic groups have very strong norms about caregiving, and may expect specific family members (such as the eldest son in Chinese families) to be responsible for caregiving [49]. Further studies are needed to investigate racial/ethnic differences among cancer caregivers and to heighten our ability to provide culturally sensitive care to diverse families. Stress process models have been applied to the study of cancer caregiving [16]. Fundamental to stress process models is that there are marked individual differences in reactions to caregiving. Some caregivers react with depression, poor health, or feel substantial burden, while other families show little or no negative impact (and may even report benefits from caregiving). These models have been generally supported and suggest that caregivers who subjectively appraise stress in a benign manner, and with greater social support, cope best with the stress of caregiving [16]. In addition, personality styles such as optimism [50], and use of problem-focused coping approaches are related to better caregiving outcomes [16]. Measures of the objective severity of patient impairment account for less variance in caregiver well-being than patient behavioral problems, pain, and mood disturbances and caregivers subjective reactions to caregiving stressors [5,51]. 6. Interventions to minimize the costs of caregiving There has been considerable research investigating psychosocial interventions intended to improve caregiver depression and well-being but most of this research has been conducted with Alzheimer s caregivers. In a meta-analysis of dementia caregiving interventions [52], it was found that individual and family interventions showed particular promise, when compared with group interventions such as support groups. Another recent review [53] found that more active and individually targeted caregiver interventions are more effective than support group interventions. These

6 156 W.E. Haley / Critical Reviews in Oncology/Hematology 48 (2003) findings are encouraging in that positive effects have been well documented with caregivers, but these interventions are less generally available to families than are support groups. One of the most important needs of caregivers is information regarding the disease and its treatment, as well as that of caregiving. In a group of family caregivers of cancer patients during bone marrow transplantation, five categories of information needs emerged: (1) preparing for caregiving, (2) managing the care, (3) facing challenges, (4) developing supportive strategies, and (5) discovering unanticipated rewards and benefits [54]. Research has also shown that education about cancer pain improves family caregivers knowledge about pain and their experience caring for the elderly patient in pain [55]. Several studies have evaluated the impact of intervention protocols on the well-being of the cancer caregiver. One individualized intervention that introduced problem solving skills to aid cancer caregivers did not find greater improvement in the treatment group and the control group on a broad range of psychosocial measures [56]. However, many of the caregivers in this project were found to have relatively low levels of caregiving activities, and the authors suggest that greater benefits of intervention were found among a highly distressed subsample of caregivers [56]. A number of recent intervention studies have produced impressive evidence of positive results for the caregiver from innovative interventions targeting both the patient and the caregiver. In one intervention, specialized oncology home care services were provided to terminally ill patients with lung cancer and their families in a randomized controlled trial [57]. Psychological distress was significantly lower among spouses of patients receiving this intervention than with those who receive standard home care or office care. A very important aspect of this intervention is that its efficacy was sustained over a 13-month period. Another intervention was a transmural care intervention for terminal cancer patients. This study reported that the intervention had a significantly positive effect on the quality of life of the primary caregivers when compared with standard community care [58]. Communication and continuity of care was the emphasis of this intervention, and the effect was evident both at 1 week after discharge and 3 months after the death of the patient. The enhanced coordination and cooperation between professional caregivers working in intramural and extramural care was the main factor to which the authors attributed the results. This enhanced cooperation leads to improved supportive care for both the patients and the caregivers. Family caregivers value specific caregiving skills taught by their health care providers, such as communication, symptom management, and resource identification. A 6-h Family Caregivers Cancer Education Program encompasses education and support for caregivers [59]. Participant evaluations demonstrate that caregivers who attend the course feel less overwhelmed, more knowledgeable, and better able to cope with caregiving experience. A number of interventions have been used to assist families with the grieving process, including support groups, and family support offered through hospice programs. It is important to note that hospice provides grief counseling prior to death and follow-up contact is made in 100% of those who utilize hospice services, while only 2% of nursing homes reported the availability of these services [60]. This same study found that 76% of nursing homes were unable to offer a referral to a counseling or psychiatric professional when bereavement intervention was deemed necessary [60]. Few bereavement services are generally offered to families after death in hospitals as well [61] unless hospice is involved in care. While hospice interventions appear promising, future research needs to more rigorous in assessing the impact of interventions on the long-term outcome of bereavement. Of particular interest in the current context is whether psychosocial intervention during caregiving might prevent complications in the bereavement process. Many hospice programs attend to such issues by beginning bereavement counseling before the patient s actual death [62]. The impact of such intervention needs further research. 7. Implications for research and clinical practice Caregiving can lead to significant hidden costs for family members, including domains such as finances, mental health, physical health, and social engagement. Highly stressed caregivers have been found to have increased rates of depression, worsened physical health, and decreased levels of social engagement compared with age-matched controls. Caregivers often suffer major financial costs as well. Many of these effects can be sustained even after the death of the patient. Thus, caregiving should be viewed as more than an inconvenience, and caregivers should be considered a population at risk for depression and physical health populations. This review suggests several areas of research that are particularly lacking in the study of family caregiving for older cancer patients. More research should be placed on the special needs of ethnically diverse caregivers, and on the physical health consequences of caregiving. More intervention research, particularly in the area of bereavement care, is also needed. There are few studies of the practice behaviors of oncologists in regard to family caregivers, an area that could be particularly important because of the significance of the physician for the family member. Research in other areas, such as end-of-life care, shows that family caregivers who perceive their physician as being a good listener report less depression and social disruption in their daily lives than caregivers who report less empathy [20]. This raises the possibility that physician care and concern may be an important component of care that could be trained and nurtured [20]. It is likely that oncologists could benefit from better training about family caregiving issues. The American Medical Association has

7 W.E. Haley / Critical Reviews in Oncology/Hematology 48 (2003) called on physicians to consider family caregivers partners in the care of frail older adults [63]. It has long been acknowledged in geriatrics that physicians, patients, and family members often form a triad essential in the care of older adults [64] and geriatric oncology is a special example of this circumstance. In instances where the oncologist is not able to provide necessary assistance to family members, referral to other professionals with expertise in dealing with caregiver issues is recommended. This review identified a number of interventions for caregivers that have shown strong evidence for efficacy in randomized trials. However, these evidence-based interventions are not widely available and many caregivers are offered only support groups, which while popular have not been shown to have potent effects on caregiver well-being. As in other areas of geriatric care, there is a gap between typical practice and the knowledge base that should be reduced [65]. Clinicians, researchers, and policy makers are urged to recognize that caregiving can lead to extensive, hidden costs for family caregivers, and that these costs occur across diverse illnesses and conditions [66]. Besides our efforts to help patients with cancer, it is important to address the needs of family caregivers as part of comprehensive care. Caregivers make enormous financial, emotional, and sometimes health sacrifices to provide this care. These impacts may vary across societies for example, in some European countries, caregivers are given credits within social insurance plans or other compensation, while American family caregivers do not receive such benefits. Regardless of the supports provided by society, family caregivers can become hidden patients and we should do everything possible to give them the support they need for this important role. 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Haley, Ph.D., received his doctorate in clinical psychology from the University of Massachusetts, Amherst, and completed a clinical internship and postdoctoral fellowship at the University of Washington, Seattle. He has over 100 publications on such topics as stress and coping in family caregivers, mental health and aging, and psychosocial interventions for older adults and their families. He is the past-president of the Section on Clinical Geropsychology of the American Psychological Association, and chair-elect of the Behavioral and Social Sciences Section of the Gerontological Society of America. He is a fellow of the American Psychological Association and the Gerontological Society of America. He is currently a professor and chair of the Department of Gerontology at the University of South Florida, where he holds joint appointments in the Department of Psychology, Division of Geriatric Medicine, and H. Lee Moffitt Cancer Center and Research Institute.