Relationship between anxiety and fatigue in dementia family caregivers: hope as a mediator

This study employed a cross-sectional design to investigate the relationships between anxiety, hope, and fatigue in family caregivers of individuals with dementia who lived in the community. Data were collected from July 2023 to May 2024 at the dementia daycare center, community dementia service sites, and dementia care center at Tzu Chi Hospital in Hualien, eastern Taiwan.

A total of 84 caregivers of individuals with dementia were recruited and completed scales measuring their anxiety, hope, and fatigue. The inclusion criteria were as follows: (1) aged between 20 and 75 years and able to communicate in Mandarin or Taiwanese; (2) currently not hospitalized or receiving treatment for severe physical or mental health problems; and (3) a family member serving as a caregiver for a patient with dementia rather than a hired caregiver.

The hospital’s institutional review board approved the study protocol. All family caregivers were thoroughly informed about the study’s objectives and procedures and the time required to complete the questionnaire. They were also informed of their right to withdraw from the study at any time. Before completing the questionnaire, each participant provided written informed consent.

The data were analyzed via SPSS version 20.0. The statistical analysis was divided into two parts. The first part involved using descriptive statistics to assess the distributions of the dependent and independent variables. Frequency distributions and percentages were used to analyze variables such as gender, age, education level, marital status, religious beliefs, cohabitation status, caregiver relationships, availability of additional caregiving support, and the CDR of family members with dementia. The second part involved inferential statistics, including Pearson correlation analysis and the PROCESS model, to explore the relationships between anxiety, hope, and fatigue in family caregivers.

As presented in Table 1, the study sample comprised 84 participants with a mean age of 58.8 (SD = 11.18) years. The majority of the participants were female (63; 75%). Among the participants, 74% were married, and 53 (63%) had a college education. In terms of religious affiliation, the most practiced religion was Buddhism (40 individuals, 47.6%). With respect to daily caregiving duration, 43 participants (51.2%) provided care for more than 10 h per day. The caregivers’ relationship with the patients with dementia was predominantly a child–parent relationship, with 52 individuals (62%) identifying as the primary caregiver for a parent. Female caregivers had an average anxiety score of around 6.25. Overall, caregiver anxiety was higher for female than for male. The average CDR for patients with dementia was 1.3. The participants had an average anxiety score of 5.82 (SD = 4.64), an average fatigue score of 15.32 (SD = 6.39), and an average hope score of 28.33 (SD = 4.39).

As presented in Table 2, a significant positive correlation was discovered between anxiety and fatigue in dementia family caregivers (r =.584, p <.01). Additionally, a significant negative correlation was noted between fatigue and hope (r = −.431, p <.01), indicating that a lower level of hope was associated with a higher fatigue score. Furthermore, anxiety was significantly negatively correlated with hope (r = −.364, p <.01), suggesting that as anxiety increases among dementia family caregivers, their sense of hope diminishes.

The findings about the mediation effects of hope between anxiety and fatigue are presented in Table 3; Fig. 1. Anxiety had a significant effect on hope (path a: β = -0.378, p <.001), and hope had a significant effect on fatigue (path b: β = -0.332, p <.01). The total effect (path c) and direct effect (path c’) of anxiety on fatigue were significant (β = 0.804, 95% CI = 0.559, 1.050 and β = 0.678, 95% CI = 0.424, 0.932, respectively). The coefficient for the indirect effect of anxiety on fatigue through hope was statistically significant (β = 0.1262, 95% CI = 0.011, 0.314). As this confidence interval did not contain zero, it was concluded that hope was a significant mediator of the relationship between anxiety and fatigue, and hope mediated 15.6% of the total effect of anxiety on fatigue.

In some East Asian countries, caring for aging parents has even become a legal obligation emphasizing the moral duties of children. This compulsory responsibility enhances and encourages family caregivers to take on a caring role [26‐28]. Our results align with previous studies suggesting most family caregivers are women [29]. Traditional gender roles still expect women to take over caring and family obligations while men focus on their careers. At the same time, women may feel obliged to fulfill their expected role [30]. A study focusing on female caregivers reported different outcomes than mixed-gender samples did, with women often experiencing more significant pressure [31]. In addition, our study found that female caregivers had higher anxiety scores than male caregivers, which is consistent with the results of other literature. Women caregivers are also more likely to experience comorbid anxiety and depression, particularly when facing higher frequencies of disruptive behaviors from care recipients [32]. Female dementia caregivers have higher anxiety scores due to greater caregiving responsibilities and emotional involvement. They are also more reactive to dementia-related behaviors and face more substantial societal caregiving expectations.

The study identified a positive correlation between anxiety and fatigue among family caregivers of patients with dementia. Research consistently demonstrates a strong association between anxiety, depression, and fatigue across various populations. For instance, in patients with major depression, both the severity of depression and somatic anxiety independently correlate with the severity of fatigue [33]. Similarly, among individuals with chronic low back pain, anxiety sensitivity is a significant predictor of fatigue severity [34]. Prolonged physical exhaustion, psychological stress, anxiety, and depression collectively impact the overall health of caregivers, further intensifying their fatigue [2].

This study revealed significant negative correlations of hope with both anxiety and fatigue in family caregivers of patients with dementia, indicating that lower levels of hope are associated with more substantial anxiety and fatigue. This aligns with a study that employed qualitative interviews to explore the experiences of 12 caregivers caring for a spouse with dementia, which reported that maintaining hope enabled caregivers to confront better the challenges of caring for a family member with dementia [18]. Hope is a critical psychosocial factor for dementia family caregivers. A systematic review by Duggleby et al. (2021) similarly emphasized that increased hope and a reduction in maladaptive coping strategies improved caregivers’ coping abilities, self-efficacy, and readiness. The review also demonstrated that negative emotional states such as anxiety, depression, distress, grief, and guilt were negatively correlated with levels of hope in caregivers [35]. In a study examining the prospective associations of hope with subsequent anxiety, stress, and well-being in community-dwelling adults in the United States during the COVID-19 pandemic, the level of hope indirectly predicted anxiety through an effect on perceived control [36].

The present study demonstrated that hope serves as a mediating variable between anxiety and fatigue in dementia family caregivers. When family caregivers experience an increase in anxiety, their level of fatigue also increases; however, hope can weaken the impact of anxiety on fatigue. This finding contributes to a deeper understanding of the complex relationship between psychological health and fatigue in dementia family caregivers. Previous research has supported the notion that hope, in contrast to other positive psychological factors such as social intelligence, enthusiasm, and love acts, is a particularly critical resource in alleviating the burden of caregiving [37]. Hope has also been identified as a mediator of the relationship between stress and burden in caregivers of patients with Alzheimer’s disease [19]. Scholars have proposed that hope is a universal, multidimensional psychological construct closely related to individuals’ expectations of achieving ideal outcomes through realistic future goals. It serves as a motivational force, encouraging individuals to initiate or sustain actions toward goal attainment, and it can be fostered through personal support networks and interpersonal relationships [38]. As a deeply personal and complex psychological process, hope holds substantial significance for individuals regarding their perspective and outlook [39, 40].

A systematic review of interventions aimed at enhancing hope in palliative care patients identified 35 studies, all demonstrating that such interventions increased patients’ level of hope. Given the irreversible nature of dementia, these findings may also be relevant for caregivers of patients with dementia [41]. For instance, hope-focused counseling, guided imagery, and goal setting have shown promise in enhancing hope. Linking these findings to dementia caregivers, similar approaches could be adopted to address their unique challenges. Furthermore, hope can buffer the reinforcing nature of anxiety assessments and serve as a framework for individuals to focus on positive expectations and pursue pathways to desired outcomes. Studies suggest that fostering hope enables caregivers to visualize a more manageable future, which can mitigate anxiety and improve coping mechanisms [12].

Therefore, nurses can play a vital role by assisting caregivers in identifying and developing effective strategies for cultivating hope. These strategies could include structured hope-enhancing interventions, such as mindfulness practices, gratitude exercises, and guided imagery, to encourage a positive outlook. Building social connections through support groups or community resources fosters a sense of belonging while providing education and resources on caregiving skills and stress management reduces uncertainty and boosts confidence. By engaging in these activities, caregivers may engage in more hopeful thinking, thereby alleviating anxiety and the negative impact of anxiety-related fatigue.

This study offers critical theoretical implications by expanding the understanding of the interplay between anxiety, hope, and fatigue in dementia family caregivers. While previous research has explored the independent effects of these variables, our study uniquely highlights hope’s mediating role in mitigating anxiety’s impact on fatigue. This novel finding underscores the critical importance of hope as a psychosocial resource that can buffer the adverse effects of caregiving stress. Unlike prior studies, which primarily focused on caregivers’ mental health or physical burden, our research integrates these dimensions into a cohesive framework that emphasizes hope as a transformative mechanism. These insights advance theoretical knowledge in caregiver research and provide a foundation for designing targeted interventions that aim to enhance hope, reduce anxiety, and ultimately improve caregivers’ overall well-being. Future studies should build on these findings by exploring longitudinal designs further to elucidate the dynamic relationships among these variables over time.