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Informal caregiving in upstate New York Upstate New York Number of caregivers:

New York State 513,023 (13.4% of adult population)

Average hours of care per week:

10.9*

Estimated annual economic value of informal caregiving:

$4.5 billion

Number of caregivers: 1,929,000 (12.8% of adult population) Average hours of care per week: Estimated annual economic value of informal caregiving:

13.0* $19.9 billion

Central New York Region Number of caregivers:

115,015 (13.9% of adult population)

Average hours of care per week: Estimated annual economic value of informal caregiving:

14.0* $1.3 billion

Finger Lakes Region Number of caregivers:

108,134 (13.2% of adult population)

Average hours of care per week: Estimated annual economic value of informal caregiving:

9.9* $854 million

Utica/Rome/North Country Region Western New York Region Number of caregivers:

Number of caregivers:

151,564 (12.6% of adult population)

Average hours of care per week: Estimated annual economic value of informal caregiving:

89,169 (14.9% of adult population)

Average hours of care per week:

10.5*

Estimated annual economic value of informal caregiving:

10.8* $774 million

$1.3 billion

Southern Tier Region Note: Upstate New York refers to the New York counties highlighted in the map above. Figures are based on the New York State Department of Health’s Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/ *During the month prior to the survey.

5059-10CC

Number of caregivers:

49,141 (12.5% of adult population)

Average hours of care per week: Estimated annual economic value of informal caregiving:

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7.1* $280 million

1 of 14 Fall 2010

Informal or family caregiving is a major public health issue, given its growing impact on the healthrelated quality of life of millions of Americans.1 Informal caregivers are generally defined as individuals who provide assistance – usually unpaid – to family members, neighbors or friends whose chronic physical or mental impairments interfere with activities of daily living. Family caregivers are the backbone of long-term care services in the U.S., filling the major gaps fueled by an aging population, advancing technology that extends life expectancy, shorter hospital stays and decreasing numbers of health care workers.2,3,4,5 Caregivers assist with personal care and everyday activities but may also engage in more complex health-related tasks, such as medication management and wound care, among others.6 Upstate New York mirrors the well-documented national trend of population aging that will continue to drive caregiver demand in the coming decades:

Upstate New York population age distribution: 2000 versus 2009 50% 45% 40%

38.2% 35.3%

35% 30% 25%

28.1% 24.8% 22.7%

21.7% 20% 15%

12.5% 12.6%

10% 5% 1.9%

2.3%

0% Under 18

18-44

45-64 2000

65-84

Over 85

2009

Source: United States Census Bureau

• Between 2000 and 2009, the youngest upstate population groups (ages under 18 and ages 18 to 44) declined by a total of about 340,000 people, from 24.8 percent to 21.7 percent, and from 38.2 percent to 35.3 percent, respectively; • The wave of baby boomers that will soon enter their senior years comprised 28.1 percent of upstate New York’s 2009 population, an increase of 242,000 residents since the year 2000 (22.7 percent); • By 2029, all surviving upstate New York baby boomers will be in the 65-and-older age group, approaching nearly 1.4 million people; • An increase in the oldest age group has already become apparent in upstate New York, where the proportion of the population ages 85 and older rose from 1.9 percent in 2000 to 2.3 percent in 2009, an increase of more than 20,000 residents. They are the most likely of any age group to have dementia, creating an even greater need for caregiving.

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2 of 14 Fall 2010

The contributions of informal caregivers can delay or altogether avoid placing recipients in institutional care settings and are often critical to recipients’ health and well-being. Targeting programs and other supports to minimize the potential hardships facing caregivers requires knowing their characteristics, experiences and needs.7 The U.S. Department of Health and Human Services includes increasing public health surveillance of caregivers and identifying corresponding health promotion opportunities among its Healthy People 2010 objectives.8 A nationwide body of research suggests that compared to other adults, caregivers tend to be in poorer health, experience higher levels of emotional stress and have less financial security.9 Statelevel data on the caregiving experience have become available only in recent years. In 2008, the New York State Department of Health’s Behavioral Risk Factor Surveillance System (BRFSS) survey added a caregiver assessment module to its questionnaire.10 The BRFSS is a statebased, random-digit-dialed telephone survey of the non-institutionalized civilian adult population (ages 18 years and older) that is compiled and supported at the national level by the Centers for Disease Control and Prevention. It randomly samples respondents so that the results represent all of the state’s adults.11 The caregiver module of the BRFSS asks those identified as caregivers about their own and their care recipients’ characteristics, their relationship to their recipients, care intensity and the nature of challenges encountered in caregiving. This fact sheet presents a portrait of informal caregivers based on the BRFSS caregiver module administered to upstate New York adults during 2008. The BRFSS used the following screening question to determine informal caregiver status: People may provide regular care or assistance to someone who has a long-term illness or disability. During the past month, did you provide any such care or assistance to a family member or friend? Those who responded “Yes” to this question were classified as informal caregivers and completed the remainder of the caregiving module. Care providers of those younger than age 18 were included in the analysis.

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3 of 14 Fall 2010

How many upstate New York adults provide informal care?

Percentage of upstate New York adults who are informal caregivers by region 13.9%

115,015

Central New York

108,134

Finger Lakes

Southern Tier

49,141

13.2%

12.5%

Utica/Rome/North Country

89,169

Western New York

12.6%

151,564

Upstate New York

513,023

Downstate New York

1,406,165

10.0%

10.5%

11.0%

11.5%

12.0%

13.4%

12.5%

1,929,024

New York State

14.9%

12.5%

12.8%

13.0%

13.5%

14.0%

14.5%

15.0%

15.5%

16.0%

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

Nearly 2 million New York state residents (almost 13 percent of the adult population) provide unpaid care for a person with a long-term illness or disability. In upstate New York, 13.4 percent of respondents (513,000 adult residents) identified themselves as informal caregivers. Because the survey reflects caregiving only within the previous month, it likely understates the number of people who provide care at various points throughout the year: • The percentage of informal caregivers across upstate New York regions ranges from 12.5 percent in the Southern Tier (about 49,100 residents) to14.9 percent in the Utica/Rome/North Country region (about 89,100 residents); • Regional variations partially reflect differences in population age structure and may also imply varying rates of chronic illness and disability.

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4 of 14 Fall 2010

Caregiving intensity: Average hours of care per week provided by upstate New York caregivers 24.4% 15.6%

10.9% 34.6%

14.4%

1-3 hours

> 20 hours

4-10 hours

Unknown

11-20 hours

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

The 513,000 informal caregivers in upstate New York provided on average about 11 (10.9) hours of care per week over the month prior to the survey (not shown), with more than one in ten (10.9 percent) reporting an average exceeding 20 hours per week: • About a quarter (24.4 percent) of upstate New York caregivers reported average weekly care in the range of one to three hours; • The largest percentage – 34.6 percent – of upstate New York’s informal caregivers spent between four and 10 hours on average per week; • About one in seven (14.4 percent) reported average care time ranging from 11 to 20 hours per week.

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5 of 14 Fall 2010

Duration of caregiving reported by upstate New York caregivers

7.2%

34.2%

15.5%

15.3%

27.7%

< 2 years

> 10 years

2-3 years

Unknown

4-10 years

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

Many of upstate New York’s informal caregivers have been in their roles for a number of years, though about a third (34.2 percent) have been informal providers for less than two years: • Duration for about 28 percent of caregivers (27.7 percent) is between two and three years; • About one in six caregivers reported having been in this role for either four to 10 years (15.3 percent) or more than 10 years (15.5 percent). One-third have been informal providers for four or more years.

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6 of 14 Fall 2010

The economic value of caregiving in upstate New York: Determining the value of caregiver time In recent years, the role of family caregivers in the U.S. has become more widely recognized, as these unpaid providers contribute the vast majority of long-term care services and supports received by persons with disabilities of all ages.12 National estimates of the economic value of caregiving vary widely according to many factors: how the term “informal caregiver” is defined, which age groups and health conditions are included, the estimated amount and duration of care, and the economic value placed on caregiver time. For example, in many national studies, informal caregiving excludes individuals caring for people younger than age 18 who have disabilities. Further, much evaluation of informal caregiving does not consider societal costs, such as productivity losses to U.S. businesses. These include absenteeism and presenteeism, where employees attend work but function suboptimally. Given these limitations, studies estimate that between 27 million and 65.7 million U.S. adults are informal caregivers; with the annual economic value of their contributions ranging from $167 billion to $780 billion.13,14 According to the 2008 BRFSS survey, an estimated 513,000 upstate New York adults provided an average of 11 hours of caregiving per week within the previous month (572 hours per year on average). The estimated annual economic value of this care is shown in the table below:

Profile of caregiving time and average annual economic value, New York state* Region

Number of caregivers

Average hours per week

Annual value of caregiving

Central New York

115,015

14.0

$

1,293,031,787

Finger Lakes Region

108,134

9.9

$

853,919,950

49,141

7.1

$

279,828,886

Southern Tier

89,169

10.8

$

773,868,730

Western New York

Utica/Rome/North Country

151,564

10.5

$

1,276,637,854

Upstate New York

513,023

10.9

$

4,474,760,959

Downstate New York

1,406,165

14.1

$ 15,885,644,078

New York State

1,929,024

13.0

$ 19,936,610,676

*Based on the number of caregivers in each region and their average weekly hours (annualized by multiplying hours by 52 [weeks per year]) and then multiplied by an hourly rate of $15.39 (the average of the 2008 state minimum wage and the 2008 state Medicaid-approved rates for Home Health Aide I and Home Health Aide II).15 Source of data specific to individual caregivers: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

• The annual economic value of caregiving in upstate New York during 2008 was an estimated $4.5 billion, ranging from $280 million in the Southern Tier to $1.3 billion in Central New York. • New York state Medicaid payments lend perspective to these figures. The statewide value of informal caregiving ($19.9 billion) very closely approximates the state's total 2008 fiscal year Medicaid spending on long-term care services ($20.3 billion).16

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7 of 14 Fall 2010

Who are upstate New York’s informal caregivers? The average upstate New York caregiver is likely to be a woman in her 40s or 50s (mean age = 48.5) who is employed (59.9 percent), has at least some college education (67.4 percent) and has average annual household earnings of $50,000 or more (42.9 percent):

• The majority of caregivers are women (60.8 percent versus 39.2 percent of men);

GENDER AGE Male 18-44 Female 45-64

39.2%

.07% 60.8% 2.4%

AGE

65+

18-24 25-34

• Almost two in five caregivers are age 55 or older (38.7 percent) and almost one in five (18.2 percent) are age 65 or older;

7.9% 10.5%

GENDER

10.8%

Male

35-44 Female

4.7%

18.4% 4.1% 21.6%

45-54

RACE/ETHNICITY 20.5% 3.5%

55-64 White

18.2%

65+ Black

7.7%

EMPLOYMENT Hispanic

7.1%

EmployedOther Out of work

59.9%

5.2%

5.0% INCOME

Student or Less than $15,000 Homemaker

10.3%

8.5%

18.7%

$15,000-$24,999 Retired 6.0%

Unable to work $25,000-$34,999 $35,000-$49,999 INCOME

9.4% 5.4%

2.8%

$50,000 + 4.2% 1.6% Less than $15,000

• According to income, the largest percentage of caregivers reside in households with annual incomes of $50,000 or more (42.9 percent);

EDUCATION 14.7% $15,000-$24,999 Less than $25,000-$34,999 high school

11.3%

10.8%

High school graduate or GED $35,000-$49,999 Attended college $50,000 school + or technical

4.8% 17.7% 3.8%

College graduate Unknown

42.9%

2.3% 9.7%

EMPLOYMENT EDUCATION

• Nearly two-fifths (37.0 percent) are college graduates.

Student or Less than Homemaker 4.5% high school Employed 1.3% High school graduate or GED Out of work Some college

4.3% 28.1% 5.8% 30.4% 7.1% 37.0%

Retired College graduate

Unable to work 12.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20% Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

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Who receives informal care in upstate New York? Age distribution of care recipients, upstate New York .8% 3.3%

• The majority of care recipients (60.5 percent) are ages 65 and older, but more than a third (35.4 percent) are in the 18 to 64 age group. Less than 5 percent are younger than age 18. 60.5% 35.4%

1-17 years

65+ years

18-64 years

Unknown

Relationship of care recipient to caregiver, upstate New York

• Usually, care recipients are parents, parent-inlaws or other relatives of unpaid caregivers (71 percent). About one in five recipients are non-relatives. For close to one in ten (8.9 percent), the recipient is a spouse or partner.

41.4%

20.1%

29.6%

8.9%

Parent or parent in-law

Other relative

Spouse/partner

Non-relative

Care recipient living arrangements, upstate New York 25.6%

• Most care recipients (55.3 percent) live in their own homes, while about one in four (25.6 percent) reside in the same household as the caregiver. Smaller percentages (totaling 15.7 percent) are residents of congregate living arrangements, such as independent senior apartments, assisted living facilities and nursing homes.

2.2%

15.7% 55.3% 3.2%

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

Recipient’s own home

Caregiver's home

Someone else’s home

Unknown

Assisted, senior independent living or nursing home

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9 of 14 Fall 2010

Care recipients’ primary diagnoses: Primary problem as understood by caregiver, upstate New York 25.1% 11.9%

1.8% 3.8%

12.1%

4.1% 4.3%

12.6%

10.0% 14.4%

Musculoskeletal conditions

Cancer

Mental/behavioral disorders

Other/unknown

Nervous system disorders

Injury

Circulatory disease

Respiratory disease

Aging

Endocrine/metabolic

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

The question: “What do you think or what has the doctor said is the major health problem that your care recipient has?” yielded diverse results from informal caregivers: • About one in four (25.1 percent) informal caregivers did not pinpoint a specific primary diagnosis. • An additional 12.1 percent identified the recipient’s primary problem as simply aging, and similar percentages identified it as cancer (11.9 percent), circulatory diseases (12.6 percent) and mental/ behavioral disorders (10.0 percent). • About one in seven (14.4 percent) caregivers understood their recipient’s problem to be neurological, including Alzheimer’s disease, memory loss, multiple sclerosis, muscular dystrophy, cerebral palsy and Parkinson’s disease. • It is reasonable to assume that caregiving for Alzheimer’s and other dementias is understated because these cases may be captured in the categories of “Aging,” “Mental/behavioral disorders” and “Other/unknown.” The Alzheimer’s Association has estimated that 20 percent of adult caregivers in the U.S. provide care for someone age 50 or older who has dementia.17 • Relatively small percentages reported the main problem as musculoskeletal (4.3 percent), endocrine/metabolic (4.1 percent), respiratory (3.8 percent) and injury-related (1.8 percent).

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10 of 14 Fall 2010

Challenges upstate New York’s informal caregivers face

37.0%

15.2% 41.4% 5.8% 0.6% Not stressful at all

Extremely stressful

Somewhat stressful

Refused

Stressful

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

Despite its benefits and rewards, such as satisfaction in helping others and companionship, caregiving also can bring emotional, health and financial challenges. Emotional stress contributes to both physical and mental health problems. Depression affects 20 percent to 50 percent of U.S. caregivers and stressed caregivers face a 63 percent higher mortality risk than other adults of a similar age.18 Particularly stressful caregiving situations are highly correlated with caregivers engaging in harmful behaviors toward recipients.19 For example, stressed spousal caregivers, who are at risk of clinical depression and whose spouses have significant cognitive impairment and/or physical care needs are more likely to engage in harmful behavior toward their loved ones.20 Such abuse, which may include physical, emotional and financial mistreatment, may also be related to financial stressors, lack of education/training and a caregiver’s sense of other unmet needs. Stress affects a majority of upstate New York’s informal caregivers to some degree: • Most (58 percent), around 298,000 adults, experience at least some caregiving-related stress. It was rated as: – Extremely stressful by 5.8 percent; – Stressful by 15.2 percent; – Somewhat stressful by 37 percent. • About two in five upstate New York caregivers (41.4 percent) reported no caregiving-related stress.

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11 of 14 Fall 2010

Challenges reported by upstate New York caregivers 50%

Percent of caregivers (estimated numbers)

45% 40% 35% 30%

28.1% (144,005)

25% 20%

16.9%

15%

(86,547) 11.0%

10% 5%

8.0%

(56,279)

(41,144)

0% Need assistance managing challenging behaviors*

Moderate to significant financial burden

Job affected**

Retired or left work

* Behaviors such as wandering, and physical and supervision demands. ** Such as having to take time off from work or reduce hours. Estimated number of people may vary slightly due to rounding of percentages. Source: New York State Department of Health, Behavioral Risk Factor Surveillance System survey, 2008: http://www.health.state.ny.us/nysdoh/brfss/

In addition to emotional stress, family and other unpaid caregivers cite not having enough time for themselves and their families and the financial burdens that can be associated with caregiving. Some express concerns about caregiving aggravating their own health condition(s) or subjecting them to injury.21 Caregiving often takes a work-related and financial toll, and many caregivers also may require assistance in managing caregiving tasks: • 8 percent require assistance to deal with their recipients’ challenging behaviors, such as wandering and other supervision needs; • More than one in six upstate New York caregivers (16.9 percent) rated the financial burden of caregiving as moderate to significant; • For nearly one-third (28.1 percent), caregiving responsibilities negatively affected their employment by forcing them to take time off or reduce their work schedules; • 11 percent retired or left work because of caregiving responsibilities. The negative impact on work and loss of retirement income are major stressors. In addition, compared to other upstate New York adults, informal caregivers are more likely to report [Data not shown]: • Symptoms consistent with depression (40.0 percent versus 27.0 percent) according to the Patient Health Questionnaire-8;22 • Sometimes, rarely or never receiving needed emotional support (27.5 percent versus 18.0 percent); • Health-related activity limitations (26.1 percent versus 23.4 percent).

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12 of 14 Fall 2010

Care for the caregiver The National Alliance for Caregiving and the National Family Caregivers Association offer the following tips to ease the challenges faced by informal caregivers: • Identify and use available community resources. • Get caregiver training. • Maintain medical records. • Recognize caregiving as a job and seek well-deserved respite whenever possible. • Watch for signs of depression and don’t hesitate to seek professional help. • When people offer help, accept it and tell them exactly how they can be of assistance. Involve family and extended family as much as possible. • Educate yourself about your care receiver’s condition so you can best communicate with his/her physician and other providers. • Be open to opportunities and suggestions to help your loved one be more independent. • Trust your instincts. They will usually lead you in the right direction. • Caregiving can be physically demanding. Use proper lifting, pushing and pulling techniques to take care of your back. • As you grieve your losses, allow yourself to dream new dreams. • Seek the support of other caregivers. There is strength in knowing that you are not alone.

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13 of 14 Fall 2010

Additional resources National Family Caregivers Association: “Tips & Tools.” http://www.nfcacares.org/caregiving_resources/tips_and_tools.cfm Emblem Health and the National Alliance for Caregiving: “Care For the Family Caregiver: A Place to Start.” March 2010. http://www.caregiving.org/data/Emblem_CfC10_Final2.pdf Second Opinion: “Caregivers–Materials.” http://secondopinion-tv.org/caregivers/materials "Caregiver's Diary and Resource Guide." http://secondopinion-tv.org/sites/secondopinion-tv.org/files/CaregiverDiary_ResourceGuide.pdf “Agenda y Guía de Recursos del Cuidador." http://secondopinion-tv.org/sites/secondopinion-tv.org/files/Caregiver%20Diary_Spanish%20Version.pdf Compassion and Support: http://www.compassionandsupport.org/

Endnotes 1 Talley RC, Crews JE: “Framing the Public Health of Caregiving.” American Journal of Public Health, Vol. 97, No. 2, February 2007, page 224. http://ajph.aphapublications.org/cgi/reprint/97/2/224 2 The Minnesota Department of Human Services Aging and Adult Services: “2008 Minnesota Behavioral Risk Factor Surveillance Survey Caregiving Module.” December 2009, page 1: http://www.tcaging.org/downloads/2008caregiver.pdf 3 Forte GJ, Moore J, Armstrong DP, McGinnis S, and Dionne M: “New York Physician Supply and Demand through 2030.” Center for Health Workforce Studies, School of Public Health, University at Albany. April 2010, page ES-2. http://chws.albany.edu/index.php?nyphysicians 4 Moore J, Salsberg ES, Wing P, Engin D, Dill M, McGinnis S, Stapf C, Rowell MB: “The Impact of the Aging Population on the Health Workforce in the United States.” Center for Health Workforce Studies, School of Public Health, University at Albany. December 2005, page 14. http://chws.albany.edu/index.php?id=11,0,0,1,0,0 5 Martiniano R, Armstrong D, Bates A, and Moore J: “The Health Care Workforce in New York, 2008: Trends in the Supply and Demand for Health Workers.” Center for Health Workforce Studies, School of Public Health, University at Albany. April 2010. http://chws.albany.edu/index.php?nys_track 6 Houser A, Gibson MJ: “Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update.” AARP Public Policy Institute, Insight on the Issues 13, November 2008, pages 1-2. http://assets.aarp.org/rgcenter/il/i13_caregiving.pdf 7 Neugaard B, Andresen EM, DeFries EL, Talley RC, Crews JE: “Characteristics and Health of Caregivers and Care Recipients – North Carolina, 2005.” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, 56(21), June 1, 2007, pages 529-532. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5621a3.htm?s_cid=mm5621a3_e 8 Department of Health and Human Services, Healthy People 2010: “Disability and Secondary Conditions: Objectives and Subobjectives.” http://www.healthypeople.gov/data/midcourse/html/focusareas/FA06Objectives.htm 9 Alzheimer’s Association: “2010 Alzheimer’s Disease Facts and Figures.” Alzheimer's & Dementia, Vol. 6, pages 28-30. http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf 10 New York State Department of Health: “Behavioral Risk Factor Surveillance System.” For further information: http://www.health.state.ny.us/nysdoh/brfss/ 11 Hauptman H, Simmons K., DeFries E, Andresen E: “Understanding the Needs of Family Caregivers in Washington State.” Seniors Digest, Seattle-King County Edition (preview), April 1, 2009. http://www.poststat.net/pwp008/pub.50/issue.1042/article.4308/ 12 Gibson MJ and Houser A: “Valuing the Invaluable: A New Look at the Economic Value of Family Caregiving.” AARP Public Policy Institute, Issue Brief 82, June 2007, page 1. http://assets.aarp.org/rgcenter/il/ib82_caregiving.pdf 13 Ibid., pages 2, 10. 14 Naiditch L and Weber-Raley L: “Caregiving in the U.S. 2009.” National Alliance for Caregiving in Collaboration with AARP, November 2009, page 12. http://www.caregiving.org/data/Caregiving_in_the_US_2009_full_report.pdf 15 New York State Office for the Aging: “Sustaining Informal Caregivers: New York State Caregiver Support Programs Participants Survey, Report of Findings on the Aging Services Network 2009.” December 31, 2009, pages 41-42. http://www.aging.ny.gov/Caregiving/Reports/InformalCaregivers/SustainingInformalCaregiversPOMPSurveyReport.pdf 16 The Henry J. Kaiser Family Foundation, State Health Facts: “New York: Distribution of Medicaid Spending on Long Term Care, FY2008.” http://www.statehealthfacts.org/profileind.jsp?ind=180&cat=4&rgn=34 17 Family Caregiver Alliance, National Center on Caregiving: “Fact Sheet: Caregiver Statistics.” http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=439&expandnodeid=480 18 Ibid. 19 Nerenberg L: “Preventing Elder Abuse by Family Caregivers.” National Center on Elder Abuse, March 2002, pages 8-10. http://www.ncea.aoa.gov/ncearoot/main_site/pdf/family/caregiver.pdf 20 Family Caregiver Alliance. 21 Neugaard B, et al., page 2. 22 Described in: Fan AZ, Strine TW, Huang Y, Murray MR, Musingo S, Jiles R, et al.: “Self-Rated Depression and Physician-Diagnosed Depression and Anxiety in Florida Adults: Behavioral Risk Factor Surveillance System, 2006.” Centers for Disease Control and Prevention, Preventing Chronic Disease, Vol. 6, No. 1, January 2009. http://www.cdc.gov/pcd/issues/2009/jan/07_0227.htm

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