The proportion of older adults requiring support from third parties to warrant self-care and maintain dignity is a matter of concern in aging populations, with particular impact on societal costs (Dodel et al., Reference Dodel2015). Needs for care in the elderly arise from impairments in physical and/or cognitive capacities, with emphasis on those emerging in patients with dementia. Certain clinical aspects of the dementia syndrome, such as the occurrence of pervasive dependency, psychosis, abnormal motor behaviors, aggressiveness, or misidentification of close relatives, may render family carers particularly prone to psychological distress (Garre-Olmo et al., Reference Garre-Olmo, Vilalta-Franch, Calvó-Perxas, Turró-Garriga, Conde-Sala and López-Pousa2016; Molyneux et al., Reference Molyneux, McCarthy, McEniff, Cryan and Conroy2008). This topic has been extensively studied over the past years (Pinquart and Sörensen, Reference Pinquart and Sörensen2003; Park et al., Reference Park, Sung, Kim, Kim and Lee2015); nonetheless, there are still many important open questions regarding the provision of care for the actual caregivers. The study presented by Teahan et al. addresses the multiple factors associated with burden in family carers and draws our attention to possible preventive strategies by improving their physical and mental health (Teahan et al., Reference Teahan2020).

Family carers are key partners in the provision of care for patients with dementia, helping them to cope with daily living needs at home. This role is often played by a close relative to the patient (usually spouse or children) who dedicates full time to the provision of care. Informal care provided by family members is particularly important in low- and middle-income countries, where access to professional care is limited to a small proportion of cases, due to its high cost, not always covered by public or private insurance (Riffin et al., Reference Riffin, Van Ness, Wolff and Fried2019). In the paper by Teahan et al., the authors bring the noteworthy information that in Ireland, a well ranked Country in the United Nation’s Human Development Index (UNDP, 2019), the average amount of time spent by family carers in this task was close to 40 hours per week, as shown by a national census (CSO, 2017). This highlights the importance of looking into the matter in more detail, as the authors have successfully done in their recent paper. In this nation-wide, cross-sectional analysis of 2,311 family carers of older people in Ireland, the diagnosis of dementia (which was registered in one-fifth of sample) and the dependency level of the patient were significantly associated with caregiver burden; several socio-demographic variables such as gender, marital status, education level, local of residence, co-residence, and perceived support were shown to interact with the degree of burden. In particular, the study provided evidence that care burden tends to be higher in male, as compared to female, family carers, as well as among people with higher levels of education attainment. Burden was neither related to the age of the family carer nor with urban vs. rural dwelling. Regarding marital status, in spite of the prevailing notion that being married confers protection against depression and related outcomes, in the present study, all sub-categories of marital state (i.e. being married or having civil partnership; living with a partner; being divorced or separated; being widowed) were positively associated with increased burden as compared to single family carers; presumably, the baseline case in this analysis would refer to a situation where an unmarried child would become the natural carer of a demented parent, in which case “being single” would confer resilience against the emotional burden of the carer role. Finally, the authors found a coherent and strong effect of “poor quality of the relationship between the family carer and recipient of care,” as well as the occurrence of “psychological and physical abuse,” on the degree of burden (Teahan et al., Reference Teahan, Lafferty, Cullinan, Fealy and O’Shea2021).

It is well accepted that family caregivers are more vulnerable to psychological and psychiatric distress, with higher rates of depression and anxiety syndromes (Liu et al., Reference Liu2018). Complying with this difficult and often involuntarily assigned task may not only impact on the carer’s physical and emotional state but may also jeopardise the family income, since many family carers will be unable to sustain their former routines, activities, and jobs. Hence, the interruption of professional and personal routines, along with the limited availability of time for self-care and leisure, contributes to the feeling of overload, frustration, and anxiety (Connors et al., Reference Connors, Seeher, Teixeira-Pinto, Woodward, Ames and Brodaty2019). Carers of people with dementia may also face a myriad of non-implicit challenges related to this role, starting from the stigma toward the dementia status, illustrated by negative attitudes from relatives and friends, which may preclude the engagement of others in the support network and, therefore, exacerbate burden. As the authors correctly point out in discussion of their findings, this situation leads to a reduction in social capital, where stigmatized preconceptions about dementia may contribute to maladaptive cognitions and affects (Teahan et al., Reference Teahan, Lafferty, Cullinan, Fealy and O’Shea2021).

Nonetheless, caring for a loved one can be a rewarding experience, at least in the perspective of a minority of carers. The ability to build a positive appraisal of the task (which is critically related with underlying psychological assets) mitigates the perception of burden and ultimately improves quality of life. Such positive stance relies on the availability of adequate material resources and good coping abilities, which will depend on the integrity of current emotional state and on enduring personality characteristics of the caregiver. In a study conducted in our group, we assessed the influence of social skills and coping abilities on perceived stress among family carers of patients with Alzheimer’s dementia; from the repertoire of social skills, certain abilities such as “self-affirmation in the expression of positive feelings” and “self-control of aggression” were associated with a better perception of quality of life, probably through improved resilience to endure the carer’s role (Amorim et al., Reference Amorim, Giorgion and Forlenza2017). Social support is a well-accepted buffering factor that may protect caregivers against wearing out their coping capacity, helping them to deal better with the stressful situations inherent to the carer role; in this case, the perception of an empathetic network of support may work better than having an array of distinct, unarticulated supportive elements. This notion is also reinforced by the aforementioned study data, where “greater levels of perceived support were associated with lower levels of carer burden” (Teahan et al., Reference Teahan, Lafferty, Cullinan, Fealy and O’Shea2021). Psychoeducation further optimises the ability to manage the multiple tasks in the carer’s role, by yielding a better understanding about the disease, providing reassurance to deal with the multiple challenges, and to accept the deteriorating course of most dementing disorders (Tolkacheva et al., Reference Tolkacheva, Van Groenou, De Boer and Van Tilburg2011).

As a concluding remark, it is important to mention that, beyond the universal challenges of dementia, there are subfields in geriatric psychiatry where the particularities of the syndromes may impose specific challenges and require tailored solutions for the appropriate provision of care. These conditions usually imply the presence of distressing behavioral abnormalities, which is the regular picture in frontotemporal and Lewy-body dementia (Liu et al., Reference Liu2018) and in late-life bipolar disorder (Dos Santos et al., Reference Dos Santos2017; Dos Santos et al., Reference Dos Santos2018). More recently, there has been a growing awareness about the problems related to aging process in people with Down syndrome (McGlinchey et al., Reference McGlinchey, McCallion and McCarron2020). In this particular sub-group of the aging population, long-standing needs for care due to intellectual disability (at various degrees) merge with new demands that arise in middle- and late-adulthood and progress toward older age (Carvalho et al., Reference Carvalho, Ardore and Castro2015). Dementia in Down syndrome is largely related to Alzheimer’s disease and cerebrovascular pathology and is frequently associated with multiple comorbidities. In addition, it invariably presents with important behavioral changes with onset at early stages of the dementing course (Dekker et al., Reference Dekker2015). Therefore, it is undisputable that the aging process in this specific population will bring about new challenges related to the provision of care. Therefore, both at individual and population levels, the delivery of an effective care for older adults with Down syndrome must acknowledge the fact that these individuals will require attention in multiple domains, accounting for specific physical needs, prevalent medical and neuropsychiatric comorbidities, and deterioration of premorbid functional status (McCarron et al., Reference McCarron2018).