Antovsky’s Sense of Coherence as a Reference in Dementia Carers’ Interventions

Dementia causes disability and dependence, and the care and support needed by the people with dementia have wide-ranging consequences for families, health-care systems, and society as a whole [1]. Providing care to a relative with dementia has been associated with worsening physical and emotional health [2-4]. Caregiving is a complex task as family caregivers usually encounter significant challenges, such as not living in the same house or neighborhood as their relative with dementia, having other responsibilities like looking after small children (sandwich generation caregiver), and working (paid job outside the home) [5,6]. Caregivers’ burden is a high-risk factor for early institutionalization of people with dementia and for greater use of resources [7,8].

Salutogenesis is a health model defined in opposition to the pathogenic model. It is based on a dynamic approach between stressors and protective health factors and, currently, it is a referent model of health promotion [9,10]. The sense of coherence, core concept of Antonovsky’s health model, is the ability to make sense of life (because it is comprehensible, manageable and meaningful) and maintain the skills to face changes and interact with the environment. Two related consequences have been associated with developing care duties in dementia. First one is burden perception. A global construct that includes worse physical and emotional health, social isolation, perception of guilty and/or stress. A comprehensible reaction that implies an increase of medical and social costs [11]. Then, the second consequence is the amount of money associated with this higher care cost (direct and indirect) that family, community and government insurances’ policies finally assume.

A systematic review associated the sense of coherence, and other personal and contextual factors, with burden perception and better/worse experience of caring [12]. The sense of coherence is a global orientation that encourages people to reflect on stressful situations in order to make them able to understand, think about how to face them, and identify the best way to think about how dealing with a stressor [9,13,14]. Therefore, the sense of coherence seems to be determinant of the perceived burden. Directly, as a global orientation that expresses the extent to which one has a feeling of confidence that the stimuli deriving from one’s internal and external environments are structured, predictable, and explicable; the resources are available to one to meet the demands posed by these stimuli; and these demands are challenges, worthy of investment and engagement” [15]. Also, sense of coherence could be determinant indirectly. It is, reducing avoidance behaviour (such as “making jokes” or “trying not to think about the problem” and/or “increase alcohol consumption or other substances”) as strategies to cope with this situation. Also, less depressive symptoms, great self-efficacy or better social support perception have been linked with less burden perception in carers with greater sense of coherence [16]. However, more literature about how to intervene in carers’ sense of coherence or other indirect factors is needed. In my opinion, the application of the health model based on the study of the sense of coherence may give a different perspective to the intervention projects and modulate the type of actions based on the background of the person [17].

In other words, not all carers have the same personal needs as each other (support, training, etc.) and not all people have the same contextual circumstances (previous relationship, work, family responsibilities, etc.) which may determine both sense of coherence and burden. Moreover, investing in caregivers could reduce care costs in dementia. Although dementia is commonly described in a negative way (dependence, disability, and loss), some carers and professionals are changing this perception [18]. A greater sense of coherence could promote this change. Even though sense of coherence cannot significantly reduce direct and indirect monetary costs, a greater sense of coherence reduces the emotional and social costs associated with caring for people living with dementia.

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