Dimensions of Ambiguous Loss in Couples Coping with Mild Cognitive Impairment.

Abstract: We applied the theory of ambiguous loss to couples with mild cognitive impairment (MCI), an age-related decline in memory and other cognitive processes assumed not to interfere with daily activities or the maintenance of personal relationships. Face-to-face interviews with 67 older married couples revealed that lack of understanding about the behavioral manifestations of MCI resulted in much ambiguity in their lives. Fluctuations in the elders' functioning required spouses to alter their daily activities and responsibilities. As a result, couples often experienced distress that affected their emotional involvement with one another. Findings advance theoretical implications of ambiguous loss and provide educators and practitioners with suggestions for working with couples experiencing mild memory loss. Key Words: ambiguous loss, distress, marital relationships, mild cognitive impairment, older couples, support. In her writings on ambiguous loss, Pauline Boss asserted that the most difficult and stressful situations that people deal with are those involving ambiguity. Ambiguous loss arises from a perceived mismatch between the physical and the psychological presence of a person, leading not only to stress but also to unusually great difficulty in identifying and using effective coping strategies because of the psychological incongruence and confusion some people experience (Boss, 1999, 2004; Boss & Couden, 2002). Situations involving ambiguous loss affect individuals' perceptions of their relationships, the resources they use, and the degree of stress and trauma they feel. Such situations become especially problematic when relationship boundaries are blurred, decisions or future plans are put on hold, and family rituals or celebrations are canceled because of the emotional pain of a loved one's physical or psychological absence. In describing the ambiguous loss experience of caring for a family member with Alzheimer's disease (AD), Boss (1993) suggested that a high degree of confusion about the causes of the disease and the boundary ambiguity of the family system (i.e., who is in and who is out) are more burdensome than the severity of the illness. Lack of clarity prevents families from defining their situation and coping with and managing it effectively. Such situations may be particularly difficult for spouses to resolve as they interact with their partners, who now think and act in ways that are less reliable and less capable than before. Role ambiguity is revealed by inconsistent behaviors, such as supporting the autonomy of the person with AD in some situations, while acting paternalistic in other situations. High ambiguity places the family at risk for deterioration of individual and relational well-being (Boss, 2002). Effective adaptation to AD requires ongoing shifts in construction and interpretation of family roles, events, and situations (Boss, 2006; Boss, Caron, Horbal, & Mortimer, 1990). Individual and familial appraisals of the AD situation influence how caregivers change or resist changing, and ultimately, their reconstruction of family life with AD. Given increased public awareness of AD and the advent of new treatments for it, many elders now seek evaluation volitionally at the first signs of cognitive difficulty. Early disclosure of memory problems is beneficial for elders and their families as it often ends a period of doubt and confusion and provides elders access to treatment (Smith & Beattie, 2001). A relatively new diagnosis, mild cognitive impairment (MCI), refers to age-related decline in memory and other cognitive processes. Although there is no "gold standard" for diagnosing MCI, five criteria put forth by Petersen et al. (1999) are the most widely applied in clinical practice and research: (a) complaint of memory loss, (b) minimal interference with activities of daily living and personal relationships, (c) normal cognitive functioning, (d) memory loss uncharacteristic for the person's age, and (e) no evidence of dementia. …