"Difficult behaviours contribute significantly to caregiver stress. "

The contribution of difficult behaviour to caregiver stress levels is well established in the literature. As discussed earlier, the cause of difficult behaviour is not always clear to the caregiver (Cohen-Mansfield, 2001). This leads to feelings of frustration and can decrease the self-efficacy of the caregiver. Caregivers with high self-efficacy can improve the well-being of the individual in their care (Merluzzi, 2011: 16). Caregivers with low self-efficacy, on the other hand, have greater difficulty coping with the demands of caregiving and are more susceptible to burnout (Merluzzi, 2011: 16).

The appearance of difficult behaviours can be particularly upsetting for caregivers when they represent a distinct change in the personality of the individual with dementia (Thuné-Boyle, 2012). For spousal caregivers, this is exacerbated by the loss of their partner as a source for "social and psychological well-being" and stress alleviation (Scharlach, 2006: 633). These personal factors increase the emotional burden of the caregivers, interfering with their competence.

Difficult behaviour also increases the inclination for family caregivers to isolate themselves from both friends and other family members (Batsch, 2012: 11). Due to the stigma associated with cognitive decline, the prospect of having to deal with difficult behaviours in public is a daunting one (Batsch, 2012: 12). This reduces caregivers' access to social connections which might have had an alleviating effect on stress (Wiglesworth, 2010). Public displays of difficult behaviours have also been linked to increased feelings of anger on the part of the caregiver (Pillemer, 1992: 166).

These effects of difficult behaviour on the caregiver serve to increase stress. Increased stress has a range of negative outcomes in the caregiving context. Caregivers' stress levels have been linked to immunosuppression, depression and anxiety (Merluzzi, 2011). Caregiver stress also has a profoundly negative effect on the care recipient when it results in abuse.