ACoA 2012 Family Caregiver Survey of Persons with Alzheimer’s Disease and Related Dementia  

The Alaska Commission on Aging (ACoA) is conductiong the following survey to find out about famliy caregivers of seniors with Alzheimer’s disease and related dementia (ADRD). ADRD is a growing public health concern that affects the health and well-being of Alaskans. Caring for people with ADRD poses special challenges. This information will be used to inform development of a new State Plan for Persons with Alzheimer’s Disease and Related Dementia. Thank you for completing this survey.

Alaska Commission on Aging
PO Box 110693
Juneau, AK 99811-0693
Office (907) 465-3250,Fax (907) 465-1398
During the past 12 months, did you provide any care for or assistance to a friend or family member with dementia?
Please tell us how much time you provide caregiving because of his/her health problem, long-term illness, or disability?
*Do you provide caregiving for more than one person?
*Do you receive pay for this caregiving?
Please tell us about the person(s) you provide care for? In some instances, a caregiver may provide care for one or more persons. If you caring are for more than one person please tell us about them.
What is the race of the person who you provide care to? (Check all that apply)
What is his/her relationship to you? For example is this person your (parent or spouse)?
Here is a list of difficulties you may face as a caregiver. Please rank which ones pose the greatest difficulties for you?
Creates a financial burden
Does not leave enough time for myself
Interferes with my work
Does not leave enough time for my family
Creates or aggravates my health problems
Creates stress and makes me depressed
No difficulty
Affects family relationship
Other difficulty
Please identify the top three most difficult challenges that you face as a caregiver.
Please rank the following areas the person you are caring for need/s the most help?
Taking care of himself/herself such as eating, dressing, or bathing
Taking care of the residence/personal living spaces and cleaning, managing money or preparing meals
Communicating with others
Learning or remembering
Seeing or hearing
Moving around within the home
Transportation outside of the home
Getting along with people
Relieving/decreasing anxiety or depression
Wandering away from home
Protecting him/her from self-harm
Getting to medical appointments
Shopping for food and other necessities
Picking up prescriptions
Other areas the person you are caring for need/s the most help?
What has a doctor said is the major health problem, long-term illness, or disability for the person you care for?
*Do you use or the person you care for use any of the following support services? (Check all that apply)
Please check the services that are not available where you live that would be helpful with your caregiving? (Check all that apply)
Please tell us which services have been most helpful to you as a caregiver.
Are any of these services avaliable where you live? (check all that apply)
Please tell us which supports have been most helpful and which supports should be expanded to meet your needs?
Thank You for completing this caregiver survey of persons with Alzheimer’s disease and related dementia (ADRD). The mission of the Alaska Commission on Aging is to ensure the dignity and independence of all older Alaskans, and to assist them to lead useful and meaningful lives through planning, advocacy, education, and interagency cooperation.