Hope played a significant role in the subjects' perceptions of overall quality of life as well as physical, psychological, social relations and environmental domains of quality of life. This finding supports the results of Irvin and Acton's  study of hope, stress and wellbeing in which hope had a positive significant relationship with wellbeing of women who were family caregivers of persons with AD. Our study included both male and female caregivers, as such adds to Irvin and Acton's findings by suggesting that hope is a significant factor for both female and male caregivers.
Different factors of hope were significant predictors of quality of life domains. Factor 1 hope scores, which reflected questions such as believing each day has potential and having goals, were significantly related to overall quality of life, as well as the psychosocial and environmental quality of life domains. Factor 2, which reflects questions such as seeing possibilities and having a sense of direction, was a significant predictor of physical quality of life scores. The interconnectedness dimension of HHI (factor 3) was a significant predictor of psychological and social relations dimensions of quality of life. Other studies of hope and quality of life in different populations have found significant relationships between these two variables [26, 27] but did not delineate which hope factors are the most significant predictors. The increased understanding of hope and quality of life provided by this study can be used as a foundation for the development of hope interventions for family caregivers of persons with AD where critical inputs of the intervention would be targeted to specific quality of life domains.
Subjects who actively sought information and assistance as a way to deal with their transitions had a higher overall quality of life. Thus encouraging family caregivers to take action to get the information they need and to seek help, along with provision of information regarding credible resources may be a way to assist them in dealing with transitions. This finding is similar to an emerging theory of transitions of family caregiving of persons with advanced cancer, which suggests seeking information is an important part of dealing with transitions . While there may be other similarities in the experience of transitions of family caregivers of persons with AD and those with advanced cancer more research is needed to determine if this is the case.
The most significant influences on the participants' physical quality of life were external resources, such as help with care giving, and internal resources such as hope. Moreover those who understood that looking after themselves (self-care) and that the disease process influenced their transitions the most had the highest physical quality of life. These findings are similar to those of other studies of family caregivers. For example the importance of self-care as factor in reducing the effect of caregiver stress on general well-being was reported in a study of 46 family caregivers of persons with dementia . The needs of the caree with regard to assistance from their caregiver and behavioural problems, which is often a function of the disease process, have been found to impact the quality of life of family caregivers of persons with dementia . In our study, participants who perceived that the disease process had an influence on their transitions reported higher physical quality of life. This suggested that understanding that the disease process (not the person's attitude or other factors) influences the carees' behaviours and needs, may help caregivers deal with the carees' changed behaviour.
A surprising finding in our study is that income was inversely related to physical quality of life. This has also been found in other studies where higher levels of income and education are associated with higher levels of strain in family caregivers [30, 31]. It could be that family caregivers with higher income and education levels may have higher expectation of themselves as caregivers resulting in higher levels of perceived strain and decreasing levels of physical health. Further research is needed to understand the relationship among higher income and education levels and physical quality of life.
Psychological quality of life (domain 2) was the only domain where age was a significant factor. The older the caregiver and higher the hope scores, the higher the psychological quality of life score. These findings are congruent with gerotranscendence theories that suggest as we age that physical aspects of our quality of life are not as important as our psychological and existential ones [32, 33]. It is interesting based on these theories that age was also not a factor influencing the social relations quality of life domain. It may be that our small sample size precluded age from being a significant factor.
There are several limitations to the study. The first is the small sample size.
Although statistically significant findings were reported, additional variables might be significantly related with a larger sample size. As well the poor response rate brings into question the generalizability of the data. The majority of the study participants were caring for a person with AD in their homes. As such the findings reflect the experience of this population. It is possible that there are differences in the transition experience and hope and quality of life based on care setting. Future studies should look at potential differences of those caring for a person at home versus those who are caring for a person in a continuing care setting.
Another limitation is that qualitative data on the transition experience was collected using a survey and so in-depth interviews were not conducted. As well, the qualitative data is a reflection of the study participants and may not reflect the experience of those not in the study. However, without a valid and reliable measure that reflects the transition experience, collecting and transformation qualitative data did provide an understanding of the influence of transitions on quality of life.
It is important to note that even if a family member has able to integrate their transitions into their lives, this does not necessarily mean they have coped well during this process. Coping was not included in this study as a factor influencing quality of life or transitions and is a limitation of the study. However, hoping may in itself may be a form of coping strategy and may account for its significant relationship to quality of life. Future research should include measures of coping when examining quality of life in family caregivers of persons with dementia.
The study was cross-sectional in nature to gain preliminary data on hope, transitions and quality of life. Conducting a longitudinal study with a larger sample would be beneficial for the examination of changes in predictor variables over time.