Introduction
The global population of older adults is on the rise; thus, the need for family care for older adults has increased. Evidence indicates that 80% of older adults in need of care worldwide receive care from a family member. Family care for the elderly is influenced by the theories of family systems and intergenerational solidarity. Due to the rising costs of hospitalization, families prefer to care for older adults at home; however, it can be challenging and significantly affect caregivers’ mental health, leading to disorders such as depression, stress, physical illness, burnout, inadequate support, and unmet needs. The present study aims to review the existing literature to identify the psychological problems and needs of family caregivers of older adults.

Methods
This is a review study with a thematic synthesis approach and was conducted based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) checklist. A comprehensive search was conducted for relevant studies published up to August 2024. English studies were searched in PubMed, Scopus, and Web of Science databases. Persian studies were searched in national databases including MagIran, the Scientific Information Database (SID), and the Noormags. The inclusion criteria were: Being a qualitative study, being original research, participation of family caregivers, and providing care to an older adult. The studies focused on formal caregiving, those exploring the lived experiences of older adults, and review or quantitative studies were excluded. We retrieved 203 articles from English databases. After removing duplicates, 181 articles remained. After screening their titles and abstracts, 168 studies were excluded due to irrelevance. Ultimately, 13 articles were selected for inclusion. Also, three studies were retrieved from Persian databases. All studies were qualitative and aimed at exploring the real-life and personal experiences of family caregivers of older adults. The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the ID CRD42024565977.
The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklist, which consists of 10 questions with yes/no/can’t tell responses, yielding scores from 1 to 10. The results showed that four studies scored 7, five studies scored 8, three studies scored 9, and four studies received a score of 10. Quality assessment was conducted independently by two authors, and any disagreement was resolved through consensus. Relevant statements were extracted verbatim and imported into MAXQDA 2020 for coding. Data analysis and synthesis proceeded in three steps. In the first step, open codes were generated by labeling relevant statements. In the second step, these codes were organized into descriptive themes. In the final step, the descriptive themes were abstracted into analytical themes for a deeper understanding of the data.

Results
Sixteen studies (13 in English and 3 in Persian) were included in the analysis. They had been conducted from 1991 to 2023 in 13 different countries, including the United States, Portugal, Finland, China, Brazil, Switzerland, Canada, the Netherlands, Australia, and Iran. One multinational study included participants from Italy, Lithuania, the Netherlands, and Turkey. A total of 420 participants aged 25-85 had participated in these studies. Data in these studies were collected through semi-structured and in-depth interviews and focus groups.
The findings were categorized into two main themes: Psychological problems and psychological needs. The psychological problems included six sub-themes: Neglecting personal needs and weakening of individual identity, interference of caregiving role with life and recreational activities, drowning in negative and unpleasant emotions, heavy caregiving burden and disruption of other life roles, lack of intimate relationships, decreased well-being and health, and sleep disturbances. The psychological needs included four sub-themes: Need for support, need to address mental health conditions, need for empathy and appreciation, and need for a temporary break from caregiving.

Conclusion
The results of the study revealed that family caregivers of older adults face extensive challenges in terms of psychological needs and problems. Providing care for older adults, as a long-term responsibility, not only negatively affects their lives but also weakens their personal identity and social relationships. It is noteworthy that caregivers often neglect their own psychological needs while striving to maintain balance in other life roles under the pressures of caregiving.
The findings underscore the importance of raising public awareness about the psychological needs and problems of the family caregivers of older adults and highlight the necessity of providing psychosocial support to them by developing more comprehensive support policies for them, not only to reduce their psychological distress but also to improve the quality of care provided to older adults. Practical measures such as emotional support from other family members and friends, and facilitating access to counseling and psychotherapy services are recommended to enhance the family caregivers’ psychological well-being.

Ethical Considerations
Compliance with ethical guidelines
This systematic review has been registered by the International Prospective Register of Systematic Reviews (PROSPERO) (Code: CRD42024565977).

Funding
This research was extracted from the dissertation of Mojtaba Abbasi Asl at the Department of Counseling, School of Behavioral Sciences and Mental Health, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors. 

Authors' contributions
Conceptualization, methodology, validation, data analysis, review & editing, supervision, project management: All authors; investigation, and resources: Mojtaba Abbasi Asl and Mohammad Saeed Khanjani; writing the initial draft and visualization: Mojtaba Abbasi Asl.

Conflicts of interest
The authors declared no conflict of interest.

References

1. Matsuura H. Further acceleration in fertility decline in 2023: deviation of Recently published provisional fertility estimates in selected OECD countries from those in the 2022 revision of the world population prospects. Biodemography and Social Biology. 2024; 69(2):55-6. [DOI:10.1080/19485565.2024.2367861] [PMID]
2. Mahmoudzadeh H, Aghayari Hir T, Hatami D. [Study and analysis of the elderly population of the Iran (Persian)]. Geographical Research. 2022; 37(1):111-25. [Link]
3. Noroozian M. The elderly population in iran: an ever growing concern in the health system. Iranian Journal of Psychiatry and Behavioral Sciences. 2012; 6(2):1-6. [PMID]
4. Adelman RD, Tmanova LL, Delgado D, Dion S, Lachs MS. Caregiver burden: A clinical review. JAMA. 2014; 311(10):1052-60. [DOI:10.1001/jama.2014.304] [PMID]
5. Segal DL, Qualls SH, Smyer MA. Aging and mental health. New Jersey: John Wiley & Sons; 2018. [DOI:10.1002/9781119133186]
6. Cash B, Hodgkin S, Warburton J. A transformative approach to systems theory in caregiving research. Qualitative Social Work. 2019; 18(4):710-26. [DOI:10.1177/1473325017749988]
7. Xu L, Liu J, Mao W, Guo M, Chi I, Dong X. Intergenerational solidarity and being primary caregiver for older parents in Chinese American Families: Findings from PIETY study. Journal of Transcultural Nursing. 2021; 32(6):716-26. [DOI:10.1177/10436596211004677] [PMID]
8. Mohamadi Shahbalaghi F. [Self- Efficacy and Caregiver Strain in Alzheimer’s Caregivers (Persian)]. Salmand: Iranian Journal of Ageing. 2006; 1(1):26-33. [Link]
9. Arman M. [The comparison of depression, anxiety and stress between active and inactive old women in Isfahan (Persian)]. The Scientific Journal of Rehabilitation Medicine. 2014; 3(3):82-8. [Link]
10. Willemse E, Anthierens S, Farfan-Portet MI, Schmitz O, Macq J, Bastiaens H, et al. Do informal caregivers for elderly in the community use support measures? A qualitative study in five European countries. BMC Health Services Research. 2016; 16:270. [DOI:10.1186/s12913-016-1487-2] [PMID]
11. Hosseini MA, Fallahi Khoshknab M, Mohammadi Shahbolaghi F, Mohammad Zaheri S, Soltani P, Khanjani MS. [The effect of mindfulness program on the perceived stress of family caregivers of elderlies with Alzheimer’s Disease (Persian)]. Iranian Journal of Psychiatric Nursing. 2016; 4(3):1-7. [DOI:10.21859/ijpn-04031]
12. Medrano M, Rosario RL, Payano AN, Capellán NR. Burden, anxiety and depression in caregivers of Alzheimer patients in the Dominican Republic. Dementia & Neuropsychologia. 2014; 8(4):384-8. [DOI:10.1590/S1980-57642014DN84000013] [PMID]
13. Tatangelo G, McCabe M, Macleod A, You E. "I just don't focus on my needs." The unmet health needs of partner and offspring caregivers of people with dementia: A qualitative study. International Journal of Nursing Studies. 2018; 77:8-14. [DOI:10.1016/j.ijnurstu.2017.09.011] [PMID]
14. Fonareva I, Oken BS. Physiological and functional consequences of caregiving for relatives with dementia. International Psychogeriatrics. 2014; 26(5):725-47. [DOI:10.1017/S1041610214000039] [PMID]
15. Gilmore GD. Needs and Capacity Assessment strategies for health education and health promotion. Burlington: Jones & Bartlett Publishers; 2011. [Link]
16. Akgun-Citak E, Attepe-Ozden S, Vaskelyte A, van Bruchem-Visser RL, Pompili S, Kav S, et al. Challenges and needs of informal caregivers in elderly care: Qualitative research in four European countries, the TRACE project. Archives of Gerontology and Geriatrics. 2020; 87:103971. [DOI:10.1016/j.archger.2019.103971] [PMID]
17. Bierhals CC, Santos NO, Fengler FL, Raubustt KD, Forbes DA, Paskulin LM. Needs of family caregivers in home care for older adults. Revista Latino-Americana de Enfermagem. 2017; 25:e2870. [DOI:10.1590/1518-8345.1511.2870] [PMID]
18. Silva AL, Teixeira HJ, Teixeira MJC, Freitas S. The needs of informal caregivers of elderly people living at home: An integrative review. Scandinavian Journal of Caring Sciences. 2013; 27(4):792-803. [DOI:10.1111/scs.12019] [PMID]
19. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology. 2008; 8:45. [DOI:10.1186/1471-2288-8-45] [PMID]
20. Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: A critical review. BMC Medical Research Methodology. 2009; 9:59. [DOI:10.1186/1471-2288-9-59] [PMID]
21. Rawlins SR. Using the connecting process to meet family caregiver needs. Journal of Professional Nursing. 1991; 7(4):213-20. [DOI:10.1016/8755-7223(91)90030-O] [PMID]
22. Sarvimäki A, Stenbock‐Hult B, Sundell E, Oesch‐Börman C. The vulnerability of family caregivers in relation to vulnerability as understood by nurses. Scandinavian Journal of Caring Sciences. 2017; 31(1):112-9. [DOI:10.1111/scs.12325] [PMID]
23. De Sousa GS, Da Silva RM, Reinaldo AMS, Brasil CCP, Pereira MO, Minayo MCS. Metamorfosis in the lives of elderly people caring for dependent elderly in brazil. Texto & Contexto-Enfermagem. 2021; 6(8)30-44. [DOI:10.1590/1980-265x-tce-2020-0608]
24. Majidi Khamaneh F, Mahdavi M. The concept of caregiving for elderly parents based on the lived experiences of family caregivers in Tehran (A phenomenological study). Iranian Journal of Anthropology. 2018; 15(26):101-34. [Link]
25. Teixeira MJC, Abreu W, Costa N, Maddocks M. Understanding family caregivers’ needs to support relatives with advanced progressive disease at home: An ethnographic study in rural Portugal. BMC Palliative Care. 2020; 19(1):73-84. [DOI:10.1186/s12904-020-00583-4] [PMID]
26. Chan WC, Ng C, Mok CC, Wong FL, Pang SL, Chiu HF. Lived experience of caregivers of persons with dementia in Hong Kong: A qualitative study. East Asian Archives of Psychiatry. 2010; 20(4):163-8. [PMID]
27. Wawrziczny E, Pasquier F, Ducharme F, Kergoat MJ, Antoine P. Do spouse caregivers of young and older persons with dementia have different needs? A comparative study. Psychogeriatrics. 2017 ; 17(5):282-291. [DOI:10.1111/psyg.12234] [PMID]
28. Vos EE, de Bruin SR, van der Beek AJ, Proper KI. "It's Like Juggling, Constantly Trying to Keep All Balls in the Air": A qualitative study of the support needs of working caregivers taking care of older adults. International Journal of Environmental Research and Public Health. 2021; 18(11):5701. [DOI:10.3390/ijerph18115701] [PMID]
29. Shafiei N, Abdeyazdan G, Sasani L, Abedi H, Najafi M. [Family care giving needs of the elderly with Alzheimer’s disease (A phenomenological study) (Persian)]. Journal of Multidisciplinary Care. 2017; 6(2):48-58. [Link]
30. Messina A, Amati R, Albanese E, Fiordelli M. Help-seeking in informal family caregivers of people with dementia: A qualitative study with iSupport as a case in point. International Journal of Environmental Research and Public Health. 2022; 19(12):7504. [DOI:10.3390/ijerph19127504] [PMID]
31. Zhang X, Xu T, Qin Y, Wang M, Li Z, Song J, et al. Exploring the needs and coping strategies of family caregivers taking care of dying patients at home: A field study. BMC Palliative Care. 2023; 22(1):196. [DOI:10.1186/s12904-023-01315-0] [PMID]
32. Mohammadi F, Fallahi-Khoshknab M, Khanke HR. Needs of family caregivers of the patients with Alzheimer disease: Analyzing of family caregivers experiences. Advances in Nursing & Midwifery. 2011; 20(72):29-36. [DOI:10.22037/anm.v20i72.2690]
33. Zhang X, Clarke CL, Rhynas SJ. A thematic analysis of Chinese people with dementia and family caregivers’ experiences of home care in China. Dementia. 2020; 19(8):2821-35. [DOI:10.1177/1471301219861466] [PMID]
34. Hazzan AA, Dauenhauer J, Follansbee P, Hazzan JO, Allen K, Omobepade I. Family caregiver quality of life and the care provided to older people living with dementia: Qualitative analyses of caregiver interviews. BMC Geriatrics. 2022; 22(1):86.[DOI:10.1186/s12877-022-02787-0] [PMID]
35. Bonin-Guillaume S, Arlotto S, Blin A, Gentile S. Family caregiver’s loneliness and related health factors: What can be changed. International Journal of Environmental Research and Public Health. 2022; 19(12):7050. [DOI:10.3390/ijerph19127050] [PMID]
36. Kolodziej IW, Coe NB, Van Houtven CH. The impact of care intensity and work on the mental health of family caregivers: Losses and gains. The Journals of Gerontology. 2022;;77(Suppl_1):S98-111.[DOI:10.1093/geronb/gbac031] [PMID]
37. Xu J, Liu PJ, Beach S. Multiple caregivers, many minds: Family discord and caregiver outcomes. The Gerontologist. 2021; 61(5):661-9. [DOI:10.1093/geront/gnaa067] [PMID]
38. Moss KO, Kurzawa C, Daly B, Prince-Paul M. Identifying and addressing family caregiver anxiety. Journal of Hospice and Palliative Nursing. 2019; 21(1):14-20. [DOI:10.1097/NJH.0000000000000489] [PMID]
39. Orfila F, Coma-Solé M, Cabanas M, Cegri-Lombardo F, Moleras-Serra A, Pujol-Ribera E. Family caregiver mistreatment of the elderly: Prevalence of risk and associated factors. BMC Public Health. 2018; 18(1):167. [DOI:10.1186/s12889-018-5067-8] [PMID]
40. Wallace PM, Sterns HL. Considerations of family functioning and clinical interventions. Gerontology and Geriatric Medicine. 2022; 8:23337214221119054. [DOI:10.1177/23337214221119054] [PMID]
41. Aman Z, Liew SM, Ramdzan SN, Philp I, Khoo EM. The impact of caregiving on caregivers of older persons and its associated factors: A cross-sectional study. Singapore Medical Journal. 2020; 61(5):238-45. [DOI:10.11622/smedj.2019100] [PMID]
42. Hodgkin S. Intergenerational solidarity: An investigation of attitudes towards the responsibility for formal and informal elder care in Australia. Health Sociology Review. 2014; 23(1):53-64. [DOI:10.5172/hesr.2014.23.1.53]
43. Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. The American Journal of Nursing. 2008; 108(9 Suppl):23-7; quiz 27. [DOI:10.1097/01.NAJ.0000336406.45248.4c] [PMID]
44. Hailu GN, Abdelkader M, Meles HA, Teklu T. Understanding the support needs and challenges faced by family caregivers in the care of their older adults at home. A qualitative study. Clinical Interventions in Aging. 2024; 19:481-90. [DOI:10.2147/CIA.S451833] [PMID]
45. Morelli N, Barello S, Mayan M, Graffigna G. Supporting family caregiver engagement in the care of old persons living in hard to reach communities: A scoping review. Health & Social Care in The Community. 2019; 27(6):1363-74. [DOI:10.1111/hsc.12826] [PMID]
46. Ślusarczyk M. Intergenerational solidarity revisited: Migrant families in the dilemma of providing family or elderly care in the context of the covid-19 pandemic and its challenges. Comparative Population Studies. 2023; 48(12):1-16. [DOI:10.12765/CPoS-2023-05]
47. Mohammadian B, Mohammadi-Shahboulaghi F, Hosseini M, Arsalani N, Fallahi-Khoshknab M, et al. Factors influencing support provision to the family caregivers of elderly patients with cancer: A qualitative study. European Journal of Oncology Nursing. 2023; 67:102452. [DOI:10.1016/j.ejon.2023.102452] [PMID]