Over the last three decades, Alzheimer’s disease prevalence, on a global basis, has increased by 144%, with associated deaths rising by 184%. Additionally, 75% of dementia cases remain undiagnosed, affecting 41 million people (Organization for Economic Cooperation and Development [OECD, 2021]). In Portugal, around 153,000 individuals have dementia, including 90,000 with Alzheimer’s disease (OECD, 2021). Alzheimer’s disease leads to progressive cognitive decline and loss of daily living skills, causing high dependency, disability, and significant emotional and psychological impact (Bessey & Walaszek, 2019).

Family caregivers’ (FCs) quality of life (QoL) is influenced by health status, financial issues, social support, health conditions, and caregiver dependence (Damian et al., 2023). Female caregivers, especially those providing over 11 hours of care per week and those who are married, are predominantly affected by well-being and mental health concerns (Madruga et al., 2020).

Being a family caregiver (FC) significantly reduces QoL and well-being, leading to higher distress, financial burden, and negative impacts on health, relationships, and leisure. Caregivers often feel anguish, impatience, loneliness, frustration, anger, and sadness (Costa et al., 2021). Caregiving affects psychological, professional, and social status, causing burnout, poorer immune function, and loneliness (Rajovic et al., 2021). Damian et al. (2023) found that cynicism, effectiveness, distress, and sleep quality explained 87.8% of the variance in caregivers’ QoL during the Covid 19 pandemic.

The quality of prior family relationships is crucial when a family member becomes a caregiver. Healthier dynamics often lead to greater personal strengths and better QoL for caregivers, who are less likely to neglect self-care despite financial burdens. However, daily caregiving, patient dependence, and the decision to stop working can cause caregivers to postpone medical exams, which, consequently, adversely impacts upon their own health (Lindeza et al., 2020).

FCs face overwhelming demands from Alzheimer’s care while managing other commitments. Financial strain from reduced work hours or income loss increases anxiety and decreases mental QoL (Fabbietti et al., 2024). Emotional burdens, from witnessing a loved one’s decline, add to distress, with guilt, grief, helplessness, limited support, and inadequate resources exacerbating feelings of isolation and frustration (Nemcikova et al., 2023). Social support, close family relationships, and engaging in hobbies mitigate these challenges, serving as protective factors (Maggio et al., 2021).

The quality of FCs relationships with those they care for affects their QoL (Hazzan et al., 2022). Alzheimer’s increases dependency, causing role imbalances and persistent stress. Caregiving evolves from “noticing” to “balancing” and redefining roles post-diagnosis (Esandi et al., 2018). Spousal caregivers often face disrupted closeness, communication, intimacy, and support. Healthier family dynamics, such as cohesion, flexibility, communication, and empathy, boost caregivers’ mental health (Hazzan et al., 2022). Family functioning in adaptation, growth, partnership, and affection mediates caregiver burden and QoL, with higher family stress leading to lower QoL (Lindeza et al., 2020).

Research on forgiveness in stress management is limited, but it shows that using forgiveness as a coping strategy reduces marital and family stress in caregivers (Decaporale-Ryan et al., 2016). Better family relationships correlate with lower anxiety, depression, and burden (Rasmussen et al., 2019). Forgiveness involves compassion, love, and benevolent thinking, not just releasing anger and resentment (Kaleta & Mróz, 2020). It decreases distress, reduces rumination, and improves mental QoL (Çolak & Güngör, 2020). Some caregivers report forgiveness as a crucial aspect of their relationship with a person living with Alzheimer’s disease.

The results indicate that FCs involved in spiritual activities tend to be more compassionate and forgiving, suggesting spiritual support enhances these traits (McGee et al., 2021). Rasmussen et al. (2019) identified the calming effect of forgiveness on mitigating the deleterious impact upon health created by stress, reporting a positive link between forgiveness and better physical and mental health. Forgiveness can positively affect physical symptoms like heart rate and reduce psychological symptoms like stress, anxiety, and depression (López et al., 2021).

Prior research shows that during the pandemic, FCs experienced changes in responsibilities as well as in mental, physical, and financial health (de Sousa et al., 2022; Lorenz-Dant & Comas-Herrera, 2021), though other studies reported no changes in FCs’ QoL (Lara et al., 2020).

This study is based on Pearlin’s (1990) model, which conceptualizes QoL as an adaptation process of family caregiving on a caregiver’s health and well-being. The model includes four core elements: a) caregiver background (history, gender, age), b) caregiving stressors (primary and secondary), c) stress outcomes, and d) mediators/moderators affecting these relationships. Unlike the original model, which sees burden as a primary stressor, this study considers QoL as an outcome variable. Distress, forgiveness, and family stress were assessed at baseline (T1), and 6 months later (T2). QoL (physical and mental dimensions) was assessed at 12 months later (T3).

Longitudinal studies of FCs of Alzheimer’s patients are limited but essential to understand their evolving experiences and QoL. Such studies reveal how caregiver stress and coping mechanisms change, guiding targeted interventions. This study aims to explore the roles of distress, family stress, and forgiveness in physical and mental QoL over time. By focusing on emotional and interpersonal factors, it seeks to provide a deeper understanding of their impact on FCs’ QoL and capture the broader effects of caregiving beyond immediate demands.

Further research is needed to explore forgiveness as a mediator in enhancing interpersonal dynamics, aligning with Pearlin’s (1990) framework. Forgiveness, being an ongoing process, with lasting effects on family caregivers’ physical and psychological health, warrants research as a mediator between caregiver psychological well-being, family stress, and QoL. The comprehension of the role of forgiveness at T1 may inform interventions aimed at bolstering caregiver resilience and well-being, over the long term.

The main goal of this study was to evaluate the impact of psychosocial variables, specifically family stress, distress, and forgiveness, on FCs’ Qol over time, within the framework of Pearlin’s (1990) Stress Process Model.

Higher distress levels at T1 correlated positively with family stress at T1 and T2, indicating an increased strain in family relationships for caregivers. These results are consistent with previous research linking stress to increased family conflicts (Rajovic et al., 2021). Additionally, higher distress at T1 was associated with less use of forgiveness, consistent with findings that stress impedes forgiveness (Worthington & Sandage, 2016). Strained family dynamics at T1, also hindered forgiveness, highlighting how conflicts can complicate forgiveness and add to caregivers’ emotional burdens (Pietromonaco & Overall, 2022). Forgiveness significantly influenced FCs’ QoL. Positive correlations between forgiveness at T1 and T2, and forgiveness at T2 and mental QoL at T3, suggest that early adoption of forgiveness may lead to sustained benefits for long-term mental health. These findings support forgiveness as a crucial coping mechanism that enhances emotional resilience and well-being over time (Toussaint et al., 2015).

The negative correlations of distress at T2 with forgiveness at T1 and T2, and from the later mental and physical QoL at T3, suggest that ongoing distress may impact the capacity to forgive that consequently negatively impacts QoL. This result is in line with findings from previous studies that showed the adverse effects of chronic stress on QoL (Damian et al., 2023; Maggio et al., 2021).

The strong positive correlation between mental and physical QoL at T3, underscores the close relationship between mental and physical health. This supports the holistic view that interventions enhancing mental well-being can also improve physical health outcomes (Wiegelmann et al., 2021).

A significant finding in this study was the cascade effect of family stress at T1 predicting family stress at T2. This result highlights how initial stressors within the family context can persist over time, emphasizing the long-term impact of early stressors. Early interventions are therefore crucial for mitigating prolonged distress. Higher family stress at T2 predicted lower forgiveness at the same time point. This suggests that ongoing family conflicts can inhibit the forgiveness process, potentially perpetuating negative relational patterns and compromising family cohesion. Addressing family stress early is crucial to prevent the erosion of forgiveness, which is essential for maintaining emotional well-being and family unity. Family stress encompasses factors such as: interpersonal conflicts, caregiving responsibilities, financial strains, and emotional burdens within the family unit (Lindeza et al., 2020). These conflicts often stem from differences in caregiving approaches and financial matters, contributing to emotional distress among FC.

Forgiveness at T1 predicted forgiveness at T2, which in turn predicted mental QoL at T3, highlighting forgiveness as a potential buffer against the adverse effects of family stress. This suggests that early forgiveness practices tend to be sustained over time, fostering a positive emotional environment, despite ongoing challenges in caregiving. Embracing forgiveness involves letting go of resentment, anger, and negative emotions related to caregiving experiences. Research indicates that forgiveness enables FCs to adopt a more compassionate and empathetic outlook, reducing emotional burdens and promoting psychological well-being (Rasmussen et al., 2019).

Distress at T1 positively predicted distress at T2. Initial levels of distress had a compounding effect, leading to increased distress later. This result underscores the chronic nature of distress in caregiving, suggesting that without effective interventions, distress may escalate over time. These findings are consistent with prior research emphasizing the cumulative burden of caregiving responsibilities, which frequently results in sustained psychological strain (Costa et al., 2021). Moreover, the results showed that distress at T2 also negatively predicted mental QoL at T3. This finding is crucial, as it underscores the long-term negative impact on mental health outcomes, indicating that FCs experiencing high initial distress, are more likely to suffer from poor mental QoL over time. The continuous demands of caregiving and witnessing the inexorable decline of a loved one, may intensify distress levels among FCs, leading to adverse effects on their mental health and overall QoL. During the pandemic, FCs and those they care for, were among the most affected groups. The caregiving role, already physically, emotionally, and economically challenging, became even harder with reduced formal and informal support. The increased challenges, stress, and often a sense of helplessness in managing the situation or seeking assistance (Bergmann & Wagner, 2021).

One key finding of the present study was the detrimental impact of distress on forgiveness at both T1 and T2. The present results indicated that higher distress at T1 predicted less use of forgiveness at T1. Furthermore, the findings revealed a persistent negative impact of distress on forgiveness over time, with distress at T2 also predicting less use of forgiveness, as a coping strategy, at T2. Initial distress negatively affects emotional regulation and forgiveness over time, posing challenges in resolving conflicts and letting go of negative emotions among FCs. Coping through forgiveness is crucial as it reduces stress and promotes positive adaptation to adversity (Strelan, 2020). Research indicates that forgiveness offers significant physical and psychological benefits for well-being (Çolak & Güngör, 2020; López et al., 2021) underscoring the importance of managing distress effectively to mitigate the risk of prolonged emotional strain and unresolved conflicts (López et al., 2021).

Interestingly, the present study also revealed that forgiveness was a mediator in the relationship between distress and mental QoL. Specifically, significant distress at T1 predicted mental QoL at T3, mediated by forgiveness at T1 and T2. Fostering forgiveness early, and maintaining it, may protect FCs from the detrimental effects of distress on long-term mental well-being. Forgiveness reduces stress, anger, and frustration, promoting compassion and positive emotions towards the person living with Alzheimer’s disease (Levy et al., 2021). The practice of forgiveness also prevents negative emotions, behaviors, and obsessive thoughts, which can improve mental QoL over time (Çolak & Güngör, 2020; Kaleta & Mróz, 2020). Integrating forgiveness into caregiving strategies could significantly benefit FCs’ emotional health and overall QoL.

Furthermore, mental QoL at T3 was predictive of physical QoL at T3, suggesting that mental QoL may have a cascading effect on physical health outcomes. Improved mental well-being among FCs leads to better physical health and more effective management of caregiving responsibilities (Madruga et al., 2020; Maggio et al., 2021), better sleep, increased physical activity, and adherence to medical recommendations, all enhancing overall physical QoL (Gräler et al., 2022).

The results revealed that Alzheimer’s disease severity (mild, moderate, and severe) moderated the final model. In both the moderate and severe disease groups, a strong positive relationship was observed between distress at T1 and subsequent distress at T2. This finding aligns with research by Clare et al. (2022) and Quinn et al. (2019), indicating that FCs of persons living with advanced dementia experience sustained high levels of stress. The progressive nature of the disease and increasing caregiving demands lead to prolonged exposure to emotional and physical challenges, contributing to persistent distress among FCs.

For both mild and severe dementia, distress at T1 correlated negatively with forgiveness at T1. Over time, ongoing distress at T2 was associated with decreased forgiveness at T2. This relationship was particularly significant in the mild group, underscoring the early psychological strain in the caregiving journey as FCs adapt to new roles and evolving needs of their loved ones (Hazzan et al., 2022). The ongoing negative relationship between distress at T2 and forgiveness at T2 in the mild dementia group indicated that early distress has lasting effects. FCs starting with high stress levels may struggle to cultivate and sustain forgiveness over time, leading to chronic emotional strain that impacts their well-being and caregiving effectiveness (Clare et al., 2022; Quinn et al., 2019). In cases of severe dementia, FCs face intensified and prolonged demands, resulting in higher distress levels and a greater need for effective coping strategies like forgiveness which is consistent with the significant cognitive and functional impairments, in severe stages, increasing caregiving burdens and distress ppersistently. FCs showing more use of forgiveness often adopt better coping mechanisms and maintain a positive outlook, aiding in effective stress management (Rasmussen et al., 2019). This finding underscores the importance of early support for FCs caring for both mild and severe Alzheimer’s disease patients, starting from T1, as emphasized by Callahan et al. (2024).

In the mild dementia group, a negative relationship between forgiveness at T1 and family stress at T1 was found, which may indicate a protective role against family stress over time. FCs who exhibited more use of forgiveness experienced lower levels of family stress. In the early stages of Alzheimer’s disease, FCs face significant emotional adjustments upon realizing their loved one’s diagnosis and its implications for the future. Forgiveness in this context reflects the caregiver’s capacity to release negative emotions and resentments, fostering healthier family dynamics (Damian et al., 2023; Rasmussen et al., 2019). For caregivers in the moderate dementia group, increased use of forgiveness at T1 was positively linked to sustained forgiveness at T2, indicating that those who began with a forgiving attitude were likely to maintain this coping strategy over time.

Regarding the mediating effects, forgiveness at T1 and T2 had a mediator effect in the relationship between distress at T1, and mental QoL at T3. Furthermore, forgiveness at T1 and T2 and mental QoL at T3 were mediators between distress at T1 and physical QoL at T3 in the moderate and severe groups. These results showed that early distress may have long-term detrimental effects on the caregiver’s overall well-being. In advanced stages of dementia, FCs face heightened challenges due to intensified caregiving demands, which strain their emotional, physical, and financial well-being (Borges-Machado et al., 2020). Early distress predicted long-term well-being outcomes, reflecting the enduring impact of caregiving stress (Connelly et al., 2024). In mild dementia, forgiveness at T2 and mental QoL at T3 mediated the relationship between forgiveness at T1 and physical QoL at T3, illustrating forgiveness as a beneficial coping strategy that enhances physical QoL (Worthington & Sandage, 2016). These findings align with research highlighting the role of forgiveness in promoting emotional resilience and improving overall QoL.

FCs’ age did not act as a moderator, indicating that distress, forgiveness, family stress, and QoL dynamics are consistent across different age groups of caregivers. This finding suggests that the challenges and stress, associated with caring for persons living with Alzheimer’s disease, are similar whether caregivers are younger or older (Fabbietti et al., 2024). Caregiving tasks—such as managing behavioral symptoms, providing personal care, and coping with emotional distress—represent universal challenges that appear to transcend age among FCs. However, this finding contrasts with previous studies highlighting age as a significant factor influencing caregivers’ QoL (Madruga et al., 2020). It is possible that the characteristics of our sample, where a majority were retired or unemployed, focused primarily on caregiving rather than balancing it with work responsibilities, may explain this result. Future research could explore this hypothesis further.