Interconnected Challenges in Dementia Caregiving: A Co-occurrence Network Analysis of Burden, Unmet Needs, and System Failures Among Caregivers

Background: Alzheimer's Disease and Related Dementias (ADRD) is a growing global public health challenge, and caregivers experience high rates of burden, unmet needs, and system failures. These challenges vary by caregiver role and relationship to the care recipient, reflecting the heterogeneous nature of caregiving. Yet prior work has largely studied burden, unmet needs, and system failures as separate domains rather than examining how they co-occur within individual caregivers. Methods: We applied an LLM-based classification framework (Claude 3.5 Sonnet) to 7,198 posts from three ALZConnected caregiver forums (general, spouse/partner, and adult child caregivers), coding each post for burden, unmet needs, and system failures across 9, 12, and 10 categories respectively. We compared expression rates by caregiver role (primary vs. secondary) and relationship to the care recipient (spousal vs. child) and used post-level co-occurrence networks to map how categories cluster within and across domains. Results: Burden was expressed in 89.0% of posts and unmet needs in 93.3%, while system failures appeared in 34.8%. Primary caregivers reported burden more often than secondary caregivers (91.6% vs. 84.7%), while secondary caregivers reported more unmet needs (94.6% vs. 92.5%) and more system failures (37.2% vs. 33.4%). Child caregivers reported higher rates than spousal caregivers across all three domains. Co-occurrence networks showed dense within-domain clustering (density 0.61-0.65) and 84 significant cross-domain connections, with the strongest links between behavioral/safety burden and safety-management needs (21.7% of posts) and between emotional burden and emotional-support needs (20.9%). Conclusion: Burden, unmet needs, and system failures are not independent problems but form interconnected challenge ecosystems that vary by caregiver role and relationship. This suggests caregiver support should be designed around these connected patterns rather than treated as separate, single-domain interventions.