A meta-review of stress, coping and interventions in dementia and dementia caregiving

Assessing an evidence-based intervention for spouse caregivers of persons with Alzheimer's disease: results of a community implementation of the NYUCI in Israel

OBJECTIVES

Alzheimer's disease (AD) affects not only the person with the illness, but family caregivers as well. The NYU Caregiver Intervention (NYUCI), a psychosocial intervention which has demonstrated both short and long-term benefits for caregivers, has been used widely in the United States and in Australia and England. The Israeli study was a hybrid between a community implementation study and a randomized controlled trial (RCT) of the NYUCI in a non-English speaking country.

METHOD

A sample of 100 spouse caregivers participated in trial comparing the NYUCI provided by ten Israeli clinicians (enhanced care), to support group participation (usual care). The major outcome of interest was caregiver depressive symptoms, measured with the Geriatric Depression Scale. A linear random effects regression model controlling for factors associated with depressive symptoms was used to plot the longitudinal trajectories of depressive symptoms over the two-year study period and compare outcomes for the enhanced care and control groups.

RESULTS

One hundred spouse caregivers enrolled, of whom 81 provided data at baseline and at one or more post intervention assessments. The Israeli adaptation of the NYUCI was effective in reducing depressive symptoms reported by caregivers compared to their counterparts in the control group, b= -1.29 [95%CI (-2.43, -0.15)], p= .0265.

CONCLUSION

While implementing a randomized controlled trial of an intervention developed and tested in traditional research settings using community providers in Israel, posed unique challenges, the study demonstrated benefits to caregivers. As a result, 30 municipalities in Israel are currently implementing an ongoing adaptation of the NYUCI.

Assessing attitudes towards online psychoeducational interventions: Psychometric properties of a Brief Attitudes Scale

Participant attitudes are an explanatory factor for attrition in online health-related interventions. However, its assessment prior to interventions start is uncommon, partly because proper measures are missing. This study presents the psychometric properties of a new scale measuring attitudes towards online psychoeducational interventions (OPIs). Structural validity, reliability and screening performance of the Online Psychoeducational Intervention - Brief Attitudes Scale (OPI-BAS) were studied in a sample of 157 dementia caregivers. Scale cut-off scores were derived to categorise the participants into 'OPIs sympathisers' or 'non-sympathisers'. Groups were compared across sociodemographic and internet use variables. A parsimonious five-item version of OPI-BAS demonstrated good structural validity, with one factor explaining 63.3% of variance. Internal consistency of the scale was high (α = 0.85). OPI-BAS showed good screening performance in identifying individuals with either a preference to use conventional face-to-face or online psychoeducational interventions (area under the curve = 0.84). An optimal cut-off score of 20 was suggested by the receiver operating characteristic graph, providing good sensitivity (74%) and specificity (84%). No significant differences were found between groups on sociodemographic and internet use variables. Attitudes towards OPIs were overall positive, but face-to-face interventions were preferred. This study offers preliminary support to the psychometric quality of OPI-BAS. This short scale has practical applications for research and intervention.

Interpersonal Correlates of Dementia Caregivers' Emotional Support Networks: Considering Family History

Caregiving networks of individuals with Alzheimer's disease and related dementias (ADRD) are comprised of family and friends directly involved in caregiving activities and those supporting these activities. The purpose of this study was to investigate whether caregiving-related behaviors and interactions (i.e., uplift, malfeasance, and nonfeasance), kinship tie (i.e., friend, family), and family history of ADRD were associated with caregivers' emotional support networks. Seventy-one caregivers across 30 families provided information about 776 network members. Perceived emotional support and interactions representing uplift, malfeasance, and nonfeasance were assessed. Results indicated that uplift and friendship were associated with increased, whereas nonfeasance was associated with decreased, likelihood of perceived emotional support. Caregivers with a family history of ADRD were particularly more likely to report emotional support from friends and uplifting network members. Findings suggest the need for differential strategies based on families' prior caregiving experience to facilitate positive and minimize negative interactions within caregiving networks.

Sociodemographic aspects and health care-related outcomes: a latent class analysis of informal dementia care dyads

BACKGROUND

Studies revealed the importance to assess dementia care dyads, composed of persons with dementia and their primary informal caregivers, in a differentiated way and to tailor support services to particular living and care circumstances. Therefore, this study aims first to identify classes of dementia care dyads that differ according to sociodemographic, care-related and dementia-specific characteristics and second, to compare these classes with regard to healthcare-related outcomes.

METHODS

We used data from the cross-sectional German DemNet-D study (n = 551) and conducted a latent class analysis to investigate different classes of dementia care dyads. In addition, we compared these classes with regard to the use of health care services, caregiver burden (BIZA-D), general health of the informal caregiver (EQ-VAS) as well as quality of life (QoL-AD) and social participation (SACA) of the person with dementia. Furthermore, we compared the stability of the home-based care arrangements.

RESULTS

Six different classes of dementia care dyads were identified, based on best Bayesian Information Criterion (BIC), significant likelihood ratio test (p <  0.001), high entropy (0.87) and substantive interpretability. Classes were labelled as "adult child parent relationship & younger informal caregiver", "adult child parent relationship & middle aged informal caregiver", "non family relationship & younger informal caregiver", "couple & male informal caregiver of older age", "couple & female informal caregiver of older age", "couple & younger informal caregiver". The classes showed significant differences regarding health care service use. Caregiver burden, quality of life of the person with dementia and stability of the care arrangement differed also significantly between the classes.

CONCLUSION

Based on a latent class analysis this study indicates differences between classes of informal dementia care dyads. The findings may give direction for better tailoring of support services to particular circumstances to improve healthcare-related outcomes of persons with dementia and informal caregivers.

Coping Patterns Among Primary Informal Dementia Caregivers in Singapore and Its Impact on Caregivers-Implications of a Latent Class Analysis

BACKGROUND AND OBJECTIVES

Existing studies typically explore the factor structure of coping strategies among dementia caregivers. However, this approach overlooks the fact that caregivers often use different coping strategies simultaneously. This study aims to explore the coping patterns of primary informal dementia caregivers in Singapore, examine their significant correlates, and investigate whether different patterns would affect the depressive symptoms of caregivers.

RESEARCH DESIGN AND METHODS

Two hundred eighty-one primary informal caregivers of persons with dementia (PWD) were assessed. Coping strategies were measured by the Brief Coping Orientation to Problem Experienced inventory. A latent class analysis was performed to explore caregivers' coping patterns, followed by logistic regressions to identify the significant correlates and the relationships between coping patterns and caregiver depression.

RESULTS

The latent class analysis suggested a three-class solution that was featured by the frequency and variety of coping strategies used by caregivers-high coping (36.3%), medium coping (37.7%), and low coping (26.0%). Factors influencing the coping patterns of our sample were mainly related to caregivers' individual resources such as personal characteristics and caregiving stressors like PWD's problematic behaviors and caregiving burden. Compared to caregivers in the low coping group, those in the medium coping group had significantly higher risks of potential depression.

DISCUSSION AND IMPLICATIONS

The current study confirmed that there are distinct coping patterns among primary informal dementia caregivers, and caregivers with the low coping pattern had fewer depressive symptoms. Future research is needed to explore if coping patterns from our sample are generalizable to dementia caregivers elsewhere.

Factors predicting coping in older people with dementia: A cross-sectional study

Coping can buffer the effect of stress on well-being. Information about factors predicting coping is essential knowledge for developing programs to promote effective coping among older people with dementia and serves as basic knowledge for further study. A cross-sectional study design was employed to investigate the associated and predictive factors of coping. The factors were derived from the Stress Process Model for people with dementia. A group of 364 participants was determined by power analysis and purposively selected from out-patient dementia clinics of hospitals in Thailand. Data were collected from interviews using questionnaires and were analyzed using Spearman's rank correlation coefficient and the enter method of multiple regression analysis. With reference to the conceptual framework of the Stress Process Model, the results revealed that three background and context factors (gender, personal income, and relationships with family members), two stressor factors (cognitive ability, and self-esteem), and four mediator factors (optimism, hope, hardiness, and perceived social support) were significantly related to coping. Of the variation in coping scores, 47% could be explained by hope, perceived social support, cognitive ability, and gender.

Social Interactions between Family and Community-Based Service Providers in Dementia Caregiving

Objectives: This study aimed to evaluate the psychosocial experiences in community-based dementia caregiving by assessing the characteristics of social interactions between family caregivers and community-based service providers and associated psychological responses.Methods: Two independent groups of participants (family caregivers and community-based service providers) completed a one-time survey to report their social interactions and psychological states. A linear regression model was fit for each outcome (satisfaction, 10-item CES-D) while controlling for significant relevant covariates.Results: Higher perceived levels of collaboration were associated with higher job satisfaction and lower depression score among service providers, and higher satisfaction with providers among family caregivers. Higher perceived social support from the provider was associated with higher satisfaction among family caregivers.Conclusions: Participants reported varying levels of provider-family collaboration. The extent of collaborations and support exchange may have implications on the psychological well-being of those providing care to individuals with dementia including families and providers.Clinical implications: It may be beneficial to identify providers and families who perceive low levels of collaboration and implement intervention to facilitate positive social interactions. Developing organizational culture and payment systems that value high-quality social interactions may help enhance the psychological well-being of service providers and satisfaction among families who receive their services.

Satisfaction, utilization, and feasibility of a telehealth intervention for in-home dementia care support: A mixed methods study

BACKGROUND

Technology can enhance support for families caring for persons living with dementia but must be acceptable to be adopted. The FamTechCare clinical trial engaged caregivers in video recording care encounters that were reviewed by an expert panel who provided tailored feedback. The intervention reduced caregiver depression and improved caregiver competence. This mixed methods study reports on caregiver satisfaction and utilization of the intervention and expert panel evaluation of the intervention.

METHODS

A convergent parallel mixed methods design was used to evaluate the satisfaction, usability, and feasibility of the FamTechCare intervention. In the multisite randomized controlled trial, caregiver-person living with dementia dyads were randomized to the FamTechCare video support or attention control telephone support groups. Caregivers completed a satisfaction survey at the completion of the 3-month trial. Utilization was evaluated using the number and duration of videos submitted and calls received by caregivers. Relationships between participant characteristics and their satisfaction and utilization were evaluated. Feasibility of the intervention was assessed through content analysis of interviews with the expert panel.

RESULTS

The majority of caregivers in both groups reported benefits from participation. More FamTechCare caregivers found the interventionist support to be helpful (p = 0.001) and effective (p = 0.020) compared to attention control caregivers. FamTechCare caregivers of persons with more severe dementia were more likely to report that video recording intruded on their privacy (p = 0.050). Caregiver age, gender, education, dyad relationship, rural status, and type and severity of dementia were not associated with ratings of acceptability, ease of use, or intervention utilization. The expert panel described the FamTechCare intervention as useful and identified adaptations to enhance feasibility.

CONCLUSION

Regardless of age, gender, and relationship, caregivers found the intervention acceptable and easy to use and rated the expert feedback as effective in addressing care challenges. Further adaptation may be needed for FamTechCare to be readily implemented.

Childrens' and young adults' perspectives of having a parent with dementia diagnosis: A scoping review

BACKGROUND

Dementia is a key health issue worldwide. In Sweden, as in other European countries, most persons with dementia live in domestic settings and are often cared for by their family members. This scoping review aims to describe the perspectives of children and young adults with a parent diagnosed with dementia. Young family members may be alone and without support despite their high level of care burden.

DESIGN AND METHODS

Three electronic databases (PubMed, Web of Science and PsycINFO) were used to search for English-language articles focusing on children and young adults between the ages of 6 and 34 who have a parent diagnosed with dementia. A thematic synthesis of the included articles was performed.

FINDINGS

Sixteen original published qualitative studies were identified. These studies were categorised based on information about the authors, year of publication, study location, participants, aim of the study, data collection, analysis and main findings. Five main analytical themes were identified: (1) children and young adults identify changes in their parents' behaviour and personality, (2) children and young adults experience changed roles and relationships within the family, (3) children and young adults need to cope with an uncertain future, (4) children and young adults relate changes in their parent to their own mixed emotions and (5) children and young adults need help and seek it out but experience inadequate support.

CONCLUSIONS

The children and young adults in the included studies seem to provide significant levels of care and support to their affected parent, which may affect their own health, social relations, community participation, employment, education, finances and sense of security. This means that it is important for health care systems and social services to identify barriers to these young family members' access to relevant care and support for themselves.

Family caregivers' distress responses to daily behavioral and psychological symptoms of dementia: The moderating role of relationship quality

OBJECTIVES

Behavioral and psychological symptoms of dementia (BPSD) are associated with distress among caregivers of persons with dementia (PWD), but less is known about how relationship quality may buffer this association. This study examines the association between daily BPSD and daily perceived distress among family caregivers and the moderating role of relationship quality.

METHODS

Data were from 173 family caregivers of PWD from the Daily Stress and Health study. Relationship quality was assessed at the baseline interview; then on each of the 8 following consecutive days, caregivers reported frequency of daily BPSD (six domains) and their respective distress (calculated as daily distress sum and daily distress mean scores) through daily evening phone interviews at home. A 2-level multilevel model approach was employed to differentiate within-person (WP) and between-person (BP) effects.

RESULTS

Greater daily BPSD occurrence was associated with higher daily distress (sum and mean scores) at WP and BP levels. However, relationship quality moderated the association between daily BPSD occurrence and daily distress sum scores at both WP and BP levels. Caregivers who reported better relationship quality with the PWD had lower levels of daily distress sum scores in response to daily BPSD occurrence, compared to their counterparts with poorer relationship quality.

CONCLUSIONS

This study revealed that relationship quality attenuated the effect of daily BPSD occurrence on caregivers' distress. Future dementia caregiver education and support programs should consider building relationship quality into the personalized program design to improve caregiver mental health and well-being.

A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association

A healthy brain is critical for living a longer and fuller life. The projected aging of the population, however, raises new challenges in maintaining quality of life. As we age, there is increasing compromise of neuronal activity that affects functions such as cognition, also making the brain vulnerable to disease. Once pathology-induced decline begins, few therapeutic options are available. Prevention is therefore paramount, and primary care can play a critical role. The purpose of this American Heart Association scientific statement is to provide an up-to-date summary for primary care providers in the assessment and modification of risk factors at the individual level that maintain brain health and prevent cognitive impairment. Building on the 2017 American Heart Association/American Stroke Association presidential advisory on defining brain health that included "Life's Simple 7," we describe here modifiable risk factors for cognitive decline, including depression, hypertension, physical inactivity, diabetes, obesity, hyperlipidemia, poor diet, smoking, social isolation, excessive alcohol use, sleep disorders, and hearing loss. These risk factors include behaviors, conditions, and lifestyles that can emerge before adulthood and can be routinely identified and managed by primary care clinicians.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities

BACKGROUND AND OBJECTIVES

Assisted living (AL) residents with dementia commonly exhibit behavioral expressions (BEs), yet no study has examined how AL staff perceive of and respond to BEs in terms of the "ABC" model of antecedents, behaviors and consequences, or how perceptions relate to organizational characteristics. Understanding staff perceptions may inform interventions.

RESEARCH DESIGN AND METHODS

A convergent, mixed-methods design was used in a study of health care supervisors from 250 AL communities in seven states who reported 366 cases of resident BEs (one successful and one unsuccessful case). Qualitative analysis identified antecedents, BEs, staff responses, resident outcomes, and disposition (aging in place or discharge). Content analysis identified themes and compared case types. Descriptive statistics examined organizational characteristics associated with identifying antecedents.

RESULTS

One-quarter of cases recognized antecedents; slightly more were identified in successful (28%) compared to unsuccessful cases (20%); staff in dementia-only and smaller communities identified antecedents more often. Combativeness and anxiety were the most frequently reported BEs. The majority of both types of cases reported staff responses. Medication management was enacted as a response in 40% of cases compared to psychiatric assessment in 33% of cases.

DISCUSSION AND IMPLICATIONS

Staff training is indicated to increase AL staff recognition of antecedents; doing so might reduce use of antipsychotic medications. Psychiatric assessment plays an important role in dementia care in AL and warrants further examination. Results could be helpful for applied behavioral researchers interested in developing ways to improve identification of antecedents of BEs of persons with dementia.

Rural-urban differences in informal caregiving and health-related quality of life

OBJECTIVES

Rural-urban health disparities are pervasive among older adults. Rural US locations have a disproportionately high population of older adults, have reduced access to services, and are therefore more reliant on family and friends for care. However, little is known about rural-urban disparities among the 40+ million informal caregivers nationwide. There is a critical need to understand how rural-urban disparities impact caregiving experiences and health-related quality of life (HRQoL). The objectives of this study were to assess rural-urban differences in informal caregiving status, caregiving intensity (caregiving hours/week and types of care provided), and caregiver HRQoL.

METHODS

Data were abstracted from the 2018 Behavioral Risk Factor Surveillance System. The primary measure of rural-urban status was "metropolitan status." Associations between rural-urban status and caregiving and rural-urban differences in caregiving intensity and HRQoL were examined using generalized linear models, controlling for confounding and accounting for complex sampling.

RESULTS

Rural respondents were more likely to be caregivers than urban respondents (OR = 1.17, 95% CI: 1.02-1.34). After adjustment for confounders, rural caregivers were more likely than urban caregivers to provide 20 or more hours of caregiving per week (OR 1.38, 95% CI: 1.07-1.77), although the findings for health and HRQoL were somewhat mixed.

CONCLUSION

Results indicate that rural older adults offer more care than urban counterparts, which may have implications for caregiver health, well-being, and quality of life. These results can inform policies designed to improve caregiver health, and facilitate the translation and adaptation of existing policies, programs, and interventions to address rural caregivers' needs.

Adaptation of an online training and support program for caregivers of people with dementia to Indian cultural setting

Support for caregivers of people with dementia has been identified as an action area in the Global Action Plan on the Public Health Response to Dementia 2017-2025 by the World Health Organization (WHO). As a step towards that, WHO developed iSupport - an online program to provide support and training for caregivers of people with dementia. To address the need of caregivers in India, the iSupport program was adapted to the Indian cultural setting. The process of adaptation consisted of four phases: (a) information gathering (review of literature and focus group discussions), (b) preliminary adaptation design (modifications using an adaptation guide), (c) preliminary adaptation tests (face-to-face interviews and online test run), and (d) adaptation refinement (final modifications to the intervention and study process). The initial adaptation was carried out by effecting changes in words, names, resources, caregiving scenarios and audio files to make the English version of iSupport suitable to the Indian cultural context. The results of the qualitative adaptation tests provided additional recommendations like changing the links to India specific websites, revising the eligibility criterion for caregiving duration, re-wording of e-mail texts, inclusion of a time estimate required to complete the assessments and decreasing the numbers of screens that the caregivers had to navigate in the program, which were incorporated in the final phase. Preliminary data showed that the caregivers who participated in the adaptation process found the changes acceptable. Translation of iSupport to different Indian languages could be undertaken after initial effectiveness of the program is established.

Health Promotion Behavior among Older Korean Family Caregivers of People with Dementia

People adopt health promotion behaviors to promote their health as they interact within the environment. The purpose of this study was to examine factors influencing health promotion behaviors among older adults caring for family members with dementia. For this cross-sectional study, data from 135 older adults who were the main caregivers were collected at an outpatient clinic at a university hospital in the capital city of South Korea between September and October in 2020. Sociodemographic characteristics, caregiver-related characteristics, dementia knowledge, fear of dementia, and health promotion behaviors were measured. Univariate analysis revealed that the level of health promotion behaviors differed by age, sex, educational level, monthly income, relationship with the family member with dementia, and cohabitation with family members with dementia. In the multivariate analysis, a hierarchical multiple regression model explained 33.9% of the variance. Sex, duration of caregiving, use of long-term care service, and fear of dementia predicted health promotion behavior. A strategic tailored care plan for target population is needed to improve the health promotion behavior of older adults caring for family members with dementia.

How Can the Arts Influence the Attitudes of Dementia Caregivers? A Mixed-Methods Longitudinal Investigation

Background and Objectives

Arts activities can improve social connectedness and foster reciprocity between people living with dementia and their caregivers. The extent to which the arts can help shape attitudes towards dementia remains unclear. This paper explores the impact of a 12-week visual arts program “Dementia and Imagination” on the attitudes of family and professional caregivers through a mixed-methods longitudinal investigation, underpinned by a conceptual framework of the arts in dementia care.

Research Design and Methods

One hundred and forty-six family and professional caregivers were recruited across three settings in England and Wales (residential care homes, a county hospital, and community venues). Quantitative and qualitative data on caregivers’ attitudes and perceptions of the impact of the arts program were collected through interviews at three time points.

Results

Thematic analysis identified four themes shared across the caregivers: (1) Recognizing capabilities, (2) Social connectedness, (3) Improvements to well-being, and (4) Equality and personhood. Two further themes were distinct to family caregivers: (5) Duration of the effects of the art program, and (6) Enriched perspective. The final theme Inspiring professional development was distinct to the professional caregivers. The quantitative analysis found no effect for caregivers’ attitude change over time. Family caregivers scored significantly lower than professional caregivers at each of the three time points.

Discussion and Implications

Art programs have the potential to make visible the capabilities of the people living with dementia, enabling caregivers to see the person behind the condition. This study highlights practice implications for future implementation, such as the role of the arts in dementia care education.

Caring ahead: Mixed methods development of a questionnaire to measure caregiver preparedness for end-of-life with dementia

BACKGROUND

Family caregivers of persons with dementia often feel unprepared for end-of-life and preparedness predicts caregiver outcomes in bereavement. Existing questionnaires assessing preparedness have limitations. A multi-dimensional questionnaire assessing family caregiver preparedness for the end-of-life of persons with dementia is needed to identify caregivers at risk for negative outcomes in bereavement and evaluate the quality of strategies within a palliative approach.

AIM

To develop a multi-dimensional questionnaire titled 'Caring Ahead' to assess feelings of preparedness for end-of-life in family caregivers of persons with dementia.

DESIGN

A mixed methods, sequential design employed semi-structured interviews, a Delphi-survey and pilot-testing of the questionnaire, June 2018 to July 2019.

SETTING/POPULATION

Participants included five current and 16 bereaved family caregivers of persons with symptoms advanced dementia from long-term care homes in Ontario, Canada; and 12 professional experts from clinical and academic settings in Canada, Europe, United States.

RESULTS

Interviews generated three core concepts and 114 indicators of preparedness sampling cognitive, affective and behavioural traits in four domains (i.e., medical, psychosocial, spiritual, practical). Indicators were translated and reduced to a pool of 73 potential questionnaire items. 30-items were selected to create the 'Caring Ahead' preparedness questionnaire through a Delphi-survey. Items were revised through a pilot-test with cognitive interviewing.

CONCLUSIONS

Family caregivers' feelings of preparedness for end-of-life need to be assessed and the quality of strategies within a palliative approach evaluated. Future psychometric testing of the Caring Ahead questionnaire will evaluate evidence for validity and reliability.

Nursing, Caregiving and Psychological support in Chronic Disorders of Consciousness: a scoping review

BACKGROUND AND AIMS

The major disorders of consciousness include Coma, Vegetative State, and Minimally Conscious State. The care and the management of patients with Disorders of Consciousness (DOC) have raised several important ethical, social and medical issues. Aim of this review is to evaluate the role of nursing and psychological support in DOC management, in order to improve the quality of life of both patients and their caregivers.

METHODS

Studies dealing with DOC, nursing and caregiving pubblished in the last 20 years (from January 2000 to June 2020) were identified by searching on PubMed, Web of Science and Cochrane databases.

RESULTS

This review highlights the important role of DOC carevigers in the complex management of these frail patients, as well as the need for a specific support and counselling of caregivers. This psychological support may be given by nurses, as they are the healthcare professionals more involved in DOC care and cure.

DISCUSSION

Over the last years, specific recommendations for the assessment and rehabilitation of patients with DOC have been promulgated by neurorehabilitation organizations to provide some guidelines for the care and cure of such frail patients. Indeed, DOC patients need a multidisciplinary approach in which both caregivers and nurses have a pivotal role.

CONCLUSIONS

As the family is a critical and fundamental aspect in the management of DOC patients, it should be considered an integral part of care in the future guidelines.

Sleep Disruption Due to Stress in Women Veterans: A Comparison between Caregivers and Noncaregivers

Objective/Background: Sleep problems are common in women and caregiving for an adult is a common role among women. However, the effects of caregiving on sleep and related daytime impairment are poorly understood among women veterans. This study compared stress-related sleep disturbances, insomnia symptoms, and sleep-related daytime impairment between women veterans who were caregivers and those who did not have a caregiving role. Participants: Of 12,225 women veterans who received care in one Veterans Administration Healthcare System, 1,457 completed data on a postal survey (mean age = 51.7 ± 15.9 years). Two hundred forty three (17%) respondents (mean age 53.8 ± 12.7 years) were caregivers for an adult, predominantly for a parent, providing transportation. Methods: The survey included items that addressed insomnia symptoms, total sleep time, sleep-related daytime impairments, caregiving characteristics, self-rated health, pain, stress, body mass index, and demographic information. Results: In adjusted analyses, caregiver status did not directly predict sleep complaints alone. However, in multiple regression analyses, being a caregiver (odds ratio 1.7, p = .001) significantly predicted stress-related sleep disturbance, even after adjusting for age, pain, self-rated health, and other characteristics. Furthermore, being a caregiver (β = 3.9, p = .031) significantly predicted more symptoms of sleep-related daytime impairment after adjusting for age, pain, self-rated health, and other factors. Conclusions: Compared to noncaregivers, women veterans who were caregivers for an adult were more likely to report stress causing poor sleep, and more daytime impairment due to poor sleep. These findings suggest the need to target stress and other factors when addressing sleep disturbance among women veterans who are caregivers.

Opening Minds through Art: A preliminary study evaluating the effects of a creative-expression program on persons living with dementia and their primary care partners

For people living with dementia and their care partners, a decline in the ability to effectively communicate can cause significant distress. However, in recent decades, the arts have emerged as an effective care modality in fostering communication and expression for those with declining verbal skills and memory loss. Opening Minds through Art (OMA) is a national initiative that empowers people living with dementia by facilitating creative expression and social engagement through art-making in partnership with trained college student volunteers. Research has demonstrated that participation in the program benefits quality of life for those living with dementia and also improves student attitudes toward dementia. To date, however, no research has involved primary care partners. We implemented an OMA program at three residential care homes in State College, Pennsylvania, with residents cocreating artwork alongside primary care partners (i.e., a family member or primary medical personnel) over the course of four art-making sessions. We evaluated the effects of participation on quality of life and care partner burnout through pre-post use of "emotional thermometers" (measuring levels of distress, anxiety, depression, anger, and perceived quality of life), the National Institute of Health NIH emotional support scale, and the NIH caregiver assessment (care partner burnout). For people living with dementia, participation significantly increased perceived quality of life while decreasing distress, anxiety, depression, and anger (p < .01; n = 12) after each class; however, the intervention did not significantly impact perceived emotional support. For care partners, participation significantly lowered post-intervention measures of burnout and self-rated stress (p < .01; n = 9). This preliminary study suggests that a structured art-based activity appears to positively impact acute mood for patients and, importantly, decrease care partner burnout. Future research can bring more robust methods to bear in determining how to use OMA and other arts interventions to optimize social support for people living with dementia and their care partners.

Stress-related physical and mental disorders: a new paradigm

Stress-related disorders are diverse and they may be mental and physical. Often, several body systems and organs are involved simultaneously. The pathophysiology of stress-related disorders involves many factors: an observable or perceived stressor, an individual dynamically evolving vulnerability and maladaptation leading to imbalance, as well as environmental, cultural, gender and life-cycle variables. There is a need to develop a comprehensive quantifiable stress assessment instrument. It would be based on the ‘stress factor’, a dimension that would integrate biological, psychological, social, economic and spiritual parameters and would allow for cultural sensitivity. It would contribute to clinical operational sophistication and would illuminate treatment options and multidimensional well-being interventions. Hopefully, it would facilitate development of culturally sensitive pharmaceutical or biophysiological adaptogens and homeostatic interventions.

Psychosocial interventions to support the mental health of informal caregivers of persons living with dementia - a systematic literature review

Background

Informal caregivers of persons living with dementia have an increased risk of adverse mental health effects. It is therefore important to systematically summarize published literature in order to find out which mental health interventions generate effective support for informal caregivers of persons living with dementia. The objective of this study is to conduct a systematic review of intervention content, effectiveness and subgroup differentiation of mental health interventions for informal caregivers of persons with dementia living at home.

Method

We searched four electronic databases (PubMed, PsychINFO, Scopus and CINAHL) and included only methodically high-quality randomized controlled trials (RCTs), published in English or German language between 2009 and 2018. The intervention programmes focused on mental health of family caregivers. A narrative synthesis of the included studies is given.

Results

Forty-eight publications relating to 46 intervention programmes met the inclusion criteria. Burden, depression and quality of life (QoL) are the predominant parameters that were investigated. Twenty-five of forty-six interventions (54.3%) show positive effects on at least one of the outcomes examined. Most often, positive effects are reported for the outcome subjective burden (46.2%). Only six studies explicitly target on a certain subgroup of informal dementia caregivers (13%), whereas all other interventions (87%) target the group as a whole without differentiation.

Conclusion

The most beneficial results were found for cognitive behavioural approaches, especially concerning the reduction of depressive symptoms. Besides this, leisure and physical activity interventions show some good results in reducing subjective caregiver burden. In order to improve effectiveness, research and practice may focus on developing more targeted interventions for special dementia informal caregiver subgroups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02020-4.

Cost-effectiveness of a telehealth intervention for in-home dementia care support: Findings from the FamTechCare clinical trial

Determining the cost-effectiveness of technological interventions is a crucial aspect in assuring these interventions can be adopted. The FamTechCare intervention is an innovative telehealth support that links family caregivers of persons living with dementia to tailored feedback from dementia care experts based on caregiver-initiated video recordings of challenging care situations. The FamTechCare intervention has demonstrated significant reductions in caregiver depression and increases in caregiver competence when compared to standard telephone support. The purpose of this article is to report on the cost-effectiveness of the FamTechCare telehealth intervention. Process-based costing and a cost-effectiveness analysis using the incremental cost-effectiveness ratio (ICER) was completed with 68 caregiver and person living dementia with dyads. The cost of the 12-week FamTechCare telehealth intervention was found to be greater ($48.43 per dyad per week) due to the telehealth equipment, recording application, and expert panel time compared with the telephone support intervention ($6.96 per dyad per week). The ICER was $18.51 for caregiver depression and $36.31 for caregiver competence indicating that it cost no more than $36.38 per dyad per week over 12 weeks to achieve significant improvement in depression and competence in the FamTechCare caregivers compared to the telephone support caregivers. The FamTechCare intervention appears to be cost-effective when compared to the telephone support intervention and remains near the willingness-to-pay threshold for caregivers providing in-home dementia care support.

Development and evaluation of an intervention on suPpoRting infOrmal cAregivers of older people with early CogniTIVe declinE (PROACTIVE): a study protocol based on the Medical Research Council framework

INTRODUCTION

Caring for people with cognitive problems can have an impact on informal caregivers' health and well-being, and especially increases pressure on healthcare systems due to an increasing ageing society. In response to a higher demand of informal care, evidence suggests that timely support for informal caregivers is essential. The New York University Caregiver Intervention (NYUCI) has proven consistent effectiveness and high adaptability over 30 years. This study has three main objectives: to develop and evaluate the Flemish adaptation of the NYUCI in the context of caregiving for older people with early cognitive decline; to explore the causal mechanism of changes in caregivers' health and well-being and to evaluate the validity and feasibility of the interRAI Family Carer Needs Assessment in Flanders.

METHODS AND ANALYSIS

Guided by Medical Research Council framework, this study covers the development and evaluation phases of the adapted NYUCI, named PROACTIVE-suPpoRting infOrmal cAregivers of older people with early CogniTIVe declinE. In the development phase, we will identify the evidence base and prominent theory, and develop the PROACTIVE intervention in the Flemish context. In the evaluation phase, we will evaluate the PROACTIVE intervention with a pretest and posttest design in 1 year. Quantitative data will be collected with the BelRAI Screener, the BelRAI Social Supplement and the interRAI Family Carer Needs Assessment at baseline and follow-up points (at 4, 8 and 12 months). Qualitative data will be collected using counselling logs, evaluation forms and focus groups. Quantitative data and qualitative data will be analysed with SAS 9.4 software and NVivo software, respectively. Efficacy and process evaluation of the intervention will be performed.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of KU Leuven with a dossier number G-2020-1771-R2(MAR). Findings will be disseminated through community information sessions, peer-reviewed publications and national and international conference presentations.

[Influence of Self-care on Burnout in Primary Family Caregiver of Person with Dementia]

PURPOSE

The purpose of this study was to identify the influence of self-care on burnout experienced by primary family caregivers of persons with dementia.

METHODS

The subjects of the study were 156 primary family caregivers of persons with dementia at home in Korea. Data were analyzed using descriptive statistics, independent t-test, one-way ANOVA, Pearson correlation coefficient, and hierarchical multiple regression using IBM SPSS Statistics ver. 24.0 for Windows.

RESULTS

The mean scores for self-care and burnout were 42.35 and 61.60, respectively. Self-care, subjective health status, living with a person with dementia, and behavioral and psychological symptoms of dementia were significant factors affecting burnout in family caregivers. Self-care was identified as the strongest factor affecting burnout, explaining 13.9% of burnout with controlling factors in caregivers and care receivers.

CONCLUSION

To prevent burnout in primary family caregivers of persons with dementia, self-care of family caregivers should be emphasized. In nursing education, family caregivers should be recognized and approached as nursing clients who are responsible for taking care of their health. In nursing practice and research, digital self-care or self-care improvement intervention programs should be designed to help family caregivers, and further studies on self-care centered on health of family caregivers should be conducted.

The experiences of grandchildren who provide care for a grandparent with dementia: A systematic review

Much of the research exploring the experiences of family caregivers of people with dementia has focussed on spouses and adult children. It is hypothesised that other family members at different life stages and with different family roles may experience and perceive the caregiving role differently. The objective of the current review was to explore the experiences of grandchildren who provide care to a grandparent with dementia. A systematic search of four databases identified 12 studies which met the inclusion criteria. An assessment of quality was completed for each of the included studies. Grandchildren described dementia-related changes, changes to their role and relationship with their grandparent, multiple impacts of caregiving, influences of other family relationships on caregiving and positive aspects of caregiving. Many of the included studies met most of the quality criteria for the respective methodological design; however, there was some variation in quality and sample across included studies. The review indicates that assessments and interventions to incorporate grandchildren and the wider family system may help to support family carers to continue to provide care for grandparents with dementia. The research and clinical implications and limitations of the review are also considered.

Online Education and Cognitive Behavior Therapy Improve Dementia Caregivers' Mental Health: A Randomized Trial

OBJECTIVES

To compare online cognitive-behavioral therapy (CBT) with and without telephone support respectively to online psychoeducation in a randomized controlled trial (RCT) in caregivers of people with dementia with mild anxiety or depression.

DESIGN

Three-arm parallel-group RCT comparing online CBT with and without telephone support respectively to online psychoeducation.

SETTING AND PARTICIPANTS

Online study with caregivers of people with dementia.

MEASURES

The primary outcome measure was mental health measured by General Health Questionnaire-12 (GHQ-12) at 26 weeks. Secondary outcomes included the Hospital Anxiety and Depression Scale (HADS); the Relative Stress Scale (RSS) and the Short Sense of Competency Questionnaire. The primary analysis focused on people completing GHQ-12 at both baseline and 26 weeks, evaluated using analysis of covariance.

RESULTS

638 people were randomized to the 3 treatment arms, of whom 208 were included in the analysis population. There were significant improvements in GHQ-12 in all treatment arms compared to baseline (P < .001 for all interventions), but neither CBT with nor without telephone support conferred any significant advantage compared to psychoeducation. For the secondary outcomes, there were no significant differences between CBT with telephone support and psychoeducation, but CBT without telephone support was less effective than psychoeducation with respect to HADS depression subscale [mean difference 1.86, 95% confidence interval (CI) 0.61, 3.11; P = .004] and caregiver stress (RSS mean difference 3.11, 95% CI 0.13, 6.09; P = .04). Good safety was achieved in all 3 treatment arms, with no deaths or serious adverse events.

CONCLUSIONS AND IMPLICATIONS

Online CBT with telephone support and psychoeducation both achieved significant benefits over 26 weeks compared with baseline in mental health and mood, but there were no advantages for CBT compared with the psychoeducation intervention. CBT without telephone support was less effective with respect to mood outcomes than psychoeducation and should not be recommended based on current evidence.

Gaining Longitudinal Accounts of Carers' Experiences Using IPA and Photograph Elicitation

Fluctuations in positive and negative caregiving experiences remain only partially explained as the significant variability over time of potential predictive factors themselves is understudied. The current study aims to gain considerable insight into caregiving experiences and perceptions over time by using photovoice methodology to support semi-structured interviews. A case study, longitudinal design is taken with three female caregivers who provide detailed insight into their caregivers' experiences over a 12 month period. The interview transcripts were analyzed using IPA- Interpretative Phenomenological Analysis. This innovative combination of methods resulted in the emergence of three related themes which included consuming the role, feeling consumed by the role, and letting go of the role. The idiographic approach taken allowed both within case differences to be examined over time, and also between carer differences to be highlighted. Implications of illness type and its characteristics, and of attachment and relationship quality with the care recipient were seen in terms of how and when the caregivers moved between the themes identified. The use of others' support or respite care is examined vis-a vis caregiver's own beliefs, emotions, relationship attachment and motivations to care. Caregivers self-efficacy beliefs also shifted over time and were influential in caregiver experience as the care recipient condition or needs changed. No previous studies have found that negative caregiving consequences are, in part, under volitional control and yet our data on the underlying reasons for consuming caregiving or allowing themselves to consume, would suggest this may in part be true. This is important because it suggests that interventions to support caregivers should address relational and motivational factors more fully.

The necessity for sustainable intervention effects: lessons-learned from an experience sampling intervention for spousal carers of people with dementia

OBJECTIVES

Caring for a person with dementia can be challenging over the years. To support family carers throughout their entire caregiving career, interventions with a sustained effectivity are needed. A novel 6-week mobile health (mHealth) intervention using the experience sampling method (ESM) showed positive effects on carers' well-being over a period of 2 months after the intervention. In this study, the effects after 6 months of the selfsame intervention were examined to evaluate the sustainability of positive intervention effects.

METHOD

The 6-week mHealth intervention consisted of an experimental group (ESM self-monitoring and personalized feedback), a pseudo-experimental group (ESM self-monitoring without feedback), and a control group (providing regular care without ESM self-monitoring or feedback). Carers' sense of competence, mastery, and psychological complaints (depression, anxiety and perceived stress) were evaluated pre- and post-intervention as well as at two follow-up time points. The present study focuses on the 6-month follow-up data (n = 50).

RESULTS

Positive intervention effects on sense of competence, perceived stress, and depressive symptoms were not sustained over 6-month follow-up.

CONCLUSION

The benefits of this mHealth intervention for carers of people living with dementia were not sustained over a long time. Similarly, other psychosocial interventions for carers of people with dementia rarely reported long-lasting effects. In order to sustainably contribute to carers' well-being, researchers and clinicians should continuously ensure flexible adjustment of the intervention and consider additional features such as ad-hoc counseling options and booster sessions. In this regard, mHealth interventions can offer ideally suited and unique opportunities.

CCCDTD5: Individual and community-based psychosocial and other non-pharmacological interventions to support persons living with dementia and their caregivers

INTRODUCTION

Current pharmacological therapies for dementia have limited efficacy. Thus it is important to provide recommendations on individual and community-based psychosocial and non-pharmacological interventions for persons living with dementia (PLWDs) and their caregivers.

METHODS

Phase 1: A systematic review for developing recommendations on psychosocial and non-pharmacological interventions at the individual and community level for PLWDs and their caregivers. Phase 2: Rating of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Phase 3: Delphi process (>50 dementia experts) for approving recommendations by the 5th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD5).

RESULTS

The CCCDTD5 approved the following recommendations: Exercise (1B) and group cognitive stimulation for PLWDs (2B), psychosocial and psychoeducational interventions for caregivers (2C), development of dementia friendly organization and communities (2C), and case management for PLWDs (2B).

DISCUSSION

The CCCDTD5 provides for the first time, evidence-based recommendations on psychosocial and non-pharmacological interventions for PLWDs and their caregivers that can inform evidence-based policies for PLWDs in Canada.

Access and Retention of Informal Dementia Caregivers in Psychosocial Interventions: A Cross-Sectional Study

Underutilization of community care services has been described for informal dementia caregivers. Most research has however examined caregivers' access to home or respite care rather than to services for themselves. The aims of this study are: to describe access and retention of informal dementia caregivers in psychosocial interventions; examine the perceived effects of interventions among users and motives for non-use among non-users; and compare caregivers with and without lifetime access and retention in psychosocial interventions across predisposing, enabling and need variables. A cross-sectional study was conducted with 179 Portuguese caregivers, who replied to a web-based survey. Participants were fairly distributed among those who have never (49.7%) and those who have ever accessed (50.3%) psychosocial interventions. Individual psychological support was the most used intervention (32.2%). Caregivers' age, time elapsed since diagnosis and the relationship with the care receiver were associated with lifetime access to various intervention types. Dropout was above 50% for most intervention types, except for psychoeducation (31.8%). Associations were found between a history of dropout/retention and caregivers' education, perceived mental health, and the number of hours spent caring. Most users of psychoeducational interventions (>80%) appraised it as beneficial to learn about the disease, provide quality care and cope with caregiving. Informational barriers were the most reported by non-users of psychoeducational interventions (45.1%). The findings show that dementia caregivers continue facing barriers to use and keep using community services for themselves. The influence of particular predisposing and need variables on access to psychosocial interventions can vary according to intervention types.

Family Caregiving for Older Adults

Family members are the primary source of support for older adults with chronic illness and disability. Thousands of published empirical studies and dozens of reviews have documented the psychological and physical health effects of caregiving, identified caregivers at risk for adverse outcomes, and evaluated a wide range of intervention strategies to support caregivers. Caregiving as chronic stress exposure is the conceptual driver for much of this research. We review and synthesize the literature on the impact of caregiving and intervention strategies for supporting caregivers. The impact of caregiving is highly variable, driven largely by the intensity of care provided and the suffering of the care recipient. The intervention literature is littered with many failures and some successes. Successful interventions address both the pragmatics of care and the emotional toll of caregiving. We conclude with both research and policy recommendations that address a national agenda for caregiving.

The impact of assistive technology on burden and psychological well-being in informal caregivers of people with dementia (ATTILA Study)

INTRODUCTION

Assistive technology and telecare (ATT) may alleviate psychological burden in informal caregivers of people with dementia. This study assessed the impact of ATT on informal caregivers' burden and psychological well-being.

METHODS

Individuals with dementia and their informal caregivers were recruited to a randomized-controlled trial assessing effectiveness of ATT. Caregivers were allocated to two groups according to their cared-for person's randomization to a full or basic package of ATT and were assessed on caregiver burden, state anxiety, and depression. Caregivers' data from three assessments over 6 months of the trial were analyzed.

RESULTS

No significant between- or within-group differences at any time point on caregivers' burden, anxiety, and depression levels were found.

DISCUSSION

Full ATT for people with dementia did not impact caregivers' psychological outcomes compared to basic ATT. The length of follow up was restricted to 6 months.

Antonovsky's sense of coherence and resistance resources reduce perception of burden in family carers of people with Alzheimer's disease

Objectives: Taking care of people with dementia (PWD) has been associated with some degree of burden. The variability of the carer's burden can be partially explained by their personal characteristics. Antonovsky's model of health defined the resistance resources (RRs) as essential mechanisms to cope with stressors, and to shape the personal sense of coherence (SOC). This study identifies the RRs related with carer's SOC, and their implications in the perception of burden in family dementia carers.Methods: A sample of 308 participants from the 'SOC & DEM study' (154 carers and 154 PWD) was recruited from two memory clinics. Carer's personal characteristics of burden, SOC, self-efficacy, coping strategies, perceived social support, and depression were evaluated using standardized instruments. PWD's degree of dependence and behaviour and psychological symptoms of dementia (BPSD) were assessed too. A path analysis was used to test the relationship between caregiver burden and SOC including the personal RRs of the carers and clinical data of PWD.Results: The path model identified SOC as a major factor related to carer's burden perception (r = -.327). Self-efficacy (r = .285), two coping strategies, 'use instrumental support' (r = -.235) and 'behavioural disengagement' (r = -.219), and social support perceived (r = .304) were the main carer's personal characteristics directly related with SOC. Caring experience (r = -.281) was the main carer factor related with burden while dependence (r = .156) and BPSD (r = .157) were the dementia factors.Conclusion: The SOC has previously related with carer's burden. The results contributed to identify relevant and modifiable personal characteristics as RRs that could reduce this burden.

Effects of a Video-based Intervention on Caregiver Confidence for Managing Dementia Care Challenges: Findings from the FamTechCare Clinical Trial

OBJECTIVES

The Supporting Family Caregivers with Technology trial tested the FamTechCare video support intervention against telephone support. Dementia caregivers' video-recorded challenging care encounters and an interdisciplinary team provided tailored feedback. This paper reports on the effects of the intervention on caregiver confidence in managing priority challenges, a secondary outcome of this non-blinded parallel randomized controlled trial.

METHODS

Caregiver/person living with dementia dyads were randomized to the experimental FamTechCare video support (n = 43) or attention control telephone support (n = 41) groups. Caregivers providing in-home care to a person living with mild or more severe dementia were eligible. Caregivers identified three priority challenges using the Caregiver Target Problems Questionnaire and rated the frequency and severity of each challenge and their confidence managing the challenge at baseline and 3-months. Challenges were classified using the FamTechCare Technology-supported Dementia Care Typology. Effects on confidence were compared between groups using the Wilcoxon rank-sum test and within groups using the Wilcoxon signed-rank test.

RESULTS

Caregiver priority challenges included managing dementia behaviors, understanding disease expectations, and performing activity of daily living care. Improvements were observed across the three categories in both groups; however, not all changes were statistically significant. No significant differences were identified between groups.

CONCLUSION

Caregivers in the FamTechCare group reported benefit across all priority challenges including managing dementia behaviors, understanding disease expectations, and performing activity of daily living care.

CLINICAL IMPLICATIONS

Innovative technology provides new opportunities to support family caregivers in dementia home care. Video-recording can be used to enhance support for family caregivers facing care challenges.

Interventions for Family Members After Long-Term Care Placement of a Relative With Dementia: A Systematic Review and Meta-Analysis

The current systematic review aimed to identify, appraise, and synthesize the available evidence regarding interventions that assisted family members of long-term care facility residents with dementia to cope with stressful situations. A search of published articles in eight databases was performed. In total, 1,293 records were identified, with six studies included in this systematic review. Interventions were categorized as education/skill training, psychoeducation, and psychosocial support. The risk of bias across the included studies varied from moderate to high. The intervention components, dose, and delivery methods differed widely with mixed results. The interventions showed potential benefits for reducing family members' stress-related outcomes (e.g., stress appraisal, guilt) and residents' problematic behaviors. Yet, meta-analysis yielded a non-significant pooled effect for reducing family members' depressive symptoms (mean difference = 1.38, 95% confidence interval [-2.27, 5.04], p = 0.46). Evidence in this field is currently insufficient and more well-designed studies with larger sample sizes and use of theoretical frameworks are needed. [Research in Gerontological Nursing, 14(1), 43-52.].

Effect of the COVID-19 pandemic on the mental health of carers of people with intellectual disabilities

INTRODUCTION

The measures implemented to manage the COVID-19 pandemic have been shown to impair mental health. This problem is likely to be exacerbated for carers.

METHOD

Informal carers (mainly parents) of children and adults with intellectual disabilities, and a comparison group of parents of children without disabilities, completed an online questionnaire. Almost all the data were collected while strict lockdown conditions were in place.

RESULTS

Relative to carers of children without intellectual disability, carers of both children and adults with intellectual disability had significantly greater levels of a wish fulfilment coping style, defeat/entrapment, anxiety, and depression. Differences were 2-3 times greater than reported in earlier pre-pandemic studies. Positive correlations were found between objective stress scores and all mental health outcomes. Despite their greater mental health needs, carers of those with intellectual disability received less social support from a variety of sources.

CONCLUSIONS

The greater mental health needs of carers in the context of lesser social support raises serious concerns. We consider the policy implications of these findings.

Internet-Based Supportive Interventions for Family Caregivers of People With Dementia: Systematic Review and Meta-Analysis

Background

Caring for people with dementia is perceived as one of the most stressful and difficult forms of caring. Family caregivers always experience high levels of psychological burden and physical strain, so effective and practical support is essential. Internet-based supportive interventions can provide convenient and efficient support and education to potentially reduce the physical and psychological burden associated with providing care.

Objective

This review aimed to (1) assess the efficacy of internet-based supportive interventions in ameliorating health outcomes for family caregivers of people with dementia, and (2) evaluate the potential effects of internet-based supportive intervention access by caregivers on their care recipients.

Methods

An electronic literature search of the PubMed, EMBASE, Web of Science, CINAHL, Cochrane Library, and PsycINFO databases was conducted up to January 2020. Two reviewers (ML and YZ) worked independently to identify randomized controlled trials (RCTs) that met the inclusion criteria and independently extracted data. The quality of the included RCTs was evaluated using the approach recommended by the Cochrane Handbook for Systematic Reviews of Interventions. Standardized mean differences (SMDs) with 95% CIs were applied to calculate the pooled effect sizes.

Results

In total, 17 RCTs met the eligibility criteria and were included in this systematic review. The meta-analysis showed that internet-based supportive interventions significantly ameliorated depressive symptoms (SMD=–0.21; 95% CI –0.31 to –0.10; P<.001), perceived stress (SMD=–0.40; 95% CI –0.55 to –0.24; P<.001), anxiety (SMD=–0.33; 95% CI –0.51 to –0.16; P<.001), and self-efficacy (SMD=0.19; 95% CI 0.05-0.33; P=.007) in dementia caregivers. No significant improvements were found in caregiver burden, coping competence, caregiver reactions to behavioral symptoms, or quality of life. Six studies assessed the unintended effects of internet-based supportive intervention access by caregivers on their care recipients. The results showed that internet-based supportive interventions had potential benefits on the quality of life and neuropsychiatric symptoms in care recipients.

Conclusions

Internet-based supportive interventions are generally effective at ameliorating depressive symptoms, perceived stress, anxiety, and self-efficacy in dementia caregivers and have potential benefits on care recipients. Future studies are encouraged to adopt personalized internet-based supportive interventions to improve the health of family caregivers and their care recipients.

Trial Registration

PROSPERO CRD42020162434; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=162434

A dyadic perspective on assessment in Alzheimer's dementia: Supporting both care partners across the disease continuum

Written from a dyadic strength-based perspective, this article first provides a brief overview of the Education, Information, and Support section of the 2018 Alzheimer's Disease Dementia Care Practice Recommendations.1 Subsequent sections present a comprehensive overview of available valid and reliable psychosocial measures that assess a selection of important domains for dementia care planning that can be used by families from early stage until end-of-life. Measures selected for the purposes of this article will focus on concepts that are strength-based and most relevant to care dyads as they navigate the difficult disease trajectory: readiness, knowledge, coping, dyadic relationship, care values and preferences. We will also highlight measures that have traditionally targeted the family care partner but can potentially be considered for use with the care partner with dementia, with adjustments, beyond the early stages. Part of this discussion will include various strategies for including persons with dementia in all aspects of their own care using a strength-based perspective, potentially enabling them to answer questions more reliably across disease stages. Last, gaps in existing measures will be identified to provide options to better assess areas of need most meaningful to families, and in ways that positively contribute to the successful aging of those living with dementia and their care partners.

Determinants of overburdening among informal carers: a systematic review

Background

The world’s population is ageing, resulting in rising care demands and healthcare costs, which in turn lead to a shift from formal to informal care. However, not only is the number of potential informal carers fast decreasing, but also informal caregivers are experiencing a higher caregiver burden. This literature review aims to synthesize the literature on the common determinants of caregiver burden in Western countries, to help ensure future continuation of informal care in the home context, and to improve or sustain the quality of life of caregivers and patients alike.

Method

A systematic review of peer-reviewed articles included in PubMed, Scopus, and/or PsychInfo was conducted.

Results

Seventeen articles were included. The most important predictors were the duration of caregiving and the patient’s dependency level, in terms of both physical and mental dependency stemming from decreased cognitive capacity or behavioural problems. Some specific illnesses and role conflicts or captivity also increased caregiver burden, whereas social support lowered it. Being a female caregiver or having an adult–child relationship led to a higher burden.

Conclusions

The most important predictors of caregiver burden are the duration of caregiving and the patient’s dependency level. In addition, the patient’s behavioural problems and cognitive capacity determine dependency level, and thus care burden. Interventions to relieve burden need to be adapted to the illness trajectory of specific diseases and corresponding needs for social support for both the recipient and the caregiver. Changing role expectations, leading to men being more involved, could reduce the disproportionately high burden for women.

Dementia caregivers training needs and preferences for online interventions: A mixed-methods study

AIM

To explore how informal caregivers of persons with dementia perceive training needs and preferences in the context of online training and support interventions.

BACKGROUND

Informal dementia caregivers commonly present high needs across several domains. Paradoxically, they are more likely to have unmet needs and lower levels of service usage when compared to other caregivers. Most studies on unmet needs of dementia caregivers have been quantitative and resorted to assessment checklists, with a minority focusing on subjective needs.

DESIGN

Mixed-methods.

METHODS

Eighty-eight Portuguese digitally literate caregivers filled a web-based questionnaire collecting written statements on training needs and importance ratings on design preferences. Content analysis of text data was carried out by two independent researchers to check the reliability of the analytic process. Descriptive statistics were produced for ratings on design preferences, and associations with caregivers' sociodemographic and care-related variables were inspected. Reporting followed the criteria for reporting qualitative research checklist.

RESULTS

Five main categories of training needs have emerged: knowledge of dementia; care interactions; caregiver self-care; community resources; and laws or regulations affecting the caregiver and the care recipient. The most reported need was on care interactions, on the subcategory of providing good quality care. Thematic prominence was analysed according to the caregiver, caregiving and health perception characteristics, with trends found on formal education, relationship with the care recipient, number of hours caring per week, perceived level of dependence of the care recipient and perceived physical and psychological health status of the caregiver. Most valued design features included the use of plain language, easy to interact interface and communication with a professional.

CONCLUSIONS

Findings from this study further support the delivery of comprehensive interventions addressing the multiple needs of caregivers.

RELEVANCE TO CLINICAL PRACTICE

Clues are provided for the delivery of online interventions, and conclusions are useful to health professionals working with dementia caregivers.

Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Since 1989, four Canadian Consensus Conferences on the Diagnosis and Treatment of Dementia (CCCDTD) have provided evidence-based dementia guidelines for Canadian clinicians and researchers. We present the results of the 5th CCCDTD, which convened in October 2019, to address topics chosen by the steering committee to reflect advances in the field, and build on previous guidelines. Topics included: (1) utility of the National Institute on Aging research framework for clinical Alzheimer's disease (AD) diagnosis; (2) updating diagnostic criteria for vascular cognitive impairment, and its management; (3) dementia case finding and detection; (4) neuroimaging and fluid biomarkers in diagnosis; (5) use of non-cognitive markers of dementia for better dementia detection; (6) risk reduction/prevention; (7) psychosocial and non-pharmacological interventions; and (8) deprescription of medications used to treat dementia. We hope the guidelines are useful for clinicians, researchers, policy makers, and the lay public, to inform a current and evidence-based approach to dementia.

The Longitudinal Effects of Caregiver Grief in Dementia and the Modifying Effects of Social Services: A Prospective Cohort Study

BACKGROUND

Caregivers of persons with dementia (PWD) can experience loss and grief long before the death of the PWD, with such caregiver grief postulated to affect the well-being of the PWD-caregiver dyads. However, the longitudinal effects of caregiver grief and the moderating effects of social services are not yet clear.

OBJECTIVES

We investigated the longitudinal effects of caregiver grief on caregiver depression, caregivers' quality of life (QoL), and caregivers' perceived positive aspects of caregiving (PAC); and examined potential effect modification of social service utilization (dementia care services, caregiver programs, and paid caregivers).

DESIGN AND SETTING

A prospective cohort study with three time points of assessments (at 0, 6, and 12 months).

PARTICIPANTS

Family caregivers of community-dwelling PWD (n = 178).

MEASUREMENTS

At time point 1 (baseline), participants completed questionnaires that captured caregiver grief, burden, and social service utilization. Outcomes that were captured over time were: depression (time points 1-3), QoL (time point 2), and PAC (time point 3). Caregiver grief as well as interaction terms with social service utilization were included in Tobit regression to examine the association with outcomes.

RESULTS

After accounting for the effect of caregiver burden, caregiver grief remained associated with depressive symptoms (P < .001) and poorer QoL (P < .001). However, compared with burden, grief contributed to larger magnitudes of the adverse effects. Grief, not burden, was associated with less PAC (P = .006 and P = .746, respectively). In contrast, burden, not grief, was associated with poorer physical health (P = .010 and P = .110, respectively). Dementia care services attenuated the effect of burden but not grief; caregiver programs did not affect burden but appeared to aggravate the effect of grief; and paid caregivers attenuated the effect of burden, and partially attenuated the effect of grief.

CONCLUSION

Caregiver grief has an impact on dementia caregivers, likely through a distinct mechanism from that of caregiver burden. However, prevailing social services may not be sufficient to address grief, highlighting the need to further train care workers in this respect. J Am Geriatr Soc 68:2348-2353, 2020.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Who internalizes courtesy stigma and how? A study among Israeli Arab family caregivers of persons with dementia

Objectives: The expected rise in the number of persons with dementia is accompanied by an increasing interest in understanding and reducing the stigmatic beliefs experienced by family caregivers of persons with the disease. While researchers have recently distinguished between family caregivers' perceptions of public stereotypes (i.e., courtesy stigma) and the internalization of these perceptions (i.e., affiliate stigma), no study has yet assessed the characteristics of dementia caregivers who internalize courtesy stigma and how they do so. The aim of this study was to examine the characteristics of family caregivers of persons with dementia who internalize courtesy stigma, and to investigate this internalization process.Method: Structured face-to-face interviews were conducted with 175 Israeli Arab family caregivers (87.4% female; 71.4% adult children; mean age = 54.28) for persons with Alzheimer's disease.Results: Overall, half of the participants reported experiencing affiliate stigma as a result of taking care of a relative with dementia. Regression analyses showed that lower educational level, increased courtesy stigma and lower levels of social support were the main predictors of affiliate stigma. Social support partially mediated the association between courtesy and affiliate stigma.Conclusion: Our findings provide important insights for the conceptual understanding and the development of interventions to reduce stigma among family caregivers of persons with dementia.

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care

Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.

Altruism and the Difficult Patient

BACKGROUND

For some nurses, providing altruistic care to difficult patients is a challenge, leading to the use of negative coping strategies such as anger or avoidance, leaving the nurse frustrated and patients feeling rejected. Yet other nurses can deal positively with difficult patients.

PURPOSE

To study how the stress of caring for difficult patients affects the level of altruism and use of negative coping strategies in their care and to find out what positive coping strategies and interventions could be used.

DESIGN/METHOD

A mixed-methods design was used. A survey tested the level of altruism, the use of negative coping strategies, and several demographics. Thematic analysis examined narratives generated by participants to three questions regarding how to provide altruistic care to difficult patients.

FINDINGS

A purposive sample of 67 registered nurses (RNs) participated. The average level of altruism used by RNs with difficult patients was 99.7/120 points. An inverse relationship was found between the level of altruism and use of negative coping strategies (r = -0.577, p < .001). Qualitative analysis of narratives identified three themes-Developing Psychological Hardiness, Bearing Witness, and Fending for Oneself.

CONCLUSIONS

This study provides insight into the experiences of RNs caring for difficult patients and how to ensure altruistic caring.

Developing a social capital scale for family caregivers of people with dementia

Although several scales have been designed to measure social capital, none have been specialized for caregivers of people with dementia, even though social capital is important in terms of continuing care provision. Therefore, we developed and validated a 17-item measure to assess social capital among caregivers of people with dementia. We assessed psychometric properties using responses from a questionnaire survey that included a draft of a social capital scale. Factor analysis identified three factors involving 17 items with a Cronbach's alpha of .85. The intra-class coefficient for test-retest reliability was .71. The correlation with positive aspects of caregiving was .62 (p < .01). The results suggest that our scale could be a useful tool to assess social capital among caregivers of people with dementia.

The Effect of a Nurse-Led Cognitive Behavioral Protocol on Depressive Symptoms and Coping Strategies of Dementia Caregivers

BACKGROUND

Family caregivers of patients with dementia (PWD) often experience depressive symptoms and use poor coping strategies. Cognitive behavioral interventions may enhance positive appraisals of caregiving-related issues and the utilization of active coping strategies among caregivers, which may help prevent caregiver depression. However, there is a shortage of primary, community-based mental health services in China, and little research has been conducted on the effect of nurse-led mental health programs in this population.

PURPOSE

This study explored the effect of a nurse-led cognitive behavioral intervention on depressive symptoms and coping strategies among family caregivers of PWD in China.

METHODS

This randomized controlled trial used data from a sample of 112 caregivers screened from 276 potential participants in a city in southeastern China. The sample was randomly assigned to an intervention group (n = 56) and a control group (n = 56). The intervention group received five monthly in-home, nurse-led cognitive behavioral sessions and telephone consultations after each session. The control group received five monthly, short, general conversations with nurse interventionists at the participants' homes, in the hospital, or via telephone. Depressive symptoms, coping strategies, and the demographics of caregiving dyads were collected at Time 1 (baseline), Time 2 (the end of the 5-month intervention), and Time 3 (2-month follow-up). IBM SPSS Statistics Version 19.0 was used for data analysis.

RESULTS

Eighty-two participants (intervention group: n = 47, control group: n = 35) completed the three evaluations. No significant group differences were found in baseline characteristics between the two groups. The general linear model repeated-measures analysis of variance indicated a significant difference in depressive symptoms and active coping between groups over time, with p < .001 for the interaction between depressive symptoms and groups and p < .01 for the interaction between active coping and groups. A similar result did not occur for passive coping. The t tests further supported a significant interventional effect on participants' depressive symptoms and active coping.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

This nurse-led cognitive behavioral intervention was effective in decreasing depressive symptoms and improving active coping among study participants. The findings suggest the improvement of mental health services and social policies in China to support family caregivers of PWD.

Consensus-Based Recommendations for an Adequate Workforce to Care for People with Serious Illness

The lack of an adequately prepared workforce is a critical barrier to delivering high-quality community-based care for individuals living with serious illness. This article presents 16 consensus-based recommendations to improve the capacity of the workforce in this area within the next 5 years, focusing on older adults. The recommendations were developed at a summit of 40 national leaders from practice, payment, labor, advocacy, and research arenas. The consensus-based recommendations include specific steps for geriatrics leaders including curriculum reforms to increase skills in the care of older and seriously ill populations, expanding experiential learning opportunities for students to increase interest in careers in geriatric and palliative care, developing and improving curriculum in interprofessional and cultural competency skills, preparing clinicians to support incorporation of home care aides and family caregivers as healthcare team members, development of skills to support shared decision making with patients, and requiring specific skills related to serious illness care in licensing, accreditation, and continuing education regulations. Together, these recommendations put forward a charge to healthcare leaders to act to ensure a workforce that will optimize support for those with serious illness living in the community. J Am Geriatr Soc 67:S392-S399, 2019.