A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia

Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review

OBJECTIVES

The objective of this review was to assess the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community.

INCLUSION CRITERIA

Types of participants Adult caregivers who provide support for people with dementia living in the community (non-institutional care).Types of interventions Interventions designed to support caregivers in their role such as skills training, education to assist in caring for a person living with dementia and support groups/programs. Interventions of formal approaches to care designed to support caregivers in their role, care planning, case management and specially designated members of the healthcare team - for example dementia nurse specialist or volunteers trained in caring for someone with dementia.Types of studies This review considered any meta-analyses, systematic reviews, randomised control trials, quasi-experimental studies, cohort studies, case control studies and observational studies without control groups that addressed the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community.

SEARCH STRATEGY

The search sought to identify published studies from 2000 to 2005 through the use of electronic databases. Only studies in English were considered for inclusion. The initial search was conducted of the databases, CINAHL, MEDLINE and PsychINFO using search strategies adapted from the Cochrane Dementia and Cognitive Improvement Group. A second more extensive search was then conducted using the appropriate Medical Subject Headings (MeSH) and keywords for other available databases. Finally, hand searching of reference lists of articles retrieved and of core dementia, geriatric and psycho geriatric journals was undertaken.

ASSESSMENT OF QUALITY

Methodological quality of each of the articles was assessed by two independent reviewers using appraisal checklist developed by the Joanna Briggs Institute and based on the work of the Cochrane Collaboration and Centre for Reviews and Dissemination.

DATA COLLECTION AND ANALYSIS

Standardised mean differences or weighted mean differences and their 95% confidence intervals were calculated for each included study reported in the meta-analysis. Results from comparable groups of studies were pooled in statistical meta-analysis using Review Manager Software from the Cochrane Collaboration. Heterogeneity between combined studies was tested using standard chi-square test. Where statistical pooling was not appropriate or possible, the findings are summarised in narrative form.

RESULTS

A comprehensive search of relevant databases, hand searching and cross referencing found 685 articles that were assessed for relevance to the review. Eighty-five papers appeared to meet the inclusion criteria based on title and abstract, and the full paper was retrieved. Of the 85 full papers reviewed, 40 were accepted for inclusion, three were systematic reviews, three were meta-analysis, and the remaining 34 were randomised controlled trials. For the randomised controlled trials that were able to be included in a meta-analysis, standardised mean differences or weighted mean differences and their 95% confidence intervals were calculated for each. Results from comparable groups of studies were pooled in statistical meta-analysis using Review Manager Software and heterogeneity between combined studies was assessed by using the chi-square test. Where statistical pooling was not appropriate or possible, the findings are summarised in narrative form.The results are discussed in two main sections. Firstly it was possible to assess the effectiveness of different types of caregiver interventions on the outcome categories of depression, health, subjective well-being, self-efficacy and burden. Secondly, results are reported by main outcome category. For each of these sections, meta-analysis was conducted where it was possible; otherwise, a narrative summary describes the findings.

EFFECTIVENESS OF INTERVENTION TYPE

Four categories of intervention were included in the review - psycho-educational, support, multi-component and other.Psycho-educational Thirteen studies used psycho-educational interventions, and all but one showed positive results across a range of outcomes. Eight studies were entered in a meta-analysis. No significant impact of psycho-educational interventions was found for the outcome categories of subjective well-being, self-efficacy or health. However, small but significant results were found for the categories of depression and burden.Support Seven studies discussed support only interventions and two of these showed significant results. These two studies were suitable for meta-analysis and demonstrated a small but significant improvement on caregiver burden.Multi-component Twelve of the studies report multi-component interventions and 10 of these report significant outcomes across a broad range of outcome measures including self-efficacy, depression, subjective well-being and burden. Unfortunately because of the heterogeneity of study designs and outcome measures, no meta-analysis was possible.Other interventions Other interventions included the use of exercise or nutrition which resulted in improvements in psychological distress and health benefits. Case management and a computer aided support intervention provided mixed results. One cognitive behavioural therapy study reported a reduction in anxiety and positive impacts on patient behaviour.

EFFECTIVENESS OF INTERVENTIONS USING SPECIFIC OUTCOME CATEGORIES

In addition to analysis by type of intervention it was possible to analyse results based on some outcome categories that were used across the studies. In particular the impact of interventions on caregiver depression was available for meta-analysis from eight studies. This indicated that multi-component and psycho-educational interventions showed a small but significant positive effect on caregiver depression.Five studies using the outcome category of caregiver burden were entered into a meta-analysis and findings indicated that there were no significant effects of any of interventions. No meta-analysis was possible for the outcome categories of health, self-efficacy or subjective well-being.

IMPLICATIONS FOR PRACTICE

From this review there is evidence to support the use of well-designed psycho-educational or multi-component interventions for caregivers of people with dementia who live in the community. Factors that appear to positively contribute to effective interventions are those which:Factors which do not appear to have benefit in interventions are those which.

Effects of combined intervention programmes for people with dementia living at home and their caregivers: a systematic review

OBJECTIVE

This study reviews the evidence for effects of combined intervention programmes for both the informal caregiver and the person with dementia.

METHOD

Systematic review. Electronic databases and key articles were searched for effect studies of combined programmes, published between January 1992 and February 2005. The resulting 52 reports were scored according to set inclusion criteria.

RESULTS

Twenty five reports relating to 22 programmes met the inclusion criteria. Various aspects of caregivers' mental health and burden were studied. Best results were obtained regarding general mental health. Other aspects often showed modest and varying results. Caregivers' competence was less often addressed. The effects on the cognitive and physical functioning, behavioural problems and survival of the persons with dementia were modest and inconsistent, whereas their mental health is positively affected and admittance to long stay care is often delayed.

CONCLUSION

Combined programmes may improve some, not all, aspects of functioning for caregiver and person with dementia. Care professionals must define their programme goals and target groups before advising their clients on a combined programme. Research may focus on the effects of programmes that were introduced fairly recently and on subgroups of caregivers (female caregivers, depressed caregivers and people with dementia, and minorities).

Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: a randomized controlled trial

BACKGROUND

Cure of dementia is not possible, but quality of life of patients and caregivers can be improved. Our aim is to investigate effects of community occupational therapy on dementia patients' and caregivers' quality of life, mood, and health status and caregivers' sense of control over life.

METHODS

Community-dwelling patients aged 65 years or older, with mild-to-moderate dementia, and their informal caregivers (n = 135 couples of patients with their caregivers) were randomly assigned to 10 sessions of occupational therapy over 5 weeks or no intervention. Cognitive and behavioral interventions were used to train patients in the use of aids to compensate for cognitive decline and caregivers in coping behaviors and supervision. Outcomes, measured at baseline, 6 weeks, and 12 weeks, were patients' and caregivers' quality of life (Dementia Quality of Life Instrument, Dqol), patients' mood (Cornell Scale for Depression, CSD), caregivers' mood (Center for Epidemiologic Studies Depression Scale, CES-D), patients' and caregivers' health status (General Health Questionnaire, GHQ-12), and caregivers' sense of control over life (Mastery Scale).

RESULTS

Improvement on patients' Dqol overall (0.8; 95% confidence interval [CI], 0.6-.1, effect size 1.3) and caregivers' Dqol overall (0.7; 95% CI, 0.5-.9, effect size 1.2) was significantly better in the intervention group as compared to controls. Scores on other outcome measures also improved significantly. This improvement was still significant at 12 weeks.

CONCLUSION

Community occupational therapy should be advocated both for dementia patients and their caregivers, because it improves their mood, quality of life, and health status and caregivers' sense of control over life. Effects were still present at follow-up.

[Multimodal training of general practitioners--evaluation and knowledge increase within the framework of the dementia management initiative in general medicine (IDA)]

BACKGROUND AND OBJECTIVE

In many industrialized countries diagnostic and therapeutic deficits in the management of patients with dementia are well documented. Due to demographic trends the next years will see a further rise in the number of affected patients. Accordingly, the knowledge and competence of the physicians taking care of these patients need to be keep up-to-date. In the context of the three-armed cluster-randomized IDA trial (IDA = "Initiative Demenzversorgung in der Allgemeinmedizin"; Dementia Management Initiative in General Medicine), general practitioners (GPs) from the trial area (Bavaria, Germany) were trained in the diagnosis and treatment of dementia.

METHODS

The educational training concept was based on the evidence-based guideline of Witten/Herdecke University (UWH). All participating GPs (n = 137, January 2006) received three hours training in the diagnosis of dementia. In addition, a subgroup was trained for two hours in dementia therapy (n = 90). Both groups obtained information about the study design. The didactic concept included screen and oral presentations by opinion leaders, video and interactive elements. At the beginning of the training sessions participants had to fill in a pilot-tested questionnaire with 20 multiple choice questions addressing the diagnosis and therapy of dementia (pretest). The same questionnaire was completed at the end of the training session (posttest) complemented by an evaluation sheet. Overall and intergroup differences between pre- and post-test results (increase in knowledge) were compared using the Chi-Square test.

RESULTS

Overall, the quality of the training received a positive rating by the participants. By the end of January 2006, 137 doctors had been trained. The mean knowledge gain was 4.0+2.6 correctly answered questions (p<0.001; Cl 3.6 to 4.5) comparing pre- and posttest (n = 132). In the group trained on diagnosis alone (n = 45), the gain averaged 2.0+/-1.9 questions. The group with additional training on therapy (n = 87) achieved a difference of 5.1 -2.3 questions (p<0.001).

DISCUSSION

Participants of the dementia training achieved a substantial gain of knowledge. The extent of this knowledge increase was associated with the attendance to respective training modules. An ongoing trial will add further information about knowledge translation in the field of dementia.

Efficacy of behavioral interventions for dementia caregivers

Behavioral symptoms of Alzheimer's disease, particularly agitation, appear to be a major contributing factor to the emotional distress exhibited by family caregivers. Psychosocial interventions have been shown to reduce caregiver emotional distress, but few studies have examined the efficacy of these interventions with caregivers exposed to high levels of dementia-related behavioral symptoms. The purpose of this study is to test the efficacy of a caregiver skill building intervention in reducing emotional distress to agitated behaviors of care recipients. This study analyzed data from a subgroup of caregivers who participated in a larger randomized clinical trial (N = 295). Data from 143 caregivers of family members with baseline agitated behaviors indicate that the skill building intervention was more effective than an information and support oriented comparison condition in reducing emotional distress over an 18-month period. These findings indicate that dementia caregivers exposed to agitated behaviors can benefit from psychosocial interventions, particularly those aimed at building behavioral management skills.

Comparative outcomes of two distance-based interventions for male caregivers of family members with dementia

Data are presented on a preliminary study investigating the efficacy of 2 distance-based psychosocial interventions (N = 32) for male family dementia caregivers. Male caregivers were randomly assigned to either a basic education intervention (ie, educational booklet and biweekly check-in telephone calls) or a video intervention (ie, set of 10 videos, an accompanying workbook, and weekly telephone coaching sessions using behavioral strategies to manage challenging caregiving situations). Results did not support the greater efficacy of the video condition in reducing psychosocial distress (eg, negative affect, upset and annoyance following behavior problems) or increasing positive affect or caregiving self-efficacy. There was, however, a statistically significant effect for postintervention improvement in both the video/coaching and the educational booklet/check-in conditions. Potential reasons for the lack of differential treatment effects are discussed, along with implications for recruitment of male dementia caregivers.

Feasibility and results of a randomised pilot-study of pre-discharge occupational therapy home visits

Background

Pre-discharge home visits aim to maximise independence in the community. These visits involve assessment of a person in their own home prior to discharge from hospital, typically by an occupational therapist. The therapist may provide equipment, adapt the home environment and/or provide education. The aims of this study were to investigate the feasibility of a randomised controlled trial in a clinical setting and the effect of pre-discharge home visits on functional performance in older people undergoing rehabilitation.

Methods

Ten patients participating in an inpatient rehabilitation program were randomly assigned to receive either a pre-discharge home visit (intervention), or standard practice in-hospital assessment and education (control), both conducted by an occupational therapist. The pre-discharge home visit involved assessment of the older person's function and environment, and education, and took an average of 1.5 hours. The hospital-based interview took an average of 40 minutes. Outcome data were collected by a blinded assessor at 0, 2, 4, 8 and 12 weeks. Outcomes included performance of activities of daily living, reintegration to community living, quality of life, readmission and fall rates.

Results

Recruitment of 10 participants was slow and took three months. Observed performance of functional abilities did not differ between groups due to the small sample size. Difference in activities of daily living participation, as recorded by the Nottingham Extended Activities of Daily Living scale, was statistically significant but wide confidence intervals and low statistical power limit interpretation of results.

Conclusion

Evaluation of pre-discharge home visits by occupational therapists in a rehabilitation setting is feasible, but a more effective recruitment strategy for a main study is favored by application of a multi-centre setting.

Efficacy of recreational and occupational activities associated to psychologic support in mild to moderate Alzheimer disease: a multicenter controlled study

We evaluated the efficacy of a stimulation program mainly based on recreational and occupational activities, associated with a brief cycle of support psychotherapy for patients and caregivers, in mild to moderate Alzheimer Disease (AD) associated or not with cerebrovascular lesions. Sixty-seven patients and 31 controls from 2 Italian towns entered the study. The control group was comprised of AD subjects who voluntarily declined to participate in the program for practical reasons. Patients were divided in groups of 4 subjects: treatment was delivered for 6 weeks. Multidimensional efficacy assessment of functional, behavioral, and neuropsychologic aspects was performed. When comparing baseline with posttraining condition, patients displayed a substantial reduction in disruptive behavior, and a tendency to a general reduction of behavioral symptoms compared with controls (Revised Memory and Behavior Problems Checklist--RMBPC--symptoms frequency-total P=0.07; frequency of disruptive behavior P=0.008). This reduction was mirrored by a significant reduction of caregiver reaction to behavioral disturbances (RMBPC caregiver reaction-total P=0.035; reaction to disruptive behavior, P=0.011). At 3 months follow-up, the reduction of caregiver reaction to behavioral symptoms results was confirmed (RMBPC caregiver reaction-total P=0.014, caregiver reaction to disruptive behavior P=0.028). No other significant difference was detected. These results partially confirm findings of previous studies, showing that AD patients treated with similar techniques demonstrated an improvement in behavioral disturbances.

Non-pharmacological interventions for wandering of people with dementia in the domestic setting

BACKGROUND

A number of studies exist of interventions for wandering in the institutional setting, but much less work has been done on wandering in the domestic setting. The prevalence of wandering by people with dementia is difficult to assess; wandering is not a simple or static behaviour and the reasons why people wander remain unclear. In the absence of a theory of wandering and an agreed definition of wandering, it is difficult to discover effective strategies for managing wandering and difficult to design appropriate intervention strategies. Also, the same behaviour or type of wandering might occur for different reasons in different individuals; any theoretical formulation is going to have to allow for different triggers for the behaviour and so to get a 'one size fits all' kind of explanation is unlikely. Thus what we mostly encounter in this field is a 'trial and error' approach which does not always do justice to the complex interactions of personal and environmental factors that lead people with dementia to wander. While there seems to be a consensus in the literature that in the majority of cases non-pharmacological approaches may work as well as drug treatment and with fewer side effects, in practice clinicians often resort to drugs as the first line of treatment. This review reports the lack of evidence from RCTs and discusses the range of non-pharmacological interventions that have been carried out using other study designs.

OBJECTIVES

To evaluate the effectiveness and safety of non-pharmacological interventions in reducing wandering in the domestic setting by people with dementia. The secondary objective is to highlight the quality and quantity of research evidence available and to set an agenda for future research.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 11 May 2006 using the terms exit* or wander* or elopement or ambulat* or walk*. This Register contains records from all major healthcare databases and many ongoing trial databases and is updated regularly.

SELECTION CRITERIA

Randomised clinical trials comparing intervention with no intervention or usual treatment ('standard care') or another intervention.

DATA COLLECTION AND ANALYSIS

No suitable trials of non-pharmacological interventions for the prevention and management of wandering in the domestic setting were found.

MAIN RESULTS

As no randomised controlled trials were found, no results can be reported.

AUTHORS' CONCLUSIONS

There is an urgent need for randomised controlled trials of non-pharmacological interventions for wandering in the domestic setting.

Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial

OBJECTIVE

To determine the effectiveness of community based occupational therapy on daily functioning of patients with dementia and the sense of competence of their care givers.

DESIGN

Single blind randomised controlled trial. Assessors were blinded for treatment allocation.

SETTING

Memory clinic and day clinic of a geriatrics department and participants' homes.

PARTICIPANTS

135 patients aged > or =65 with mild to moderate dementia living in the community and their primary care givers.

INTERVENTIONS

10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision.

MAIN OUTCOME MEASURES

Patients' daily functioning assessed with the assessment of motor and process skills (AMPS) and the performance scale of the interview of deterioration in daily activities in dementia (IDDD). Care giver burden assessed with the sense of competence questionnaire (SCQ). Participants were evaluated at baseline, six weeks, and three months.

RESULTS

Scores improved significantly relative to baseline in patients and care givers in the intervention group compared with the controls (differences were 1.5 (95% confidence interval 1.3 to 1.7) for the process scale; -11.7 (-13.6 to -9.7) for the performance scale; and (11.0; 9.2 to 12.8) for the competence scale). This improvement was still significant at three months. The number needed to treat to reach a clinically relevant improvement in motor and process skills score was 1.3 (1.2 to 1.4) at six weeks. Effect sizes were 2.5, 2.3, and 1.2, respectively, at six weeks and 2.7, 2.4, and 0.8, respectively, at 12 weeks.

CONCLUSIONS

Occupational therapy improved patients' daily functioning and reduced the burden on the care giver, despite the patients' limited learning ability. Effects were still present at 12 weeks, which justifies implementation of this intervention.

TRIAL REGISTRATION

Clinical Trials NCT00295152 [ClinicalTrials.gov].

Informal caregiver burden among survivors of prolonged mechanical ventilation

RATIONALE

Although caregiver burden is well described in chronic illness, few studies have examined burden among caregivers of survivors of critical illness. In existing studies, it is unclear whether the observed burden is a consequence of critical illness or of preexisting patient illness.

OBJECTIVES

To describe 1-yr longitudinal outcomes for caregivers of patients who survived critical illness, and to compare depression risk between caregivers of patients with and without pre-intensive care unit (ICU) functional dependency.

METHODS

Prospective, parallel, cohort study of survivors of prolonged (greater than 48 h) mechanical ventilation and their informal caregivers. Caregivers were divided into two cohorts on the basis of whether patients were functionally independent (n = 99, 59%), or dependent (n = 70, 41%) before admission. Functional dependency was defined as dependency in one or more activities of daily living or in three or more instrumental activities of daily living. Patient and caregiver outcomes were measured 2, 6, and 12 mo after mechanical ventilation initiation.

MEASUREMENTS AND MAIN RESULTS

We studied three caregiver outcomes: depression risk, lifestyle disruption, and employment reduction. Most patients were male (59.8%), with a mean (SD) age of 56.6 (19.0) yr. Caregivers were mostly female (75.7%), with a mean (SD) age of 54.6 (14.7) yr. Prevalence of caregiver depression risk was high at all time points (33.9, 30.8, and 22.8%; p = 0.83) and did not vary by patient pre-ICU functional status. Lifestyle disruption and employment reduction were also common and persistent.

CONCLUSIONS

Depression symptoms, lifestyle disruption, and employment reduction were common among informal caregivers of critical illness survivors. Depression risk was high regardless of patient pre-ICU functional status.

Home modification

Almost 50 million Americans--about one in five--live with a mental or physical disability, many in homes that are inconvenient, restrictive, or dangerous for them. Modifying the home using universal (barrier-free) design, architectural accessibility, and other such concepts can reduce the risk of falls and improve overall function. Nurses can be involved by assessing patients' living quarters and recommending specific modifications.

Investigating differences among older adults' access to specialized rehabilitation services

The purpose of this study was to (a) describe rehabilitation in-patients aged 65 and older who received specialized occupational therapy home evaluation services and (b) examine these data for evidence of inequalities based on patient gender, race, age, and health insurance status. An archival review was conducted of all in-patient admissions (2,767) to a large urban rehabilitation hospital who were 65 years and older and eligible to receive a home evaluation. Logistic regression was used to predict the likelihood of receiving an occupational therapy home evaluation. Analysis showed that 9.7% of subjects received an in-home evaluation and those who did had significantly longer rehabilitation hospital stays (p < 0.0001) and were significantly more dependent at discharge as measured by the Functional Independence Measure (p < 0.0001) than those who did not. We found no evidence of inequalities on the basis of gender, race, age, and health insurance type after controlling for the level of functional independence of patients. Although this study found little evidence of inequalities, it does raise several critical policy questions including "How many rehabilitation in-patients should receive a home evaluation?" and "How should rehabilitation services be allocated?"

Changes in accessibility and usability in housing: an exploration of the housing adaptation process

The purpose of a housing adaptation is to enhance daily activities and to improve housing accessibility and usability by removing physical barriers in the home. The aim of this study was to investigate longitudinal changes in housing accessibility among clients receiving grants for housing adaptations. Baseline assessments were administered one month before the housing adaptation, with the first follow-up after two to three months, and the second follow-up after eight to nine months. The Housing Enabler and the Usability in My Home instruments were used to collect data from 131 consecutively enrolled clients living in general housing. Accessibility and usability improved significantly, the number of physical environmental barriers decreased and dependence on mobility devices increased, but at different times along the process. The results indicate the complexity of the housing adaptation process and the need to consider person-environment interactions over time. The methodology seems useful for quality development of assessment, intervention and evaluation processes in housing adaptations performed by occupational therapists.

[Treatment of Alzheimer's disease: recommendations and suggestions of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology]

The present recommendations and suggestions on "Treatment of Alzheimer's Disease" were elaborated by a work group constituted by participants of the IV Meeting of Researchers on Alzheimer's Disease and Related Disorders, sponsored by the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. They comprise topics on pharmacological and non-pharmacological treatment of cognitive impairment and functional decline, as well as of behavioral and psychological symptoms of this dementing disease. Several levels of evidence and of recommendations and suggestions are used for the various proposed drugs, as well as for non-pharmacological treatment, underpinned by a wide national and international bibliographical review.

Care Intervention for Older Adults with Alzheimer's Disease and Related Dementias: Effect of Family Involvement on Cognitive and Functional Outcomes in Nursing Homes

The purpose of this quasi-experimental study was to examine the effect of an intervention for caregivers of individuals with Alzheimer's disease and related dementias (ADRD) on nursing home residents' functional and cognitive status. Fourteen special care units (SCUs) in 14 midwestern nursing homes were paired according to size, ownership, and staff turnover. The paired nursing homes were randomly assigned to either experimental or control groups. The intervention consisted of the Family Involvement in Care (FIC) protocol. The FIC intervention was designed to help family caregivers of nursing home residents with dementia negotiate and establish a partnership with the staff caregivers for the care of residents. One hundred sixty-four residents participated in the study, 71 in the control group and 93 in the experimental group. Sixty-three residents were lost to attrition (38%). The experimental group exhibited less global deterioration throughout the study. Inappropriate behavior, cognition, and functional status remained relatively unchanged over time within and between the groups. Increased family involvement did slow global deterioration in individuals with ADRD. The findings of the study show that more factors need to be examined to discover those interventions that preserve functional and cognitive abilities.

Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment

BACKGROUND

While the deleterious psychosocial and mental health effects of dementia caregiving are firmly established, very little is known about the burdens or psychiatric outcomes of providing care to a spouse with less severe cognitive impairment, such as mild cognitive impairment (MCI). We characterized the nature and level of caregiver burden and psychiatric morbidity in spouses of persons diagnosed with MCI.

METHODS

Interview assessments were completed on a cohort of 27 spouses of persons with a recent diagnosis of MCI. Patient medical records were reviewed to collect information regarding the MCI patient's medical history.

RESULTS

Respondents endorsed elevated levels of both task-related responsibilities and subjective caregiver burden. Depression and anxiety symptom levels also showed some elevations. Measures of caregiver burden were significantly associated with depression and anxiety levels. In particular, even after controlling for demographic risk factors for distress, nursing task burden was correlated with elevated depressive symptoms, and greater lifestyle constraints were correlated with higher anxiety levels.

CONCLUSIONS

Although caregiver burden and psychiatric morbidity levels were lower than those typically observed in family dementia caregiving samples, our findings suggest that MCI caregivers have already begun to experience distress in association with elevated caregiving burden. These individuals may be ideal targets for selective preventive interventions to maximize their psychological well-being as caregiving burdens related to their spouses' cognitive impairment increase.

Family caregiving and congestive heart failure. Review and analysis

BACKGROUND

There is increasing evidence that discharge planning and post-discharge support for CHF patients can contribute greatly to the medical management of heart failure (CHF) in the community and that the quality of the CHF patient's close personal relationships can influence outcome in CHF. However, there has been little research on the impact of CHF on the family or the role of the family in the management of the condition. In this paper, we provide a review and analysis of studies that have explicitly investigated these issues in the informal carers of CHF patients.

RESULTS OF THE REVIEW

Sixteen papers were identified that examined the role and/or impact of informal caregiving for CHF patients. Our main findings were: demands specific to CHF caregiving were identified, e.g., monitoring complex medical and self-care regimen, disturbed sleep and frequent hospitalisation of patients. Relatively high levels of emotional distress were identified in CHF caregivers. Few studies explicitly investigated the role of informal carers in the management of CHF. Studies were limited in number, scope and quality.

CONCLUSION

Caring for a family member with CHF can affect the well-being of those responsible for care, which may have consequences for the CHF patient's health. Further studies are needed to clarify these issues and to examine the role of informal caregivers in the management of CHF in the community.

[Development and perspectives of gerontological research: the sample case of housing research]

The present work addresses the historical development of environmental gerontology and housing research. Emphasis is placed on the development of ecological perspectives in gerontology as a research program, its scientific reception and acknowledgment in gerontology, the unfolding of housing-related theories and housing studies. Furthermore, the situation in Germany is juxtaposed against the situation in the US. As is found, between the 1930s and 1960 housing research gained substantial importance predominantly in the US as a consequence of the emergence of the field of social gerontology. There was however not much theoretical impetus from housing research on social and behavioral gerontology at large. In the time period between the 1960s and the mid 1980s many large-scale studies focused on housing in old age. At the same time, grand theories related to housing were introduced with the Ecological Theory of Aging (Lawton) as its flagship conception, able to have an impact on gerontology and its research guiding fundamental ideas (person-environment view of aging). Germany's social and behavioral gerontology saw during this time period the profound discussion of, as was frequently said, social-ecological approaches, while empirical studies tended to concentrate on institutions for the aged. Since the beginning of the 1990s dementia-related themes have largely been taken over as a driving force of North American housing research. In some contrast, gerontological housing research in Germany has strongly addressed the diversity of aging in the private household situation. In conclusion, housing research was important for gerontology in terms of the promotion of a person-environment perspective of aging on the conceptual and empirical level. This function should continue into the future.

Caregiver appraisals of functional dependence in individuals with dementia and associated caregiver upset: psychometric properties of a new scale and response patterns by caregiver and care recipient characteristics

To evaluate psychometric properties and response patterns of the Care-giver Assessment of Function and Upset (CAFU), a 15-item multidimensional measure of dependence in dementia patients and caregiver reaction.

METHOD

640 families were administered the CAFU (53% White, 43% African American, and 4% mixed race and ethnicity). We created a random split of the sample and conducted exploratory factor analyses on Sample 1 and confirmatory factor analyses on Sample 2. Convergent and discriminant validity were evaluated using Spearman rank correlation coefficients.

RESULTS

A two-factor structure for functional items was derived, and excellent factorial validity was obtained. Convergent and discriminant validity were obtained for function and upset measures. Differential response patterns for dependence and caregiver upset were found for caregiver race, relationship, and care recipient gender but not for caregiver gender.

DISCUSSION

The CAFU is easily administered, reliable, and valid for evaluating appraisals of dependencies and upsetting care areas.

Les symptômes psychologiques et comportementaux de la démence : description et prise en charge

Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.

Maintenance of Effects of the Home Environmental Skill-Building Program for Family Caregivers and Individuals With Alzheimer's Disease and Related Disorders

BACKGROUND

Few studies evaluate whether short-term intervention effects are maintained over time for families caring for persons with dementia. This article examines whether treatment effects found at 6 months following active treatment were sustained at 12 months for 127 family caregivers who participated in an occupational therapy intervention tested as part of the National Institutes of Health Resources for Enhancing Alzheimer's Caregiver Health (REACH) initiative.

METHODS

A randomized two-group design was implemented with three assessment points: baseline, 6 months, and 12 months. Caregivers were randomly assigned to a usual care control group or intervention that consisted of six occupational therapy sessions to help families modify the environment to support daily function of the person with dementia and reduce caregiver burden. Following 6-month active treatment, a maintenance phase consisted of one home and three brief telephone sessions to reinforce strategy use and obtain closure. Non-inferiority statistical analysis was used to evaluate whether intervention caregivers maintained treatment benefits from 6 to 12 months in comparison to controls.

RESULTS

For the sample of 127 at 6 months, caregivers in intervention reported improved skills (p = .028), less need for help providing assistance (p = .043), and fewer behavioral occurrences (p = .019) compared to caregivers in control. At 12 months, caregiver affect improved (p = .033), and there was a trend for maintenance of skills and reduced behavioral occurrences, but not for other outcome measures.

CONCLUSION

An in-home skills training program helps sustain caregiver affect for those enrolled for more than 1 year. More frequent professional contact and ongoing skills training may be necessary to maintain other clinically important outcomes such as reduced upset with behaviors.

Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness

Links between chronic illness and family relationships have led to psychosocial interventions targeted at the patient's closest family member or both patient and family member. The authors conducted a meta-analytic review of randomized studies comparing these interventions with usual medical care (k=70), focusing on patient outcomes (depression, anxiety, relationship satisfaction, disability, and mortality) and family member outcomes (depression, anxiety, relationship satisfaction, and caregiving burden). Among patients, interventions had positive effects on depression when the spouse was included and, in some cases, on mortality. Among family members, positive effects were found for caregiving burden, depression, and anxiety; these effects were strongest for nondementing illnesses and for interventions that targeted only the family member and that addressed relationship issues. Although statistically significant aggregate effects were found, they were generally small in magnitude. These findings provide guidance in developing future interventions in this area.

Brief Screening Tests for the Diagnosis of Dementia: Comparison With the Mini-Mental State Exam

Dementia is a common and under-diagnosed problem among the elderly. An accurate screening test would greatly aid the ability of physicians to evaluate dementia and memory problems in clinical practice. We sought to determine whether simple and brief psychometric tests perform similarly to the Mini-Mental State Examination (MMSE) in screening for dementia. Using a retrospective analysis, a series of standard, brief, psychometric tests were compared with each other and to the MMSE as screening tests for very mild dementia, using DSM-III-R criterion as the gold standard. Two independent cohorts from the Baltimore Longitudinal Study of Aging and the Washington University Alzheimer's Disease Research Center were evaluated. We found that two brief and simple-to-administer tests appear to offer similar degrees of sensitivity and specificity to the MMSE. These are the recall of a five-item name and address, "John Brown 42 Market Street Chicago" and the one-minute verbal fluency for animals. Combining these two tests further improves sensitivity and specificity, surpassing the MMSE, to detect dementia in individuals with memory complaints.

Kontrollierte Studien zur Wirksamkeit von Ergotherapie bei �lteren

OBJECTIVE

To identify the evidence for the efficacy of occupational therapy on prioritized diseases and disabilities of the elderly.

METHOD

Reviews, meta-analyses and clinical trials with control group design regarding "occupational therapy" were identified by an electronic search of pubmed and reviewed based on the CONSORT-Statement. The study results were summarised in regard to diseases and commented considering further literature.

RESULTS

A total of 31 studies were identified: 10 on stroke, 6 on dementia, 5 on prevention of falls, growing loneliness or inactivity, 4 on need of nursing care, and 6 on other diseases or disabilities. There is evidence for a positive efficacy of occupational therapy on the level of several controlled trials or reviews.

CONCLUSION

Especially in Germany, further research specific to occupational therapy is needed in the fields of depression, diabetes mellitus and nursing care in the community.

Using telerehabilitation to identify home modification needs

Teleconferencing technology has great potential for providing cost-effective in-home assessment for home modification services from anywhere to anyone in need. Despite its enormous potential, the use of this technology as a means to deliver these specific services had not been investigated. This project investigated the use of televideo technology to provide remote home assessment services to patients prior to discharge so that they could function as independently as possible in their own homes after being discharged from a specialty clinic. Specifically, an assessment protocol that could be implemented using video-conferencing technology was developed and feasibility of the remote assessment process was determined by validating it against the standard of practice, an in-home assessment by a home modifications specialist. Independent in-home and remote home assessments were completed by two occupational therapists who specialize in home modifications. The results were compared for agreement in identification of specific accessibility problems in and quantitative measurements of the home. The remote assessment correctly identified a total of 51 of the 59 problems (86.4%) identified by the in-home assessment and only identified five problems (8.9%) that were not identified by the on-site assessment. In addition, 54 of 60 (90%) of the quantitative measurements from the remote assessment matched those from the in-home assessment. Findings suggest that remote telerehabilitation assessments have the potential to enable specialists to diagnose potential accessibility problems in home environments and prescribe appropriate modifications regardless of the location of the client, home, or specialist.

Feeding and hydration issues for older adults with dementia

All cultures dictate the need to feed the hungry and create rituals for almost every life passage around the consumption of food and beverage. Yet, in old age and among those who cannot advocate for themselves, mealtime is medicalized and demoted to an insignificant event without dignity or regard for individualized needs. Attention must be paid to not only what people eat, but how they eat, and how they are supported in that process. Kayser-Jones summarized the extensive findings of several ethnographic studies in nursing homes by noting the multi-factorial issues involved in delivering excellent care to all residents, especially those lacking an advocate. Her findings exposed how lack of staff education, inadequate staffing and supervision, disregard for personal and cultural preferences, lack of assessment for comorbid health problems, intake of food and fluids, dysphagia, and oral health problems all contributed to malnutrition and dehydration among the residents studied. This seminal set of studies, along with Dr. Kayser-Jones' testimony in US Congressional hearings directly affected the design of federal regulatory protocols to address malnutrition and dehydration. In an attempt to increase the number of staff available to assist at meals, the Centers for Medicare and Medicaid issued a change in regulations on Sept. 26, 2003, allowing reimbursement for staff trained for a total of 8 hours to act as feeding assistants. This change is intended to, "provide more residents with help in eating and drinking and reduce the incidence of unplanned weight loss and dehydration". Although seen as answering some of the staffing ratio issues at meal times,this rule change has been criticized for not addressing the complexities of resident needs at meal times. Although offering food and fluid is time-consuming and requires special knowledge of physiological changes and empathy for persons whose behavior might be objectionable at times, it may be one of the few times during the day that the individual with dementia receives normalized social interaction. Thus, as in the care of all vulnerable persons with dementia, whether at home or in an institution, perhaps the greatest challenge and need is for nurses and other caregivers to provide a social environment that promotes individual dignity and comfort.

Survival of Persons With Alzheimer's Disease: Caregiver Coping Matters

PURPOSE

Although persons with Alzheimer's disease (AD) require increasingly more assistance with activities of daily living as their disease progresses, the caregiving environment has received little attention as a source of predictors of their survival time. We report here on a study to determine whether variation in survival time of persons with AD can be better explained by including caregiver variables such as coping style and depressive symptoms as predictors.

DESIGN AND METHODS

A sample of 193 persons with AD residing in the community and their family caregivers was used to estimate the parameters of a Cox regression model of survival time that included both caregiver characteristics and care-recipient impairments as covariates.

RESULTS

Caregiver wishfulness-intrapsychic coping was related to shorter care-recipient survival time, but instrumental and acceptance coping and caregiver depressive symptoms were not associated with survival time. Care-recipient impairments (dependency in activities of daily living, low score on the Mini-Mental State Examination, and problematic behaviors) were associated with shorter survival time.

IMPLICATIONS

Because this study is the first to report the link between caregiver coping and care-recipient survival, further study to understand the dynamics is required. We discuss several possible mechanisms, including the possibility that caregivers engaging in wishfulness-intrapsychic coping are less psychologically available to the person with dementia. These caregivers may therefore provide less person-centered care that is responsive to the true capacities of the person with dementia, and thus they may inadvertently contribute to excess disability and consequent accelerated decline. Because wishfulness-intrapsychic coping was uncorrelated with instrumental or acceptance coping, our findings suggest that interventions to enhance coping skills among caregivers, which have focused primarily on increasing problem solving and acceptance coping, also may have to include specific attempts to reduce wishfulness-intrapsychic approaches to benefit not only the caregiver but the care recipient as well.

A New Conceptual Model for Assistive Technology Outcomes Research and Practice

Predictive conceptual models help us frame research questions, interpret results, and guide clinical practice. Although numerous models have appeared in the assistive technology (AT) literature, none has been shown to predict AT usage. The lack of a valid predictive model indicates the need for development of new approaches to modeling AT outcomes. This article proposes a user-centered conceptual model that predicts AT usage as a function of the perceived relative advantages of AT. Device usage is not modeled as a one-time, all-or-nothing proposition, but as a decision process recurring over time. The influence of parallel interventions working concurrently with, or as an alternative to, AT is a central consideration that ultimately drives AT usage. Usage is shown as a proximal influence on AT impact, and AT impact is shown to be a predictor of future use. Research is cited supporting various elements of the new model.

Caregivers of persons with a brain tumor: a conceptual model

Researchers have documented negative physical and emotional consequences for both family caregivers of persons with cancer as well as caregivers of persons with a neurologic disorder. However, there is a unique subset of caregivers who must provide care for someone who may suffer from both a short, terminal trajectory of disease, as well as neurological and neuropsychiatric sequelae - the caregiver of a person with a primary malignant brain tumor. The purpose of this article was to describe a conceptual framework for providing care for a person with a primary malignant brain tumor. The demands of this particular care situation are described, as well as potential resources available to the caregiver to meet those demands. Finally, the stress response that results from the balance between care demands and caregiver resources is illustrated. Development of a conceptual framework for this caregiving population is the first step in assisting nurses to identify factors that place caregivers of persons with a primary malignant brain tumor at risk for negative consequences, and to design interventions to improve caregiver health.

Risk Adjusting Rehabilitation Outcomes

The complexity and mix of rehabilitation patients varies across clinicians and institutions. Comparisons of outcomes across providers must therefore adjust for differences in risk factors across patient populations. Research on risk adjustment has generally focused on acute care hospital outcomes, although techniques for risk adjusting financial outcomes are fairly well developed in rehabilitation, primarily to support Medicare and other prospective payment systems. This article reviews important methodologic issues in risk adjusting rehabilitation outcomes in observational studies of routine clinical practice or for management, such as assessing quality or costs of care. Risk adjusting rehabilitation outcomes is more difficult than risk adjusting other clinical results, such as outcomes of many acute care services. At the outset, characterizing rehabilitation interventions is frequently difficult. Furthermore, outcomes are diverse and depend on myriad factors, including patients' physical and cognitive abilities, underlying medical diseases, sensory and emotional factors, willingness to participate in care, and supportive environments. No risk-adjustment approach can control for every factor affecting outcomes of care. Knowing which risk factors are missing helps guide interpretation of the results and determines how well risk-adjusted outcomes fairly compare providers or treatments.

Baisse rapide du Mini Mental State Examination: étude REAL.FR

BACKGROUND

Alzheimer's disease is a chronic pathology requiring regular follow-up. The predictive factors of rapid cognitive decline remain unclear.

OBJECTIVES

To analyse the baselines characteristics of patients at increased risk of rapid cognitive decline.

METHODS

This study presents transversal data on a community-based sample of 340 patients diagnosed with probable Alzheimer's disease and followed by REAL.FR group. Rapid cognitive decline was defined as a 3-points or greater loss on the Mini Mental State Examination (MMSE) within six months.

RESULTS

54% of patients presented a rapid cognitive decline. Logistic regression analysis showed a positive association between rapid cognitive decline and a MMSE < or = 20 (p < 0.003) or a greater BMI (p < 0.02) and a tendency towards a negative correlation with anxiety (p = 0.06) and negative correlation with the burden severity (p < 0.05).

CONCLUSIONS

Patients with a worse cognitive status, a greater BMI and less anxiety or burden were at increased risk of rapid cognitive decline. Future studies should focus on determining etiologies for patients with rapid cognitive loss and help clinicians target these patients for interventions aiming to delay or stabilise the course of this disease.

Family caregivers' experiences with community services: a qualitative analysis

Researchers of family caregiving have presented mixed results in evaluating the effectiveness of community services in reducing family caregiver stress and have indicated that many caregivers use limited services or access services late in their caregiving experience. The purpose of this study was to describe the experience of the use of community services, including benefits and barriers, by family caregivers of relatives with Alzheimer's disease or a related disorder. Community services included assistance with caregiving or related tasks and educational or emotional support that was provided by health professionals or community service providers. In this qualitative descriptive study, a convenience sample of 21 family caregivers was interviewed. Open-ended questions were used to explore the caregivers' experiences with community services. Transcribed data were analyzed using qualitative content-analysis techniques. Results indicated that family caregivers received benefits of renewal, sense of community, and new knowledge and believed that their patient benefited from the services. Barriers to service use included care receiver resistance, reluctance of the caregiver, hassles for the caregiver, concerns over quality, and concerns over finances. These findings provide direction for community nurses and other health professionals in targeting interventions that will meet the expressed needs of caregivers.

Measuring and enhancing self-efficacy among professional caregivers of individuals with dementia

Nurses who provide care for individuals with Alzheimer's disease and other dementias are at risk of burnout. Self-efficacy is a psychological construct with the potential to help reduce or prevent the impact of caregiver stress. Evidence supporting a link between higher levels of self-efficacy and lower levels of stress is emerging among lay caregivers. However, concurrent research for professional caregivers lags behind, partly due to a lack of appropriate self-efficacy measures for this population. We developed an intervention to enhance self-efficacy and an inventory to measure its improvements among long-term care nurses. Training resulted in lasting improvements in knowledge and self-efficacy regarding the management of challenging team, resident, and family situations. Short-term reductions in caregiver burnout were also evident. Suggestions for maintaining improvements in caregiver burnout over longer periods are offered.

Effects of the home environmental skill-building program on the caregiver-care recipient dyad: 6-month outcomes from the Philadelphia REACH Initiative

PURPOSE

We examine 6-month effects of the Environmental Skill-Building Program on caregiver well-being and care recipient functioning and whether effects vary by caregiver gender, race (White or non-White), and relationship (spouse or nonspouse).

DESIGN AND METHODS

We enrolled 255 family caregivers of community-residing persons with Alzheimer's disease or related disorders, of whom 190 participated in a follow-up interview. Caregivers were randomized to a usual care control group or intervention group that received five home contacts and one telephone contact by occupational therapists, who provided education, problem-solving training, and adaptive equipment. Baseline and 6-month follow-up included self-report measures of caregiver objective and subjective burden, caregiver well-being, and care recipient problem behaviors and physical function.

RESULTS

Compared with controls (n = 101), intervention caregivers (n = 89) reported less upset with memory-related behaviors, less need for assistance from others, and better affect. Intervention spouses reported less upset with disruptive behaviors; men reported spending less time in daily oversight; and women reported less need for help from others, better affect, and enhanced management ability, overall well-being, and mastery relative to control group counterparts. Statistically significant treatment differences were not found for hours helping with instrumental activities of daily living, upset with providing assistance with instrumental activities of daily living and activities of daily living, perceived change in somatic symptoms, White versus non-White caregivers, or care recipient outcomes.

IMPLICATIONS

The Environmental Skill-Building Program reduces burden and enhances caregiver well-being in select domains and has added benefit for women and spouses.

Effects of an automated telephone support system on caregiver burden and anxiety: findings from the REACH for TLC intervention study

PURPOSE

We determine the main outcome effects of a 12-month computer-mediated automated interactive voice response (IVR) intervention designed to assist family caregivers managing persons with disruptive behaviors related to Alzheimer's disease (AD).

DESIGN AND METHODS

We conducted a randomized controlled study of 100 caregivers, 51 in the usual care control group and 49 in the technology intervention group, who received yearlong access to an IVR-mediated system. The system provided caregiver stress monitoring and counseling information, personal voice-mail linkage to AD experts, a voice-mail telephone support group, and a distraction call for care recipients. We conducted analyses by using a repeated measures approach for longitudinal data and an intention-to-treat analytic approach. Outcomes included the caregiver's appraisal of the bothersome nature of caregiving, anxiety, depression, and mastery at baseline, 6, 12, and 18 months.

RESULTS

There was a significant intervention effect as hypothesized for participants with lower mastery at baseline on all three outcomes: bother (p =.04), anxiety (p =.01), and depression (p =.007). Additionally, wives exhibited a significant intervention effect in the reduction of the bothersome nature of caregiving (p =.02).

IMPLICATIONS

Wives who exhibited low mastery and high anxiety benefited the most from the automated telecare intervention. Findings suggest that, to optimize outcome effects, similar interventions should be tailored to match the users' characteristics and preferences.

A comparison of assistive technology and personal care in alleviating disability and unmet need

PURPOSE

The authors examine differences in reports of residual disability and unmet need by type of long-term care arrangement (assistive technology or personal care).

DESIGN AND METHODS

This study compares three specific dimensions of residual difficulty (pain, fatigue, and time intensity) and reports of unmet need across care arrangements. Samples from the U. S. 1994-1995 National Health Interview Survey Phase 2 Disability Supplements include adults with limitations in bathing, transferring, walking, and getting outside.

RESULTS

Even when differences in underlying disability are accounted for, assistive technology (AT) confers no additional benefit in the three dimensions of residual difficulty analyzed here. AT users equally or more often report that tasks are tiring, time consuming, or painful, even when they use assistance. Though this would appear to indicate unmet needs for care, fewer AT users report a desire for hands-on personal care.

IMPLICATIONS

Though disability alleviation by technology is no better on specific dimensions of difficulty, technology users report less unmet need for personal care. Designing appropriate and cost-effective home care for adults with disabilities requires a better understanding of the ways in which technology users may differ from others and the circumstances under which technology can be most effective.

A pilot study on a home-based caregiver training program for improving caregiver self-efficacy and decreasing the behavioral problems of elders with dementia in Taiwan

OBJECTIVE

To investigate the effectiveness of a home-based caregiver training program for caregivers of elders with dementia and behavioral problems.

METHODS

A prospective study was conducted in the communities of Northern Taiwan. Forty-eight patients with dementia and their family caregivers were included. The experimental group (n = 24) received a two-session in-home caregiver training program, and the control group (n = 24) received only written educational materials. The Chinese version of Cohen-Mansfield Agitation Inventory (CMAI), community form, was used to measure the behavioral problems of patients with dementia. The caregiver's self-efficacy, for managing the demented person's agitation, was measured by the Agitation Management Self-efficacy Scale (AMSS). The CMAI and AMSS were administered before (baseline), three weeks (1st post-test), and three months (2nd post-test) after the two-session training program.

RESULTS

Except for the physically aggressive behavior subscale, the scores of physically non-aggressive behavior, verbally aggressive and non-aggressive behavior subscales as well as the overall CMAI decreased significantly and continuously in the experimental group and differed significantly from the changed scores from those in the control group (p < 0.05). Physically aggressive behaviors showed a decreasing trend for both groups. Scores of the Agitation Management Self-Efficacy Scale and its subscales increased significantly and continuously in the experimental group in comparison to those in the control group (p < 0.05).

CONCLUSIONS

This home-based caregiver training program is helpful for decreasing problematic behaviors of elder people with dementia and it improves the caregiver's self-efficacy for managing problematic behaviors.

The Cleveland Alzheimer's managed care demonstration: outcomes after 12 months of implementation

PURPOSE

This demonstration evaluates the effects of integrating Alzheimer's Association care consultation service with health care services offered by a large managed care system. The primary hypothesis is that Association care consultation will decrease service utilization, increase satisfaction with managed care, and decrease caregiver depression and care-related strain. Secondary modifying-effects hypotheses posit that the effects of the intervention will be intensified when patients have not received a firm dementia diagnosis, patients have more severe memory problems, caregivers use other Association services in tandem with care consultation, and caregivers are not patients' spouses.

DESIGN AND METHODS

The demonstration is a randomized trial that examines outcomes after a 12-month study period. Interview data from 157 primary family caregivers are combined with data abstracted from medical/administrative records.

RESULTS

Support for the primary hypothesis is found for selected, but not all, service utilization outcomes and for caregiver depression. Support for secondary modifying-effects hypotheses is found for satisfaction outcomes and care-related strain outcomes.

IMPLICATIONS

Care consultation delivered within a partnership between a managed care health system and an Alzheimer's Association is a promising strategy for improving selected outcomes for patients with dementia and their caregivers.

Dementia caregiver intervention research: in search of clinical significance

PURPOSE

We reviewed intervention studies that reported dementia caregiver outcomes published since 1996, including psychosocial interventions for caregivers and environmental and pharmacological interventions for care recipients. Our goal was to focus on issues of clinical significance in caregiver intervention research in order to move the field toward a greater emphasis on achieving reliable and clinically meaningful outcomes.

DESIGN AND METHODS

MEDLINE, PsycINFO, and Cumulative Index to Nursing & Allied Health databases from 1996 through 2001 were searched to identify articles and book chapters mapping to two medical subject headings: caregivers and either dementia or Alzheimer's disease. Articles were evaluated on two dimensions, outcomes in four domains thought to be important to the individual or society and the magnitude of reported effects for these outcomes in order to determine if they were large enough to be clinically meaningful.

RESULTS

Although many studies have reported small to moderate statistically significant effects on a broad range of outcomes, only a small proportion of these studies achieved clinically meaningful outcomes. Nevertheless, caregiving intervention studies have increasingly shown promise of affecting important public health outcomes in areas such as service utilization, including delayed institutionalization; psychiatric symptomatology, including the successful treatment of major and minor depression; and providing services that are highly valued by caregivers.

IMPLICATIONS

Assessment of clinical significance in addition to statistical significance is needed in this research area. Specific recommendations on design, measurement, and conceptual issues are made to enhance the clinical significance of future research.