Self-management groups for people with dementia and their spousal caregivers. A randomized, controlled trial. Baseline findings and feasibility

How to manage comorbidities in people with dementia: A scoping review

BACKGROUND

People with dementia experience a high prevalence of comorbidities that seriously affect patient outcomes. The aim of this study was to map the evidence and components related to comorbidity management, including interventions to facilitate and support the practice of management.

METHODS

A scoping review was conducted. In June 2022, PubMed, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The National Institute of Health and Care Excellence (NICE), Open grey, and the Cochrane Library were searched to identify relevant literature. The inclusion criteria were outlined to identify studies on comorbidity management in people with dementia.

RESULTS

We found 43 items that met the inclusion criteria. The majority of the studies were published since 2010. Most research focused on medication management, health care service use and provision, and comorbidity-related monitoring and management; there were a small number of studies that involved decision-making. Only 6 studies developed interventions to support dementia care, which included comorbidity management. Studies involving the comorbidity management process were mainly based on qualitative methods, which make it difficult to quantify the impact of these processes on comorbidity management.

CONCLUSIONS

Given the serious impact of dementia on managing comorbidities, there is a need to develop systematic interventions targeting the management of comorbidities.

What is known from the existing literature about peer support interventions for carers of individuals living with dementia: A scoping review

This scoping review comprehensively describes evidence of using peer support to assist informal carers of individuals with dementia (any type). A systematic search of 11 databases (CINAHL, Cochrane Library, Medline, Embase, PsychInfo, Web of Science, Scopus, Science Direct, ProQuest, TRIP and PubMed) was conducted for research published between 2007-2017 focussing on informal dementia carers, and research designs with interventions incorporating or consisting exclusively of peer support. Authors worked independently to screen retrieved articles, review applicability and extract data. Thirty-six research papers (representing 28 original studies) were identified, from these, two modes of delivery were demonstrated: 12 studies provided the intervention online, and the remainder face-to-face. The review indicated that peer support is of potential benefit to carers if it is delivered via either mode. It is not clear what components may or may not be effective as results provided a mixed landscape of differing intervention effectiveness due to the wide variation in outcome measurements. Trial design using a multi-component intervention was the predominant choice, with the most common components being Information Sharing and Non-Healthcare Professional Support for both delivery modes. The burden/anxiety/depression compendium and health and well-being were the most frequently measured outcomes; perceived level of support was one of the least. The peer support interventions identified included various components, demonstrating no true best practice model. Nonetheless, they can be offered successfully online or face-to-face. This provides a unique opportunity to develop and supply tailored peer support interventions for informal dementia carers to ensure their specific needs are met. Further work is required to construct and evaluate the effectiveness of targeted peer-led support whether online or face-to-face to meet the individual needs of dementia carers.

Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis

Background

Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care.

Methods

Data Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses.

Findings

Seventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity.

Conclusion

Despite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Systematic review registration PROSPERO CRD42016046444.

Acceptability of psychosocial interventions for dementia caregivers: a systematic review

BACKGROUND

Most of patients with dementia are cared for by family members. Caring for people with dementia is challenging; approximately 30-55% of caregivers suffered from anxiety or depressive symptoms. A range of studies have shown that psychosocial interventions are effective and can improve caregivers' quality of life, reduce their care burden, and ease their anxiety or depressive symptoms. However, information on the acceptability of these interventions, despite being crucial, is under-reported.

METHODS

Systematic searches of databases were conducted for literature published on EMBASE, PubMed, The Cochrane Library, Web of Science, and PsycARTICLES until August 2017 and the searches were updated on June 2018. The selection criteria included primary studies with data about the acceptability of psychosocial interventions for informal caregivers and publications written in English. Two authors independently selected studies, extracted study characteristics and data, assessed the methodological quality of the included studies by using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool and Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist, and conducted a narrative synthesis of quantitative and qualitative data.

RESULTS

A total of 10,610 abstracts were identified through systematic searches. Based on screening titles and abstracts, 207 papers were identified that met the criteria for full paper review, with 42 papers from 13 different countries meeting the inclusion criteria. We found high- and moderate-quality evidence showing psychosocial interventions were acceptable, with important benefits for caregivers. Facilitators of acceptability included caregivers' need for intervention, appropriate content and organization of the intervention, and knowledge and professionalism of the staff. Barriers to acceptability included participants' poor health status and low education levels, caregiving burden, change of intervention implementers, and poor system performance of interventions.

CONCLUSION

There is preliminary evidence to support the acceptability of psychosocial interventions for dementia caregivers. However, the available supporting evidence is limited, and there is currently no adequate information from these studies indicating that the acceptability has received enough attention from researchers. More well-designed studies assessing psychosocial interventions are needed to give specific statements about acceptability, and the measure of acceptability with psychosocial interventions should be more comprehensive.

A pilot randomized controlled trial of a self-management group intervention for people with early-stage dementia (The SMART study)

BACKGROUND

Self-management equips people to manage the symptoms and lifestyle changes that occur in long-term health conditions; however, there is limited evidence about its effectiveness for people with early-stage dementia. This pilot randomized controlled trial (RCT) explored the feasibility of a self-management intervention for people with early-stage dementia.

METHODS

The participants were people with early-stage dementia (n = 24) and for each participant a caregiver also took part. Participants were randomly allocated to either an eight-week self-management group intervention or treatment as usual (TAU). Assessments were conducted at baseline, three months and six months post-randomization by a researcher blind to group allocation. The primary outcome measure was self-efficacy score at three months.

RESULTS

Thirteen people with dementia were randomized to the intervention and 11 to TAU. Two groups were run, the first consisting of six people with dementia and the second of seven people with dementia. There was a small positive effect on self-efficacy with the intervention group showing gains in self-efficacy compared to the TAU group at three months (d = 0.35), and this was maintained at six months (d = 0.23). In terms of intervention acceptability, attrition was minimal, adherence was good, and satisfaction ratings were high. Feedback from participants was analyzed with content analysis. The findings suggest the positive aspects of the intervention were that it fostered independence and reciprocity, promoted social support, offered information, and provided clinician support.

CONCLUSIONS

This study has provided preliminary evidence that self-management may be beneficial for people with early-stage dementia.

Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial

OBJECTIVES

To investigate the effect of self-management group rehabilitation for persons with dementia (PwD) and their spouses on their health-related quality of life (HRQoL), the cognition of the PwD, and the costs of health and social services.

DESIGN

A randomized controlled trial.

SETTING

Primary care and memory clinics in the Helsinki metropolitan area, Finland.

PARTICIPANTS

PwD (N = 136) and their spouses (N = 136).

INTERVENTION

Couples were randomized to usual care or eight-session self-management groups for PwD and concurrently for their spouses. Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support.

MEASUREMENTS

The primary outcome measures were the HRQoL of PwD (measured using a generic, comprehensive (15-dimensional), self-administered instrument (15D)) and spouses (measured using the RAND-36) and the spousal Sense of Competence Questionnaire (SCQ). Secondary outcome measures were PwD cognition (Verbal Fluency (VF), Clock Drawing Test (CDT)) and costs of health and social services during 24 months.

RESULTS

At 3 months, the spouse physical component of the RAND-36 improved (mean change 1.0, 95% confidence interval (CI) = -0.5 to 2.4) for those undergoing the intervention and worsened for controls (mean change -2.0, 95% CI = -3.5 to -0.4) (P = .006 adjusted for age, sex, baseline value of the physical component of the RAND-36). There were no differences between the groups on the mental component of the RAND-36, the SCQ, or the 15D. At 9 months, PwD change in VF was -0.38 (95% CI = -1.03 to 0.27) in intervention group and -1.60 (95% CI = -2.26 to -0.94) for controls (P = .011 adjusted for age, sex, baseline MMSE score). CDT changes were similar to VF changes. Differences in incremental costs between the groups was -436 € per person per year (95% CI = -4,986 to 4,115) for PwD (P = .35 adjusted for age, CDR) and -896 € per person per year (95% CI = -3,657 to 1,864) for spouses (P = .51 adjusted for PwD age, CDR).

CONCLUSIONS

The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611001173987.

A systematic narrative review of support groups for people with dementia

BACKGROUND

Provision of non-pharmacological interventions is a common policy objective for people with dementia, and support groups are an increasingly common intervention. However, there have been few attempts to synthesize evidence on the effectiveness of support groups for people with dementia. This review investigated the outcomes of support groups for people with dementia, explored participant characteristics and reviewed group formats.

METHODS

A systematic review was undertaken and a narrative synthesis of data from 29 papers (reporting on 26 groups and a survey of a range of groups) was conducted.

RESULTS

Support groups seem acceptable to people with dementia. Qualitative studies report subjective benefits for participants but there is limited evidence of positive outcomes based on quantitative data. Samples have tended to be homogenous and this may limit the generalizability of findings.

CONCLUSIONS

Although qualitative studies will remain important in this area, further mixed-methods randomized controlled trials (RCTs)or comparison group studies with longer follow-up periods are needed to strengthen the evidence base.

A Review of Self-Management Interventions for People With Dementia and Mild Cognitive Impairment

Self-management offers a way of helping people with dementia or mild cognitive impairment (MCI) to play an active role in managing their condition. Barlow, Wright, Sheasby, Turner, and Hainsworth have defined self-management as the "individual's ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition." Although commonly used in other chronic health conditions, there has been relatively little exploration of the role of self-management in dementia or MCI. This review aimed to identify group-based psychosocial interventions for people with dementia or MCI that incorporate significant elements of self-management. Fifteen interventions were included in the review: 12 for people with dementia and 3 for participants with MCI. In both the dementia and MCI interventions, the most commonly included self-management components were information, communication, and social support, and skills training. The review findings indicate that components of self-management have been incorporated into group-based interventions for people with dementia and MCI. Further studies are needed to address the methodological limitations of the included studies and to determine the effectiveness of self-management interventions with these populations.