Effective caregiving approaches for patients with Alzheimer's disease

Effects of Client-Centered Occupational Therapy on Behavioral Psychological Symptoms, Social Interaction, Occupational Performance, Quality of Life, and Caregiver Burden among the Individuals with Dementia

This study aimed to verify the effects of client-centered occupational therapy on individuals with dementia. Twenty participants were randomly assigned to an experimental group (client-centered occupational therapy) and a control group (general occupational therapy). A pretest, post-test, and follow-up tests were used to compare the effects of the intervention. The experimental group had significant changes in all variables, and the control group showed significant differences in verbal social interaction, quality of life, and burden of caregivers (p < 0.05). As a result of repeated measurement variance analysis, it was found that there was a significant effect within the group except for the NPI-Q distress items (p < 0.05), but the effect was not verified in all areas between the groups. Client-centered customized occupational therapy can be more effective than general occupational therapy in problem behavior, social interaction, quality of life, caregiver burden, and occupational performance of individuals with dementia.

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

Background

Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.

Objectives

We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.

Design

We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.

Setting

The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.

Participants

People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.

Main outcome measures

The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.

Methods

Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.

Results

Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.

Limitations

Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia.

Conclusions

Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.

Future work

Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.

Study registration

Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

How can occupational therapy improve the daily performance and communication of an older patient with dementia and his primary caregiver?

Objective: To enhance insight into the process of occupational therapy (OT) and the changes after OT, in an older patient with mild dementia and his primary caregiver.

Design and setting: Case study: content analysis of an OT patient record.

Intervention: System-based OT at home using a guideline focusing on both patient's performance in daily activities and caregiver's cognition on patient behaviour and caregiver role and focusing on adaptation of the physical environment.

Measures: Triangulation of results of qualitative content analysis and quantitative description using the following measures: Brief Cognitive Rating Scale (BCRS), Assessment of Motor and Process Skills (AMPS), Interview of Deterioration in Daily Activities in Dementia (IDDD), Canadian Occupational Performance Measurement (COPM), Dementia Quality of Life Instrument (DQOL), Sense of Competence Scale (SCQ) and the Mastery Scale.

Results: The global categories derived from content analysis were: daily performance and communication. The specific categories were the patient with dementia, his or her caregiver and the occupational therapist. Important themes derived from content analysis were: patient's capacity for pleasure, autonomy and appreciation in performing daily activities and caregiver's competence. Patient's changes reported after OT: more initiative, autonomy and pleasure in performing daily activities, increase of quality of life; caregiver's changes reported after OT: improved communication and supervision skills, changed cognition on patient behaviour and caregiver role, improved sense of competence. The quantitative results showed an improved daily performance (e.g. initiative, motor and process skills, need for assistance) and quality of life of the patient and improved sense of competence, quality of life and mastery of the situation of the caregiver after OT intervention. Thus the results of the qualitative content analysis were supported by the quantitative results. Additionally, based on the results of the content analysis an exploratory and system-based model has been developed connecting OT diagnosis and OT treatment at home for patients with dementia and their primary caregivers.

Conclusion: This case study provides information on how occupational therapy can improve the daily performance, communication, sense of competence and quality of life of an older patient with dementia and his or her primary caregiver. A combination of education, setting feasible goals, using adaptations in physical environment, training compensatory skills, training supervision skills, and changing dysfunctional cognitions on patient behaviour and caregiver role seemed to be successful. A randomized controlled trial must provide information on the effects of OT at home for older patients with dementia and their primary caregivers.

Effectiveness of Caregiver Interventions on Patient Outcomes in Adults With Dementia or Alzheimer's Disease: A Systematic Review

Objective: We conducted a systematic review to evaluate whether caregiver-involved interventions improve patient outcomes among adults with dementia or Alzheimer's disease. Method: We identified and summarized data from randomized controlled trials enrolling adults with dementia or Alzheimer's disease by searching MEDLINE, PsycINFO, and other sources. Patient outcomes included global quality of life, physical and cognitive functioning, depression/anxiety, symptom control and management, and health care utilization. Results: We identified 31 trials; 20 compared a caregiver intervention with usual care or usual care with promise of intervention at completion of study period. Fifteen compared one caregiver intervention with another individual or caregiver intervention (active control). Compared with usual care or active controls, caregiver-involved interventions had low to insufficient strength of evidence and did not consistently improve patient outcomes. Discussion: Evidence is insufficient to endorse use of most caregiver interventions to improve outcomes for patients with dementia or Alzheimer's disease.

Best practices interventions to improve quality of care of people with dementia living at home

OBJECTIVE

To identify effective interventions which improve quality of care for people with dementia (PwD) living at home.

METHODS

MEDLINE-(via PubMed), CINAHL, PsycINFO and ISI Web of Science databases were searched.

INCLUSION CRITERIA

(1) randomized controlled trials; (2) published in English-language, peer-reviewed journals between 1990 and 2012; (3) evaluated strategies to improve quality of care for PwD cared at home; and (4) participants older than 65.

RESULTS

23 studies met inclusion criteria. All the studies aimed to improve PwD quality of care and most of them focused on PwD caregivers. Psychoeducational programs are the most frequently assessed interventions and multicomponent interventions produced the most promising results.

CONCLUSION

Due to the great variety of interventions describing specific samples and contexts, comparison of practice effectiveness is difficult. However, cognitive rehabilitation in PwD is effective when applied at an early stage of the disease. Case managers have demonstrated to reduce PwD institutionalization and the use of other community services. The studies were limited by sample heterogeneity, short follow-up or insufficiently detailed description.

PRACTICE IMPLICATIONS

To improve PwD homecare, health professionals should educate and support caregivers. Before specific interventional recommendations can be made, further research addressing the limitations of current studies is needed.

Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia

OBJECTIVES

Older adults with dementia experience progressive functional decline, which contributes to caregiver burden and nursing home placement. The goal of this systematic review was to determine if any non-pharmacologic interventions have delayed functional decline among community-dwelling dementia patients.

METHOD

We completed a systematic literature review to identify controlled clinical trials reporting the impact of non-pharmacologic interventions on any measure of functional impairment or disability among community-dwelling dementia patients. We included studies that reported any proxy-respondent, self-reported, or performance-based standardized assessments.

RESULTS

We identified 18 published clinical trials that met inclusion criteria and found that study interventions fell into three different groups: occupational therapy, exercise, and multi-faceted ("other") interventions. The three groups of studies tended to vary systematically regarding the conceptual framework for the disabling process, target of intervention, and type of outcome measure. Approximately half the studies were conducted in the United States with mean sample size of 99 (from 27 to 1131) and follow-up periods between three months and two years. Instruments used to measure functional impairment or disability varied widely with 55 instruments across 18 studies. Nine studies reported a statistically significant improvement in functional decline in the intervention group.

CONCLUSION

The current literature provides clinical trial evidence that non-pharmacologic interventions can delay progression of functional impairment or disability among community-dwelling dementia patients. The clinical significance of this early evidence is uncertain. These early studies provide rationale for larger and longer-term studies to determine if these interventions are sufficiently potent to delay institutionalization.

Functional analysis-based interventions for challenging behaviour in dementia

BACKGROUND

Functional analysis (FA) for the management of challenging behaviour is a promising behavioural intervention that involves exploring the meaning or purpose of an individual's behaviour. It extends the 'ABC' approach of behavioural analysis, to overcome the restriction of having to derive a single explanatory hypothesis for the person's behaviour. It is seen as a first line alternative to traditional pharmacological management for agitation and aggression. FA typically requires the therapist to develop and evaluate hypotheses-driven strategies that aid family and staff caregivers to reduce or resolve a person's distress and its associated behavioural manifestations.

OBJECTIVES

To assess the effects of functional analysis-based interventions for people with dementia (and their caregivers) living in their own home or in other settings.

SEARCH METHODS

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 3 March 2011 using the terms: FA, behaviour (intervention, management, modification), BPSD, psychosocial and Dementia.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with reported behavioural outcomes that could be associated with functional analysis for the management of challenging behaviour in dementia.

DATA COLLECTION AND ANALYSIS

Four reviewers selected trials for inclusion. Two reviewers worked independently to extract data and assess trial quality, including bias. Meta-analyses for reported incidence, frequency, severity of care recipient challenging behaviour and mood (primary outcomes) and caregiver reaction, burden and mood were performed. Details of adverse effects were noted.

MAIN RESULTS

Eighteen trials are included in the review. The majority were in family care settings. For fourteen studies, FA was just one aspect of a broad multi-component programme of care. Assessing the effect of FA was compromised by ill-defined protocols for the duration of component parts of these programmes (i.e. frequency of the intervention or actual time spent). Therefore, establishing the real effect of the FA component was not possible.Overall, positive effects were noted at post-intervention for the frequency of reported challenging behaviour (but not for incidence or severity) and for caregiver reaction (but not burden or depression). These effects were not seen at follow-up.

AUTHORS' CONCLUSIONS

The delivery of FA has been incorporated within wide ranging multi-component programmes and study designs have varied according to setting - i.e. family care, care homes and hospital, with surprisingly few studies located in care homes. Our findings suggest potential beneficial effects of multi-component interventions, which utilise FA. Whilst functional analysis for challenging behaviour in dementia care shows promise, it is too early to draw conclusions about its efficacy.

A systematic review of 'knowledge of dementia' outcome measures

Knowledge of dementia measures are key to identifying areas of misinformation and establishing knowledge levels, thus guiding educational programmes and interventions. A three-step literature search was undertaken to identify measures of knowledge in dementia. An evaluation framework was employed articulating quality indicators for the psychometric properties of measures, based on their development and use within research studies. Five measures were identified: the Alzheimer's Disease Knowledge Test (ADKT, Dieckmann et al., 1988); the University of Alabama Alzheimer's Disease Knowledge Test for Health Professionals (UAB-ADKT, Barrett et al., 1997); the Dementia Quiz (DQ, Gilleard and Groom, 1994); the Knowledge of Aging and Memory Loss and Care (KAML-C, Kuhn et al., 2005) and the Alzheimer's Disease Knowledge Scale (ADKS, Carpenter et al., 2009). All measures followed a standard scale development process, generally with acceptable reliability and validity. Many studies used measures on populations beyond the target sample, without re-establishing the psychometric properties of the scales. There are limitations with all the measures, including weaknesses in psychometric properties, being outdated and having limited scope. Although the ADKT was once suited to international use and has established psychometric properties, some items are now outdated. The ADKS positions itself as an updated version of the ADKT, yet has not been used beyond the original development study. The DQ is most the suitable for family carers. All measures require periodic updates, to keep pace with the expanding field of dementia. More robust, contemporary measures of knowledge are required.

Cognitive reframing for carers of people with dementia

BACKGROUND

The balance of evidence about whether psychosocial interventions for caregivers of people with dementia could reduce carers' psychological morbidity and delay their relatives' institutionalisation is now widely regarded as moderately positive (Brodaty 2003; Spijker 2008). Multi-component, tailor-made psychosocial interventions are considered to be particularly promising (Brodaty 2003; Spijker 2008). These interventions involve multiple mechanisms of action. In this review we focused solely on the effectiveness of one element within psychosocial interventions, cognitive reframing. Cognitive reframing is a component of cognitive behavioral therapy (CBT). In dementia care, cognitive reframing interventions focus on family carers' maladaptive, self-defeating or distressing cognitions about their relatives' behaviors and about their own performance in the caring role.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of cognitive reframing interventions for family carers of people with dementia on their psychological morbidity and stress.

SEARCH METHODS

The trials were identified by searching (5 April 2009) the Cochrane Dementia and Cognitive Improvement Group Specialized Register, which contains records from major healthcare databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS, ongoing trial databases and grey literature sources. For more detailed information on what the Group's specialized register contains and to view the search strategies see the Cochrane Dementia and Cognitive Improvement Group methods used in reviews.The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS and a number of trial registers and grey literature sources were also searched separately on 5 April 2009.

SELECTION CRITERIA

Randomised controlled trials of cognitive reframing interventions for family carers of people with dementia.

DATA COLLECTION AND ANALYSIS

Three assessors (MVD, ID, JmC) independently judged whether the intervention being studied was documented in a trial; two assessors assessed trial quality.

MAIN RESULTS

Pooled data indicated a beneficial effect of cognitive reframing interventions on carers' psychological morbidity, specifically anxiety (standardised mean difference (SMD) -0.21; 95% confidence interval (CI) -0.39 to -0.04), depression (SMD -0.66; 95% CI -1.27 to -0.05), and subjective stress (SMD -0.23; 95% CI -0.43 to -0.04). No effects were found for carers' coping, appraisal of the burden, reactions to their relatives' behaviors, or institutionalization of the person with dementia.

AUTHORS' CONCLUSIONS

Cognitive reframing for family carers of people with dementia seems to reduce psychological morbidity and subjective stress but without altering appraisals of coping or burden. The results suggest that it may be an effective component of individualised, multi-component interventions for carers. Identifying studies with relevant interventions was a challenge for this review. The impact of cognitive reframing might be higher when used alongside other interventions because this offers better opportunities to tailor cognitive reframing to actual everyday carer problems.

Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study

OBJECTIVE

To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint.

DESIGN

Cost effectiveness study alongside a single blind randomised controlled trial.

SETTING

Memory clinic, day clinic of a geriatrics department, and participants' homes. Patients 135 patients aged > or =65 with mild to moderate dementia living in the community and their primary care givers.

INTERVENTION

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

Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures.

RESULTS

The intervention cost 1183 euros (848 pounds sterling, $1738) (95% confidence interval 1128 euros (808 pounds sterling, $1657) to 1239 euros (888 pounds sterling, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were 1748 euros (1279 pounds sterling, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9).

CONCLUSIONS

Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.

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.

Systematic review of the effect of psychological interventions on family caregivers of people with dementia

BACKGROUND

Caregivers of people with dementia are at high risk of psychological morbidity and associated breakdown in care. Many psychologically based interventions have been designed to help caregivers of people with dementia. More work is needed to identify which, if any, are helpful for such caregivers.

METHOD

We conducted a systematic review of the immediate and long term efficacy of different types of psychological interventions for the psychological health of caregivers of people with dementia, using standardized criteria, to assist clinicians in implementing rational, evidence-based management recommendations. We reviewed studies examining the effects of any therapy derived from a psychological approach that satisfied pre-specified criteria. Using the Oxford Centre for Evidence-Based Medicine criteria we rated the quality of each study, extracted data and gave overall ratings to different types of intervention.

RESULTS

We identified 244 references in our search of which 62 met our inclusion criteria.

LIMITATIONS

Our findings are limited by lack of good quality evidence, with only ten level 1 studies identified.

CONCLUSIONS

We found excellent evidence for the efficacy of six or more sessions of individual behavioral management therapy centered on the care recipient's behavior in alleviating caregiver symptoms both immediately and for up to 32 months. Teaching caregivers coping strategies either individually or in a group also appeared effective in improving caregiver psychological health both immediately and for some months afterwards. Group interventions were less effective than individual interventions. Education about dementia by itself, group behavioral therapy and supportive therapy were not effective caregiver interventions.

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].

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.

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.

Perceived Helpfulness of Telephone Calls

The purpose of this study was to determine the perceived helpfulness of telephone calls to 83 caregivers of family members with dementia. Study participants were assigned by groups to experimental (n = 41) or attention-only control (n = 42) conditions. Initial baseline interview data and narrative transcripts of telephone calls were used in this study. Major perceived reasons for helpfulness were that participants were assisted in sharing thoughts and feelings, expressing feelings of being overwhelmed, discussing physical and psychosocial problems, forgetting the situation, seeking reassurance, and asking for information; several participants perceived the telephone calls to be lacking in helpfulness. Results from this study suggest family caregivers can be helped through a variety of social support mechanisms.

Hassles and uplifts associated with caring for people with cognitive impairment in community settings

In this study we explored the hassles and uplifts (i.e. negative and positive emotional events) experienced by registered nurses, nursing assistants and personal carers working with people with cognitive impairment in community and residential healthcare settings in Brisbane, Queensland, Australia. The primary aim of the research was to explore what aspects of caring for cognitively impaired clients hassles nurses, what helps to relieve these hassles, what aspects of this work nurses find rewarding and what detracts from those rewards, as well as the intensity with which each of these aspects were felt. A questionnaire developed to explore hassles and uplifts at work was administered and 57 responses obtained. Results indicated that caring for the cognitively impaired client provides many uplifts for nurses and few hassles. However, the hassles that occurred were of high importance. This paper will be of interest to managers, nurses and carers in settings where there are people with cognitive impairment as well as scholars, who may find that assessing emotional hassles and uplifts provides additional insights into other areas of nursing.

Meta-analysis of psychosocial interventions for caregivers of people with dementia

OBJECTIVES

To review published reports of interventions for caregivers (CGs) of persons with dementia, excluding respite care, and provide recommendations to clinicians.

DESIGN

Meta-analytical review. Electronic databases and key articles were searched for controlled trials, preferably randomized, published in English from 1985 to 2001 inclusive. Thirty studies were located and scored according to set criteria, and the interventions' research quality and clinical significance were judged.

SETTING

Home or noninstitutional environment.

PARTICIPANTS

Informal CGs-persons providing unpaid care at home or in a noninstitutional setting.

MEASUREMENTS

The primary measures were psychological morbidity and burden. Other varied outcome measures such as CG coping skills and social support were combined with measures of psychological distress and burden to form a main outcome measure.

RESULTS

The quality of research increased over the 17 years. Results from 30 studies (34 interventions) indicated, at most-current follow-up, significant benefits in caregiver psychological distress (random effect size (ES) = 0.31; 95% confidence interval (CI) = 0.13-0.50), caregiver knowledge (ES = 0.51; CI = 0.05-0.98), any main caregiver outcome measure (ES = 0.32; CI = 0.15-0.48), and patient mood (ES = 0.68; CI = 0.30-1.06), but not caregiver burden (ES = 0.09; CI = -0.09-0.26). There was considerable variability in outcome, partly because of differences in methodology and intervention technique. Elements of successful interventions could be identified. Success was more likely if, in addition to CGs, patients were involved. Four of seven studies indicated delayed nursing home admission.

CONCLUSION

Some CG interventions can reduce CG psychological morbidity and help people with dementia stay at home longer. Programs that involve the patients and their families and are more intensive and modified to CGs' needs may be more successful. Future research should try to improve clinicians' abilities to prescribe interventions.

A systematic review of the effectiveness of psychosocial interventions for carers of people with dementia

Historically, there have been many attempts to develop interventions to support the carers of people with dementia. To date the evidence of effectiveness has been limited. However, the success of psychosocial interventions for carers of people with schizophrenia has suggested the possibility of utilizing this approach. A systematic review was undertaken to assess the evidence of effectiveness for psychosocial interventions with carers of people with dementia. Thirty controlled trials that evaluated a psychosocial approach were identified. The overall methodological quality of these studies was poor, particularly with regard to sample size, and methods of random allocation. Individualized interventions that utilized problem solving and behaviour management demonstrated the best evidence of effectiveness. This approach is also closest to the effective model of psychosocial interventions currently in use with other severe and enduring illnesses. This suggests that there is scope for developing interventions, based more specifically on this model, for supporting the carers of people with dementia.

The efficacy of psychosocial approaches to behaviour disorders in dementia: a systematic literature review

OBJECTIVE

This paper provides a systematic review of research findings published between 1989 and 1998 concerning non-pharmacological strategies to alleviate behavioural disturbances in elderly persons with dementia.

METHOD

Data collection strategies included computer literature searches, manual searches of selected journals and checks of references listed in previous reviews. To warrant inclusion, studies were required to include some measure of behaviour before and after the introduction of an intervention. Papers were appraised in the following domains: design, sampling technique, setting, behaviours studied, measurement tools, data collection methods, type of interventions and feasibility. An overall validity rating was assigned to each article using predetermined rules.

RESULTS

Forty-three studies met criteria for inclusion including five randomised controlled trials. Validity ratings were as follows: one strong, 15 moderate, and 27 weak. Areas of scientific weakness included small numbers of subjects, inadequate descriptions of study participants, imprecise data collection methods, high attrition rates and insufficient statistical analysis. Despite this, there is evidence to support the efficacy of activity programs, music, behaviour therapy, light therapy, carer education and changes to the physical environment. The evidence in favour of multidisciplinary teams, massage and aromatherapy is inconclusive.

CONCLUSIONS

It was easier to interpret the results of rigorously designed studies that focused on a single behaviour or single intervention tailored to the needs of individuals and carers. Future studies should seek to replicate the findings outlined here, improving methodologies where necessary and including outcome measures that encompass the interests of people with dementia, family caregivers and health professionals.