Supported Web-Based Acceptance and Commitment Therapy for Older Family Caregivers (CareACT) Compared to Usual Care

Engaging care partners of persons living with dementia in acceptance and commitment therapy (ACT) programs: a scoping review

OBJECTIVES

Acceptance and commitment therapy (ACT) is a relatively new type of psychotherapy effective for treating depression and anxiety amongst family care partners of persons living with dementia [PLWD]. However, care partner engagement in mental health services is low and specific guidelines for designing ACT programs for care partners of PLWD do not exist. The purpose of this scoping review was to examine patterns in care partner engagement in ACT programs to identify program factors potentially influencing engagement.

METHODS

A comprehensive scoping review according to Arksey and O'Malley's framework was followed. Databases and grey literature were searched for primary studies of ACT programs with care partners of PLWD. Data were charted and synthesized.

RESULTS

Ten studies met inclusion criteria and were analyzed. Amongst these, engagement was highest in three ACT programs that were delivered individually, remotely and were therapist-led or supported. Conversely, engagement was the lowest in two ACT programs that were self-directed, web-based and had minimal or no care partner-therapist interaction. Program factors perceived as influencing engagement included tailoring and personalization, mode of delivery and format, therapeutic support and connectedness, program duration and pace.

CONCLUSION

Findings from this review suggest that care partners engagement may be promoted by designing ACT programs that focus on the therapeutic client-therapist relationship, are delivered remotely and individually. Future research should focus on evaluation of best implementation practices for engagement and effectiveness.

Adherence to Online Interventions for Family Caregivers of People With Dementia: A Meta-Analysis and Systematic Review

OBJECTIVE

Online interventions hold promise in supporting the well-being of family caregivers and enhancing the quality of care they provide for individuals with long-term or chronic conditions. However, dropout rates from support programs among specific groups of caregivers, such as caregivers of people with dementia, pose a challenge. Focused reviews are needed to provide more accurate insights and estimates in this specific research area.

METHODS

A meta-analysis of dropout rates from available online interventions for family caregivers of people with dementia was conducted to assess treatment acceptability. A systematic search yielded 18 studies involving 1,215 caregivers.

RESULTS

The overall pooled dropout rate was 18.4%, with notable heterogeneity indicating varied intervention adherence. Interventions incorporating human contact, interactive features, and personalization strategies for specific types and stages of dementia predicted significantly lower dropout rates. Methodological assessment revealed variability in study quality.

CONCLUSION

Findings support the effectiveness of social support, personalization strategies, and co-design in enhancing intervention adherence among dementia family caregivers. Further research is needed to explore factors influencing dropout rates and conduct robust trials to refine the implementation of future interventions.

What works to support carers of older people and older carers? an international evidence map of interventions and outcomes

BACKGROUND

Unpaid carers of older people, and older unpaid carers, experience a range of adverse outcomes. Supporting carers should therefore be a public health priority. Our understanding of what works to support carers could be enhanced if future evaluations prioritise under-researched interventions and outcomes. To support this, we aimed to: map evidence about interventions to support carers, and the outcomes evaluated; and identify key gaps in current evidence.

METHODS

Evidence gap map review methods were used. Searches were carried out in three bibliographic databases for quantitative evaluations of carer interventions published in OECD high-income countries between 2013 and 2023. Interventions were eligible if they supported older carers (50 + years) of any aged recipient, or any aged carers of older people (50 + years).

FINDINGS

205 studies reported across 208 publications were included in the evidence map. The majority evaluated the impact of therapeutic and educational interventions on carer burden and carers' mental health. Some studies reported evidence about physical exercise interventions and befriending and peer support for carers, but these considered a limited range of outcomes. Few studies evaluated interventions that focused on delivering financial information and advice, pain management, and physical skills training for carers. Evaluations rarely considered the impact of interventions on carers' physical health, quality of life, and social and financial wellbeing. Very few studies considered whether interventions delivered equitable outcomes.

CONCLUSION

Evidence on what works best to support carers is extensive but limited in scope. A disproportionate focus on mental health and burden outcomes neglects other important areas where carers may need support. Given the impact of caring on carers' physical health, financial and social wellbeing, future research could evaluate interventions that aim to support these outcomes. Appraisal of whether interventions deliver equitable outcomes across diverse carer populations is critical.

Digital interventions to reduce social isolation and loneliness in older adults: An evidence and gap map

Background

Social isolation and loneliness are more common in older adults and are associated with a serious impact on their well-being, mental health, physical health, and longevity. They are a public health concern highlighted by the COVID-19 pandemic restrictions, hence the need for digital technology tools to enable remotely delivered interventions to alleviate the impact of social isolation and loneliness during the COVID-19 restrictions.

Objectives

To map available evidence on the effects of digital interventions to mitigate social isolation and/or loneliness in older adults in all settings except hospital settings.

Search Methods

We searched the following databases from inception to May 16, 2021, with no language restrictions. Ovid MEDLINE, Embase, APA PsycInfo via Ovid, CINAHL via EBSCO, Web of Science via Clarivate, ProQuest (all databases), International Bibliography of the Social Sciences (IBSS) via ProQuest, EBSCO (all databases except CINAHL), Global Index Medicus, and Epistemonikos.

Selection Criteria

Titles and abstracts and full text of potentially eligible articles were independently screened in duplicate following the eligibility criteria.

Data Collection and Analysis

We developed and pilot tested a data extraction code set in Eppi-Reviewer and data were individually extracted and coded based on an intervention-outcome framework which was also used to define the dimensions of the evidence and gap map.

Main Results

We included 200 articles (103 primary studies and 97 systematic reviews) that assessed the effects of digital interventions to reduce social isolation and/or loneliness in older adults. Most of the systematic reviews (72%) were classified as critically low quality, only 2% as high quality and 25% were published since the COVID-19 pandemic. The evidence is unevenly distributed with clusters predominantly in high-income countries and none in low-income countries. The most common interventions identified are digital interventions to enhance social interactions with family and friends and the community via videoconferencing and telephone calls. Digital interventions to enhance social support, particularly socially assistive robots, and virtual pets were also common. Most interventions focused on reducing loneliness and depression and improving quality of life of older adults. Major gaps were identified in community level outcomes and process indicators. No included studies or reviews assessed affordability or digital divide although the value of accessibility and barriers caused by digital divide were discussed in three primary studies and three reviews. Adverse effects were reported in only two studies and six reviews. No study or review included participants from the LGBTQIA2S+ community and only one study restricted participants to 80 years and older. Very few described how at-risk populations were recruited or conducted any equity analysis to assess differences in effects for populations experiencing inequities across PROGRESS-Plus categories.

Authors' Conclusions

The restrictions placed on people during the pandemic have shone a spotlight onto social isolation and loneliness, particularly for older adults. This evidence and gap map shows available evidence on the effectiveness of digital interventions for reducing social isolation or loneliness in older adults. Although the evidence is relatively large and recent, it is unevenly distributed and there is need for more high-quality research. This map can guide researchers and funders to consider areas of major gaps as priorities for further research.

The use of Acceptance and Commitment Therapy (ACT) in informal caregivers of people with dementia and other long-term or chronic conditions: A systematic review and conceptual integration

Informal caregivers are the primary source of support for adults with chronic conditions and disabilities. Empirical research highlights chronic stress and other risks of adverse outcomes of caregiving. Acceptance and Commitment Therapy (ACT) is an emerging evidenced-based practice that shows promise in improving an array of outcomes, theoretically by increasing psychological flexibility as the primary process of change. Research has begun to evaluate ACT among informal caregivers of adult populations, and a systematic review is now needed to summarise this evidence base. Electronic searches from five databases, including PubMed, PsycInfo, Embase, CINAHL, and Cochrane Library, yielded an initial 7896 hits, which after screening for inclusion criteria, resulted in 21 clinical trials. Studies were coded to synthesise the feasibility, effectiveness, and quality of evidence. Findings show that ACT was reported to be largely feasible and acceptable. However, the efficacy of ACT was mixed, with a more consistent pattern for informal caregivers of people with dementia. Several methodological quality issues limited the findings. However, theoretical synthesis and preliminary evidence support the promising effect of ACT in subgroups of informal caregivers. Research on the process of change, as well as larger-scale, methodologically rigorous trials, are needed to consolidate these findings.

Internet-delivered guided self-help acceptance and commitment therapy for family carers of people with dementia (iACT4CARERS): a feasibility study

OBJECTIVES

The feasibility of research into internet-delivered guided self-help Acceptance and Commitment Therapy (ACT) for family carers of people with dementia is not known. This study assessed this in an uncontrolled feasibility study.

METHOD

Family carers of people with dementia with mild to moderate anxiety or depression were recruited from primary and secondary healthcare services in the UK. Participants were offered eight, guided, self-help online ACT sessions adapted for the needs of family carers of people with dementia with optional online peer support groups. Pre-defined primary indicators of success included recruitment of 30 eligible carers over 6 months and ≥70% completing at least two online sessions.

RESULTS

Thirty-three participants (110% of the target sample) were recruited over 6 months and 30 participants (91%) completed two or more sessions, and thus both indicators of success were met. Further, 70% of participants completed seven or all eight sessions, and 27% of participants were lost to follow-up, but none of the reasons for early withdrawal were related to the intervention.

CONCLUSION

This study supports the feasibility, including recruitment and treatment completion. A full-scale trial to assess the clinical- and cost-effectiveness of the intervention including its long-term effects is warranted.

What are the educational and support needs of family carers looking after someone in the early stages of Alzheimer's disease? A qualitative retrospective approach

The current study aimed to identify the educational and support needs of family carers of people with dementia in the early stages of dementia by employing a qualitative approach with retrospective semi-structured interviews with family carers of people in the later stages of Alzheimer's disease (AD). Semi-structured individual interviews were conducted via telephone or Microsoft Teams video call. Purposive sampling was used to recruit twelve family carers of people with moderate or severe AD. An interview guide was used to explore the retrospective views of the carer's educational and support needs in the early stages of AD. The interviews were audio-recorded transcribed and analysed using thematic analysis. Three overarching themes were identified. Theme 1 highlighted that family carers experienced frequent and overwhelming need to fulfil a family obligation and feelings of guilt to seek help, which acted as barriers to seeking support, in the early stages. In theme 2, family carers rarely received support in the early stages and available resources were limited to self-help materials. Finally, in Theme 3, family carers wanted to receive interpersonal tailored support to seek practical advice and to learn psychological skills to build resilience in the early stages to overcome emotional challenges. The development of interventions that are specifically designed for family carers in the early stages is critical. The key components to be considered for future interventions are discussed.

Is acceptance and commitment therapy helpful in reducing anxiety symptomatology in people aged 65 or over? A systematic review

Anxiety-related mental health problems constitute a health challenge, especially in the elderly population. At present, there are few psychological treatments to reduce anxiety adapted to this group. The aim of this study was to conduct a systematic review of the literature to determine the therapeutic effects of Acceptance and Commitment Therapy (ACT) on anxiety in older adults, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two blinded reviewers participated in the search, selection and methodological quality assessment processes; reaching satisfactory levels of agreement between reviewers (κ > 0.70). The search was performed in PubMed, Proquest Central, Scopus and Web of Science; making use of standardized terms for the construction of the algorithm. In the general search 348 studies were found. After applying the eligibility criteria and excluding duplicates, seven articles were extracted for qualitative analysis. The total number of subjects was 633, with an average age of 68.89 years (68.94% women). The analysis of methodological rigor showed moderate indices on average. The publications focused primarily on samples with a diagnosis of generalized anxiety disorder, proposing a variety of assessment tests for related dependent variables, especially depressive symptoms and psychological flexibility. Critical analysis of the findings provides evidence for the efficacy of ACT in reducing anxious and depressive symptoms in older adults. This study proposes the use of this procedure as a non-pharmacological alternative for a group usually underrepresented in the scientific literature on this topic.

Therapists’ perceptions and acceptability of providing internet-delivered guided self-help acceptance and commitment therapy (ACT) for family carers of people with dementia (iACT4CARERS): a qualitative study

This study aimed to explore therapists’ perceptions and acceptability of providing internet-delivered, therapist-guided, self-help acceptance and commitment therapy (ACT) for family carers of people with dementia (iACT4CARERS). To achieve this, a qualitative approach with semi-structured interviews was employed with eight novice therapists recruited from primary and secondary care services taking part in a feasibility study of iACT4CARERS. The interviews were audio-recorded, transcribed, and analysed using thematic analysis. Four over-arching themes were identified: (1) positive attitudes towards the intervention, (2) therapists’ workload, (3) therapists’ confidence to perform their role, and (4) connecting with family carers in a virtual context. Theme 1 included seeing their involvement as an opportunity for personal growth and perceiving benefits to the family carers, which contributed to greater acceptability. Theme 2 reflected that while workload and the user-friendliness of the online platform were highly acceptable among the therapists, there were also time-consuming cases that increased therapists’ burden. Theme 3 revealed that practical resources provided during the training, continued supervision, and opportunities to learn from other therapists, increased therapist confidence and facilitated greater acceptability. Finally, Theme 4 highlighted that improving the connection between therapists and carers was critical in a virtual context and strategies to improve the therapist–carer relationship were recommended. The implementation of iACT4CARERS was largely acceptable for the therapists involved in the trial. Ways to strengthen the therapeutic relationship in the virtual context and practical strategies to deal with common problems may enhance therapist experience and delivery in a full-scale effectiveness trial.

Key learning aims

(1)