Analysis of the efficacy of a psychotherapeutic program to improve the emotional status of caregivers of elderly dependent relatives

Which cognitive behavioral therapy delivery formats work for depressive symptoms in dementia caregivers? - A systematic review and network meta-analysis of randomized controlled trials

BACKGROUND

Cognitive behavioral therapy (CBT) has been shown to be effective to improve depressive symptoms by changing their cognitive processes and concepts for dementia caregivers (DCs). However, whether CBT can be effectively delivered in individual, group, telephone-administered, internet, combine formats remains unclear. We aimed to examine the most effective delivery format for CBT via a network meta-analysis (NMA).

METHODS

An exhaustive literature search was conducted based on Pubmed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure database, Chinese Biomedical Literature Database, Wan Fang database, and unpublished data. RCTs were identified from their inception to January 15, 2022. We conducted pairwise and NMA to evaluate the relative effectiveness and rank probability (rank P-score) for different CBT delivery formats. A series of analyses and assessments, such as the risk of bias, and GRADE were performed concurrently. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used for abstracting data.

RESULTS

A total of 37 studies were included in our analysis based on a series of rigorous screenings, which comprised 4191 DCs. Compared with controls, internet (SMD = -1.33, confidence interval (CI): -2.18, -0.66, GRADE low), telephone (SMD = -1.29, CI: -1.89, -0.61, GRADE moderate), and individual (SMD = -1.04, CI: -2.01, -0.07, GRADE very low) showed the largest improvement on depressive symptoms, whereas the group and combine delivery formats were not effective. Notably, there were no statistically significant differences between these five delivery formats: internet, telephone, individual, group, and combine. Sensitivity analyses supported the overall findings.

CONCLUSIONS

Our results suggested that internet, telephone, individual CBT delivery formats were effective for reducing depressive symptoms in DCs. Given the limitations of the NMA approach and the number of included studies, the result should be cautiously interpreted. Further RCTs with respect to the CBT based on different delivery formats' effectiveness are needed.

Involvement in self-care and psychological well-being of Spanish family caregivers of relatives with dementia

The provision of continuous care to a dependent person can lead to a lack of self-care by the caregiver themselves with corresponding low levels of well-being. This well-being has been analysed mostly from within the perspective of the hedonic tradition, with the development of personal growth often being overlooked. This study aims to increase the understanding of the connection between this type of psychological well-being and involvement in self-care activities, and to be a starting point for the determination of categories that may serve in the screening of potential participants in social-health interventions where it is being promoted. Taking the hypothesis of a probable positive connection between psychological well-being and involvement in self-care, an observational study was carried out on 45 caregivers of relatives with dementia. In those caregivers showing greater dedication to self-care, a higher score was obtained on the well-being scales connected to personal significance and positive emotions and experiences. These findings were further reinforced by the identification of other positive connections, the involvement in self-care and the six dimensions of wellness contemplated by Ryff. It is possible to envisage the existence of a virtuous circle in respect of the caregiver, whereby a greater involvement in self-care is related to a higher psychological well-being, which in turn is related to greater self-care, and so on.

Forgiveness Interventions for Older Adults: A Review

A meta-analysis of the efficacy of forgiveness interventions in older adults was conducted. International databases (Medline, PsycINFO, Scopus, Web of Science) were searched for studies published from 1990 to 2020 that attempted to promote forgiveness in older adults. Most intervention studies are group treatments targeted towards community-dwelling older adults. Participants in these studies are mainly women. The intervention objectives and contents vary widely and often criteria are not well-defined. Participants that received forgiveness interventions reported significantly higher levels of forgiveness than participants that did not receive treatment. Additionally, forgiveness interventions resulted in more changes in depression, stress and anger than no intervention conditions. Forgiveness treatment also enhances positive states (satisfaction with life, subjective happiness, and psychological wellbeing). The reported effects are moderate. The specific treatment model (e.g., Enright’s, Worthington’s) and format (e.g., group-based interventions and individually delivered programs) do not differentially predict better outcomes. In conclusion, future intervention studies should include more male participants and utilize a broader range of follow-up periods. Caution must be exercised because of the limited number of studies developed to date; researchers must be cautious when generalizing the results.

Validation of the professional good care scale in nursing homes (GCS-NH)

BACKGROUND

There is extensive concern about older people's care in institutions, especially recently in the past years. One of the reasons is linked to the cases of elder abuse, not only shown by academic and scientific sources, but also by social and mass media and their impact on public perception of the institutional setting. What is more, current COVID-19 pandemic consequences on older people have provoked alarm and worry especially about what is happening in institutions.

METHODS

The sample for this study consists of 286 staff working in nursing homes in Spain. This study aimed to assess the psychometric properties of the Professional Good Care Scale in Nursing Homes (GCS-NH).

RESULTS

Results of parallel analyses and exploratory factor analyses (EFAs) showed a four-factor model for the 32-item scale: humanization (9 items), non-infantilization (10 items), respect (7 items) and empowerment (6 items). Then, psychometric properties were tested analysing internal consistency (reliability) and convergent, divergent and criterion validity. High internal consistency (reliability) and different validity evidence were obtained for the total scores of the GCS-NH and its subscales. GCS-NH scores were also capable of detecting risk of probable institutional elder abuse.

CONCLUSIONS

Results show that this scale is an appropriate, valid, and reliable multidimensional instrument to evaluate good care in older institutionalized people by staff. Good care is an outcome of a complex construct in which a wide range of factors converge (staff, older people, and environmental characteristics). The GCS-NH has potential to be used as a multidimensional tool to assess good care.

Effects of a home-based exercise program on mental health for caregivers of relatives with dementia: a randomized controlled trial

OBJECTIVE

This study was aimed to evaluate the effectiveness of a home-based physical exercise program on participants' mental health: psychological symptoms, depression, and burden of female informal caregivers.

DESIGN AND PARTICIPANTS

In a randomized controlled trial, a sample of 48 female informal primary caregivers completed the entire study, 25 were randomly allocated to the intervention group (IG), and 23 participants to the control group (CG).

INTERVENTION

Participants in the IG performed two 60-minute-long physical exercise sessions per week (36 weeks) that were supervised by a personal trainer at caregivers' home during 9 months. The CG continued their habitual leisure-time activities.

MEASUREMENTS

Subjective burden was assessed by the Zarit Burden Interview. The risk of depression was measured by the Geriatric Depression Scale Short Form 15-item version, and psychological symptoms were evaluated by the Symptom Check List-90-Revised (SCL-90-R). All participants were evaluated at baseline and at the end of the intervention.

RESULTS

A promising positive impact of the intervention on caregivers' subjective burden and risk of depression was found in the IG. In addition, no significant between-group differences were found in any of nine subscales scores of the SCL-90-R. Finally, care recipients' level of functional independence and area of residence were found to be predictors of the promising positive impact on caregivers' subjective burden and risk of depression.

CONCLUSIONS

The present home-based physical exercise intervention that was individually implemented has shown promising results to reduce subjective burden and risk of depression in female caregivers of relatives with dementia. However, future research efforts should elucidate both the particular dose of physical exercise and the particular duration of the intervention that are required to obtain the expected significant positive impact. Finally, future inclusion of psychological approaches, besides physical exercise, might help reduce female caregivers' psychological symptoms.

Balneotherapy with a psychoeducation program for the promotion of a balanced care in family caregivers of older adults

This study aimed to analyze the efficacy of an intervention program for informal caregivers of elderly dependent that combined balneotherapy with group psychoeducation (BT-PE) based on the balanced care model. The BT-PE intervention (N = 124) was compared with a comparison group only exposed to balneotherapy (BT) (N = 76). The two modalities included both primary and secondary informal caregivers. A three-way mixed ANOVA was conducted to determine the effects of two between-subjects´ factors (intervention group and caregiver type) and one within-subjects´ factor (time) on burden, depression, anxiety, maladjustment and care satisfaction. Results showed less burden and more care satisfaction in both primary and secondary caregivers participating in the BT-PE program after the interventions. Primary caregivers also showed lower levels of maladjustment in the experimental group at post-intervention. Although depressive symptoms and anxiety decreased significantly in both intervention groups, BT-PE did not show lower scores compared with the application of sole BT. The relevance of caregivers´ psychoeducation on the balanced care model and its combination with balneotherapy is highlighted.

The role of acceptance in parents whose child suffers from cancer

OBJECTIVE

Parents are the main caregivers when there is a child diagnosed with cancer. Receiving a diagnosis of childhood cancer is a stressful experience. The objective of this study is to explore the mediating role of emotional avoidance and acceptance in the emotional adjustment of parents throughout the disease.

METHODS

Using the qualitative methodology Interpretative Phenomenological Analysis (IPA), parent's experiences of having a child with a diagnosis of cancer were explicated. Participants (n = 10) took part in one-on-one semi-structured interviews.

RESULTS

Acceptance serves to cope with paediatric cancer because parents live day by day, actively taking care of their children. Acceptance and emotional avoidance with oneself, with the sick child and with the others play a key role in emotional adjustment. Differences between acceptance and avoidance were considered.

CONCLUSION

Three main themes emerged from the analyses. Parents' ability to overcome their emotional struggle provides a non-pathological view of the experience of a child's illness. The results also showed the possibility for parents to access new ways to support their loved ones and to maintain the quality of their relationships. Acceptance has a positive impact on parents' adjustment while avoidance showed a negative effect on parents of children with cancer.

Personal and Work-Related Factors Associated with Good Care for Institutionalized Older Adults

Despite efforts to promote good care, many institutionalized older adults (IOA) experience elevated neglectful conditions and reduced person-centered care approaches. Based on the job demand–control model, this study aimed to analyze the relationship between nursing home professionals’ personal and organizational factors and good care provided to institutionalized older people. Data was collected through a self-administered survey completed by 208 nursing home staff members. Three dimensions of personal factors (i.e., personal accomplishment, depersonalization, and negative old age stereotypes) were significant predictors of good care. Depersonalization and negative old age stereotypes were negatively associated with IOA, and both good care and personal accomplishment were positively associated with good care in nursing homes. Only one work-related factor (i.e., management support) was positively associated with good care. Personal factors may play a significant role in good care. Management support offers a promising mechanism to promote good care among nursing home professionals. The findings support the need to change the focus on entirely completing care tasks to providing good care of residents in nursing homes that promotes management support, personal accomplishment, personalization and positive old age consideration, attitudes, and behaviors. Policies and interventions should be developed to address in a more humanized way.

Interventions for preventing abuse in the elderly

BACKGROUND

Maltreatment of older people (elder abuse) includes psychological, physical, sexual abuse, neglect and financial exploitation. Evidence suggests that 10% of older adults experience some form of abuse, and only a fraction of cases are actually reported or referred to social services agencies. Elder abuse is associated with significant morbidity and premature mortality. Numerous interventions have been implemented to address the issue of elder maltreatment. It is, however, unclear which interventions best serve to prevent or reduce elder abuse.

OBJECTIVES

The objective of this review was to assess the effectiveness of primary, secondary and tertiary intervention programmes used to reduce or prevent abuse of the elderly in their own home, in organisational or institutional and community settings. The secondary objective was to investigate whether intervention effects are modified by types of abuse, types of participants, setting of intervention, or the cognitive status of older people.

SEARCH METHODS

We searched 19 databases (AgeLine, CINAHL, Psycinfo, MEDLINE, Embase, Proquest Central, Social Services Abstracts‎, ASSIA, Sociological Abstracts, ProQuest Dissertations & Theses Global, Web of Science, LILACS, EPPI, InfoBase, CENTRAL, HMIC, Opengrey and Zetoc) on 12 platforms, including multidisciplinary disciplines covering medical, health, social sciences, social services, legal, finance and education. We also browsed related organisational websites, contacted authors of relevant articles and checked reference lists. Searches of databases were conducted between 30 August 2015 and 16 March 2016 and were not restricted by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and quasi-RCTs, before-and-after studies, and interrupted time series. Only studies with at least 12 weeks of follow-up investigating the effect of interventions in preventing or reducing abuse of elderly people and those who interact with the elderly were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the studies' risk of bias. Studies were categorised as: 1) education on elder abuse, 2) programmes to reduce factors influencing elder abuse, 3) specific policies for elder abuse, 4) legislation on elder abuse, 5) programmes to increase detection rate on elder abuse, 6) programmes targeted to victims of elder abuse, and 7) rehabilitation programmes for perpetrators of elder abuse. All studies were assessed for study methodology, intervention type, setting, targeted audience, intervention components and intervention intensity.

MAIN RESULTS

The search and selection process produced seven eligible studies which included a total of 1924 elderly participants and 740 other people. Four of the above seven categories of interventions were evaluated by included studies that varied in study design. Eligible studies of rehabilitation programmes, specific policies for elder abuse and legislation on elder abuse were not found. All included studies contained a control group, with five of the seven studies describing the method of allocation as randomised. We used the Cochrane 'Risk of bias' tool and EPOC assessment criteria to assess risk of bias. The results suggest that risk of bias across the included body of research was high, with at least 40% of the included studies judged as being at high risk of bias. Only one study was judged as having no domains at high risk of bias, with two studies having two of 11 domains at high risk. One study was judged as being at high risk of bias across eight of 11 domains.All included studies were set in high-income countries, as determined by the World Bank economic classification (USA four, Taiwan one, UK two). None of the studies provided specific information or analysis on equity considerations, including by socio-economic disadvantage, although one study was described as being set in a housing project. One study performed some form of cost-effectiveness analysis on the implementation of their intervention programmes, although there were few details on the components and analysis of the costing.We are uncertain whether these interventions reduce the occurrence or recurrence of elder abuse due to variation in settings, measures and effects reported in the included studies, some of which were very small and at a high risk of bias (low- and very low-quality evidence).Two studies measured the occurrence of elder abuse. A high risk of bias study found a difference in the post-test scores (P value 0.048 and 0.18). In a low risk of bias study there was no difference found (adjusted odds ratio (OR) =0.48, 95% 0.18 to 1.27) (n = 214). For interventions measuring abuse recurrence, one small study (n = 16) reported no difference in post-test means, whilst another found higher levels of abuse reported for the intervention arms (Cox regression, combined intervention hazard ratio (HR) = 1.78, alpha level = 0.01).It is uncertain whether targeted educational interventions improve the relevant knowledge of health professionals and caregivers (very low-quality evidence), although they may improve detection of resident-to-resident abuse. The concept of measuring improvement in detection or reporting as opposed to measuring the occurrence or recurrence of abuse is complicated. An intervention of public education and support services aimed at victims may also improve rates of reporting, however it is unclear whether this was due to an increase in abuse recurrence or better reporting of abuse.The effectiveness of service planning interventions at improving the assessment and documentation of related domains is uncertain. Unintended outcomes were not reported in the studies.

AUTHORS' CONCLUSIONS

There is inadequate trustworthy evidence to assess the effects of elder abuse interventions on occurrence or recurrence of abuse, although there is some evidence to suggest it may change the combined measure of anxiety and depression of caregivers. There is a need for high-quality trials, including from low- or middle-income countries, with adequate statistical power and appropriate study characteristics to determine whether specific intervention programmes, and which components of these programmes, are effective in preventing or reducing abuse episodes among the elderly. It is uncertain whether the use of educational interventions improves knowledge and attitude of caregivers, and whether such programmes also reduce occurrence of abuse, thus future research is warranted. In addition, all future research should include a component of cost-effectiveness analysis, implementation assessment and equity considerations of the specific interventions under review.

Anger and health in dementia caregivers: exploring the mediation effect of optimism

Although previous studies indicate a negative association between caregivers' anger and health, the potential mechanisms linking this relationship are not yet fully understood. The aim of this study was to explore the potential mediating role of optimism in the relationship between anger and caregivers' physical health. Dementia caregivers (n = 108) were interviewed and filled out instruments assessing their anger (reaction), optimism and health (vitality). A mediational model was tested to determine whether optimism partially mediated the relationship between anger and vitality. Angry reaction was negatively associated with optimism and vitality; optimism was positively associated with vitality. Finally, the relationship between angry reaction and vitality decreased when optimism was entered simultaneously. A non-parametric bootstrap approach confirmed that optimism significantly mediated some of the relationship between angry reaction and vitality. These findings suggest that low optimism may help explain the association between caregivers' anger and reduced sense of vitality. The results provide a specific target for intervention with caregivers.

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.

Family caregivers of people with dementia

Family caregivers of people with dementia, often called the invisible second patients, are critical to the quality of life of the care recipients. The effects of being a family caregiver, though sometimes positive, are generally negative, with high rates of burden and psychological morbidity as well as social isolation, physical ill-health, and financial hardship. Caregivers vulnerable to adverse effects can be identified, as can factors which ameliorate or exacerbate burden and strain. Psychosocial interventions have been demonstrated to reduce caregiver burden and depression and delay nursing home admission. Comprehensive management of the patient with dementia includes building a partnership between health professionals and family caregivers, referral to Alzheimer's Associations, and psychosocial interventions where indicated.