The efficacy of dyadic interventions for community-dwelling people with dementia and their caregivers: A systematic review and meta-analysis

Most people with dementia live at home and depend on informal caregivers for care. Both caregivers and persons with dementia can experience negative psychological and behavioural effects as the disease progresses. Non-pharmacological interventions can alleviate these effects and dyadic interventions, involving both caregiver and person with dementia, may be particularly effective. In this systematic review, the effect of dyadic interventions involving community-dwelling persons with dementia and their informal caregivers was researched. This article is an update of a review of dyadic interventions up to 2012 (Van't Leven et al., 2013). Twenty-two randomized controlled trials published between January 2012 and March 2023 met eligibility criteria, representing 3857 dyads. Results of a meta-analysis showed no overall intervention effect. Thirteen studies reported positive intervention effects, 9 studies reported no intervention effects. Intervention content and participant characteristics and knowledge of the disease varied widely between the studies reviewed. Effective interventions were those that matched activities for the person with dementia to their interests and abilities and educating the caregiver about dementia and communication. Interventions of moderate length (3-4 months) tended to be more effective than longer or shorter interventions. Future studies should further explore the factors contributing to the effects of dyadic interventions.

Factors influencing access to nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia: An integrative review

WHAT IS KNOWN ON THE SUBJECT

Research has shown effectiveness of nonpharmacological interventions in improving or maintaining cognition, mood, functioning, self-efficacy and quality of life for persons with mild-to-moderate dementia (PWDs). These interventions are critical during the earlier stages of dementia. However, Canadian and international literature report underutilization of and difficulty accessing the interventions.

WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE

To our knowledge, this is the first review that explored factors influencing seniors' utilization of nonpharmacological interventions in the earlier stages of dementia. This review contributed to the discovery of unique factors such as PWDs' beliefs, fears, perceptions, and acceptability of nonpharmacological interventions and environmental influences on intervention provision. PWDs' intervention uptake may appear as a matter of personal choices related to individuals' knowledge, beliefs and perceptions. However, the analysis of the research evidence suggests that PWDs' choices are shaped by environmental factors such as formal and informal caregiver support, acceptability and accessibility of nonpharmacological interventions, dementia care workforce, community's attitudes towards dementia and funding. The complex interplay among factors highlights the importance of targeting health promotion strategies at both individuals and their environments.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

The review findings feature opportunities for healthcare practitioners, including mental health nurses, in advocating for PWDs' evidence-informed decision-making and access to desired nonpharmacological treatments. Involvement of patients and families in care-planning through ongoing assessment of health and learning needs, as well as enablers and barriers to using interventions, continuing information provision, and personalized referrals to appropriate services can promote PWDs' rights to healthcare.

ABSTRACT

INTRODUCTION: Despite the significance of nonpharmacological interventions in optimal management of mild-to-moderate dementia, it remains unclear in the literature how persons with mild-to-moderate dementia (PWDs) view, understand and access nonpharmacological interventions.

AIM

The purpose of this review was to explore the extent and nature of evidence concerning factors that influence the use of nonpharmacological interventions for community-dwelling seniors with mild-to-moderate dementia.

METHOD

An integrative review was undertaken following Toronto and Remington (A step-by-step guide to conducting an integrative review, 2020)'s instruction which expanded Torraco (Human Resource Development Review, 2016, 15, 404)'s and Whittemore and Knafl (Journal of Advanced Nursing, 2005, 52, 546)'s guidance.

RESULTS

The review of 16 studies suggests that PWDs' use of nonpharmacological interventions is shaped by a complex interplay of various personal, interpersonal, organizational, community and political influences.

DISCUSSION

The findings highlight the complex, interrelated relationships among multiple factors and subsequent limitations of behaviour-oriented health promotion strategies. To assist PWDs in making healthier choices, health promotion strategies need to direct attention to both individuals' behaviours and environmental conditions impacting the behaviours.

IMPLICATIONS FOR PRACTICE

The findings of this review can inform multidisciplinary health practitioners' (including mental health nurses) practice with seniors living with mild-to-moderate dementia. We recommend actionable ways in which they can empower patients and their families in dementia management.

The MOMANT study, a caregiver support programme with activities at home for people with dementia: a study protocol of a randomised controlled trial

BACKGROUND

Because of the expected increase in the number of people with dementia, and the associated social and economic costs, there is an urgent need to develop effective and cost-effective care for people with dementia and their caregivers. The intervention proposed here combines two approaches to caregiver support that have shown to be effective in empowering caregivers, i.e., multiple components for caregiver support and actively engaging caregivers to involve the person with dementia in activities at home. The aim is to investigate whether the intervention is effective in improving quality of life in the caregiver and the person with dementia. A further aim will be to investigate whether this intervention can improve caregivers' feeling of competence, experience of caregiving, and mood.

METHODS

The study design is a pragmatic, cluster randomised controlled trial with cost-effectiveness analysis. The study participants are informal caregivers and home-living persons with dementia for whom they care, recruited in various regions in the Netherlands. The trial will compare outcomes in two groups of participants: 85 dyads who receive the intervention, and 85 dyads who receive care as usual. The intervention is a caregiver support training that is manual based and consists of 6 group sessions over 2 months. Training takes place in small groups of caregivers led by a health care professional presented at dementia day care centres. Randomisation occurs at the level of the day care centre. Participants are assessed on the outcome measures at baseline, prior to the intervention, and at 3 and 6 months after baseline.

DISCUSSION

The study will provide insight into effectiveness and cost-effectiveness of an intervention that has not previously been evaluated or implemented in the Netherlands. The intervention potentially adds to the effective support options for informal caregivers of people with dementia without greatly increasing the workload for health- or social care professionals.

TRIAL REGISTRATION

The trial is registered at the Dutch Trial Register at NTR6643 ; August 22nd, 2017.

Meaning-making in occupational therapy interventions: a scoping review

Abstract Introduction Meaning-making is an experience-centred process. It is an essential element for understanding the impact of occupational therapy interventions focused on fostering processes of becoming, one of the four integrated dimensions of meaningful occupation (along with doing, being, and belonging). Objective This paper aims to explore further some of the aspects that are essential for meaning-making in occupational therapy interventions. Method A scoping review guided by Arksey and O’Malley’s methodological framework was conducted. In the initial search, 528 articles were retrieved from three databases; 16 met the criteria for inclusion: articles in English, peer-reviewed, published between January 2008 and December 2017, that addressed some type of occupational therapy intervention, with data related to the meanings of the participants of the studies. Results The articles address a multiplicity of populations, services, and fields of practice, in qualitative studies, with methodologies that prioritise reflection on the lived experience. Thematic analysis highlights the interconnection between being, doing, and belonging to foster meaning-making; implications of professional actions; and meaning-making triggered by reflective processes. Conclusion Meaning-making demands reflection on the lived experience, and is influenced by human and physical environments. Both conditions/limitations and new skills/abilities enhance processes of meaning-making. Implications for future research are considered.

Meeting centres support programme highly appreciated by people with dementia and carers: a European cross-country evaluation

BACKGROUND

The Meeting Centres Support Programme (MCSP) offers a combined approach to providing practical, emotional and social support to people living with mild to moderately severe dementia and their family carers in the community.

METHODS

A mixed methods explanatory design was used. The evaluation took place within the framework of the international Joint Programme - Neurodegenerative Disease Research (JPND) - MEETINGDEM study in nine Meeting Centres in Italy, Poland and the United Kingdom. Eighty-seven people with dementia and 81 family carers completed a user evaluation survey after three months and 83 people with dementia and 84 carers after 6 months of participation in MCSP. Thirty-two people with dementia and 30 carers took part in focus groups after nine months.

RESULTS

The percentage of people with dementia who were very satisfied with the programme increased significantly over time (p = 0.05). The majority of carers reported that they felt less burdened after three months of participation in MCSP (48.1% much less; 35.4% a little less). After six months, this percentage increased significantly to 91% (p = 0.04, 57.7% much less; 33.3% little less). Focus group analysis showed that people with dementia and carers in all countries/centres improved their ability to maintain emotional balance.

CONCLUSIONS

The MCSP is highly appreciated by people with dementia and carers in all countries and it confirms the results of previous research into MCSP in the Netherlands. Our findings indicate that MCSP is a model that can help its users to increase their capacity to deal with the challenges caused by dementia and can promote emotional balance.

Priorities and Preferences of People Living with Dementia or Cognitive Impairment - A Systematic Review

BACKGROUND

Knowledge about the priorities and preferences of people living with dementia (PwD) might help to individualize treatment, care, and support, which could improve patient-related outcomes. This study aimed to summarize preferences of PwD or people with mild cognitive impairment (MCI), considering all relevant aspects of health care and everyday life.

METHODS

We conducted a systematic literature review and included studies about patient preferences published in English between January 1, 1990 and October 28, 2019. The inclusion criteria were that preferences were elicited directly by PwD or patients with MCI. We used the International Consortium for Health Outcomes Management value set for dementia to categorize the preferences into the following topics: a) clinical status, b) symptoms, functioning, and quality of life, and c) sustainability of care.

RESULTS

Of 578 initially identified studies, 45 met the inclusion criteria. Patients preferred to be informed about the diagnosis as early as possible, especially for anticipatory care planning. They ranked caregiver quality of life as their highest priority. They preferred not to be a burden to others more than their caregivers' mood, their own functional status, or their own distressing behaviors. Furthermore, PwD are eager to participate in medical decisions, especially in those about creating an everyday life routine. PwD preferred their own quality of life, self-efficacy, and emotional well-being. Institutionalized PwD preferred individualized and person-centered care. According to the sustainability of care, PwD preferred to maintain close bonds with their family at the end of their life and wanted to be treated with empathy.

CONCLUSION

This systematic review provides essential insights into cognitively impaired patients' preferences, which are rarely considered in treatment, care, and support services. Further studies should evaluate whether considering preferences in treatment and care or daily living can improve patient-reported outcomes.

Memory Strategy Training Can Enhance Psychoeducation Outcomes for Dementia Family Caregivers: A Randomized Controlled Trial

This study investigated caregiver outcomes when a psychoeducation program for older people with dementia and caregivers is modified to extend practice in memory strategies. Moderation effects of increased memory strategy use were also explored. Fifty-six care dyads participated in the multicenter, randomized controlled trial comparing psychoeducation (active control) with psychoeducation and memory strategy practice (intervention). Primary outcome was memory strategy use; secondary outcome was caregiver emotional reactivity (burden, depression, and anxiety). Results showed memory strategy use significantly increased following psychoeducation for both groups. However, psychoeducation combined with memory strategy practice resulted in a significant reduction in depression for caregivers reporting at least mild baseline symptoms. Greater use of memory strategies moderated the relationship between burden and depression following intervention. Psychoeducation programs that incorporate practical memory strategy training may offer more substantial outcomes.

A Systematic Review of Home-Setting Psychoeducation Interventions for Behavioral Changes in Dementia: Some Lessons for the COVID-19 Pandemic and Post-Pandemic Assistance

BACKGROUND

Impacts of social isolation measures imposed by COVID-19 Pandemic on mental health and quality of life of older adults living with dementia and their caregivers remain unexplored. Studies have shown that psychoeducational and psychosocial interventions can manage behavioral and psychological symptoms in dementia (BPSD) and reduce the emotional burden on family members when applied in home-setting scenarios.

METHOD

a comprehensive systematic review of useful interventions for easing the BPSD burden in patients with dementia (PwD) and their caregivers in the context of COVID-19 quarantine was performed from January 2010 to March 2020.

RESULTS

From a total of 187 articles retrieved from electronic databases (MEDLINE, LILACS, Cochrane and SCOPUS), 43 studies were eligible for this review. Most of the psychosocial and psychoeducational interventions described were person-centered strategies based on the cognitive-behavioral approach or informational tools to enhance care providers' knowledge of dementia. Most studies achieved successful results in handling BPSD and mood-anxiety symptoms of care providers, contributing to an overall improvement in dyad life quality.

CONCLUSION

Evidence from the last few years suggest that low-cost techniques, tailored to the dyad well-being, with increasing use of technology through friendly online platforms and application robots, can be an alternative to conventional assistance during COVID-19 Pandemic. Nevertheless, the world's current experience regarding the duration of the COVID-19 Pandemic and its effects on the cognition, behavior, and life quality of PwD will demand research on preventive and protective factors of dementia and the pursue of efficient interventions in different scenarios.

Exploring the usefulness of indicators for referring people with dementia and their informal caregivers to activating interventions: a qualitative analysis of needs assessments

Background

People with dementia (PWDs) and their informal caregivers frequently report difficulties in maintaining their usual activities. We had previously developed a set of indicators to estimate whether dyadic, activating interventions can meet these needs for activity. This study investigates how PWDs and informal caregivers talk about the indicators in interviews for needs assessments, and how professionals identify activity needs and preferences. Our research goal was to explore the usefulness of the indicators for assessing the activity needs of community-dwelling dyads. Such assessments are needed for appropriate referral to activating interventions.

Methods

A dementia case manager assessed the needs of community-dwelling PWDs and their informal caregivers; we carried out secondary analyses on the dataset resulting from the audio-tapes and transcripts. We applied qualitative, deductive content analysis because we wanted to identify both explicit and implicit needs and preferences. We used the indicators that we had developed in previous research as codes.

Results

Both PWDs and informal caregivers do explicitly mention needs, preferences, and characteristics related to the indicators in the needs assessments. Possible implicit needs and preferences were frequently identified in their stories.

Conclusions

Needs-driven care requires high-quality needs assessments. Both PWDs and their informal caregivers need encouragement to express their latent needs and preferences. In addition, latent needs and preferences have to be further explored in needs assessments to find out the real meaning. The outcomes of this study highlight the significance of structured needs assessments for mapping the activity needs of PWDs and their informal caregivers. Many PWDs and informal caregivers reported activity needs, which suggests that activating interventions may be appropriate. The indicators can help professionals identify activity needs so that they can discuss matching activating interventions with the dyad.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1221-0) contains supplementary material, which is available to authorized users.

Motivation to participate in high-intensity functional exercise compared with a social activity in older people with dementia in nursing homes

Background

Motivation to participate in exercise among people with dementia has not been well studied. The symptoms of dementia, including apathy, may lead to low motivation to participate in exercise. The aim of this study was to evaluate the motivation of older people with dementia to participate in a high-intensity exercise program compared with motivation of those participating in a social group activity.

Methods

The Umeå Dementia and Exercise Study (UMDEX) was a cluster-randomized controlled intervention trial including 186 people (mean age; 85, 75% female) with dementia in nursing homes. Participants were randomized to participate in the High-Intensity Functional Exercise (HIFE) Program (n = 93) or a seated social group activity (n = 93). The activities were conducted in groups of 3–8 participants for 45 minutes, five times per two-week period, for 4 months (40 sessions in total). Participants’ motivation to go to and during activity sessions were assessed by the activity leaders and nursing homes staff using a five-point Likert scale. Data were analyzed using cumulative link mixed models.

Results

Motivation was high or very high during 61.0% of attended sessions in the exercise group and 62.6% in the social activity group. No overall significant difference between groups was observed, but motivation increased over time in the exercise group and decreased in the social activity group (p < 0.05). Motivation during the sessions was significantly higher than motivation to go to the sessions, especially in the exercise group [OR 2.39 (95% CI 2.38–2.40) and 1.50 (95% CI 1.32–1.70), respectively].

Conclusions

Among older people with dementia in nursing homes, motivation to participate in a high-intensity functional exercise program seems to be high, comparable to motivation to participate in a social activity, and increase over time. Since motivation during activity sessions was higher than motivation to go to sessions the promotion of strategies to encourage people with dementia to join exercise groups is of great importance.

Indicators to estimate the appropriateness of activating interventions for people living with dementia and for their informal caregivers

OBJECTIVES

Dyadic activating interventions support both people with dementia and their informal caregivers to maintain activities. For a person-centered approach referrers need insight in how specific interventions might meet individual needs, characteristics, and preferences of a dyad. This study aimed to develop a set of indicators for three psychosocial dyadic, activating interventions.

METHOD

We used the 'RAND Appropriateness Method' directed at agreement on indicators within a panel of experts. Qualitative research had identified 31 relevant conceptual indicators. A panel of 12 experts in dementia care rated the extent to which these indicators are recognizable in their clinical practice. Indicators with median ratings in the top third segment of the nine-point-scale were considered recognizable.

RESULTS

18/31 conceptual indicators (58%) were found recognizable in 75%-90% of the panelists' clients. Although consensus on the recognizability of some indicators about the need or preference for physical and social activities was lacking, the respondents nevertheless recommended including these in regular assessments. Other indicators were judged too difficult to recognize in clinical practice.

CONCLUSION

The selected indicators offer guidance to referrers on what intervention(s) to choose, and discuss the appropriateness in a shared decision-making process, thus contributing to a person-centered approach.

Working mechanisms of dyadic, psychosocial, activating interventions for people with dementia and informal caregivers: a qualitative study

Background

People living with dementia (PWD) and their informal caregivers often report difficulties in maintaining their usual activities. Several dyadic, psychosocial, activating interventions were developed to create insight into how to cope with limitations in a practical way and to increase skills for maintaining personal activities. Effects of these interventions varied so far. More knowledge on the working mechanisms of activating interventions might help to increase their impact. This study will provide more insights into the working mechanisms of three dyadic, psychosocial, activating interventions as the participating PWD, caregivers, and coaches perceived them during the interventions.

Participants and methods

We used a qualitative design with semi-structured interviews of 34 dyads that included 27 PWD, 34 caregivers, and 19 coaches. The data were analyzed with the constant comparative method.

Results

Many PWD and caregivers found capacity-building approaches beneficial. We identified “empowerment” as the core theme. Three working mechanisms explained why the interventions were perceived as having a beneficial impact: 1) enabling activities without providing false hope; 2) exploring the most important personal activity needs of the PWD and caregivers; and 3) a solution-focused approach to adapt, test, and practice activities. An individualized approach contributed to positive change.

Conclusion

For the overarching working mechanism empowerment, expertise in the field of dementia and psychological skills of coaches seem to be important. Assessing the needs, capacities, and limitations of both the PWD and the caregivers to take part in activities seems to be key, as well as the communication about it and the skills to teach a solution-focused approach. Studies on the impact of psychosocial and activating interventions might benefit from considering outcome measures directed at empowerment, along with aspects such as hope and belief in one’s own capacities versus traditional outcome measures as mood, burden, or quality of life.