Management of the demented elderly patient in the community

Burden, depression and anxiety effects on family caregivers of patients with chronic kidney disease in Greece: a comparative study between dialysis modalities and kidney transplantation

INTRODUCTION

Burden of caregivers is a status that was identified as a consequence of daily care. Anxiety and depression are probably related to complex tasks interwined with the care of a family member suffering from chronic kidney disease (CKD).

PURPOSE

To examine the experienced burden, anxiety and depression of Greek caregivers of patients with End-Stage CKD on dialysis as well as kidney transplant recipients (TX) in relation to their demographic profile and to compare among the groups.

METHODS

A total of 396 participants (198 couples of patients and caregivers) were recruited. Structured interviews and self-completed questionnaires were obtained from patients undergoing dialysis modalities as well as TX (28 peritoneal dialysis patients, 137 hemodialysis patients, 33 TX) and their caregivers. Zarit Burden Interview, Beck Depression Inventory and the Generalized Anxiety Disorder-2 scales were used as screening tools.

RESULTS

The majority of caregivers were females (67.2%), with a median age of 58 years. Total burden was indicated as mild to moderate (Mdn = 36 (24-51)). Caregivers of haemodialysis (HD) patients showed the highest burden (Mdn = 40 (26-53)) followed by peritoneal dialysis(PD) (Mdn = 29 (25-51)) and TX group (Mdn = 28 (21-43)) (p = 0.022). Caregivers' depression and anxiety were related to the type of patients' treatment, as well. Caregivers of HD and PD patients reported significantly higher depression (Mdn = 11 (5-18)) and anxiety scores (Mdn = 3 (2-5)) in comparison to TX caregivers (Mdn = 6 (2-13) and Mdn = 2 (2-4)) (p = 0.045 and p = 0.04, respectively).

CONCLUSION

Caregivers of TX patients appeared to have less burden, depression and anxiety levels compared with caregivers of patients on dialysis modalities. Caregivers' burden is significantly associated with anxiety, depressive symptoms, gender, duration of caregiving, educational level, financial status and caregivers' age.

Duration of Care Trajectories in Persons With Dementia Differs According to Demographic and Clinical Characteristics

OBJECTIVES

To estimate (1) the duration of no formal care, home care, and institutional care after dementia diagnosis, and (2) the effect of age, sex, living situation, dementia medication, migration background, and income on this dementia care duration.

DESIGN

Longitudinal retrospective study using routinely recorded general practice electronic health records linked with population-based healthcare and mortality data.

SETTING AND PARTICIPANTS

In total, 11,012 community-dwelling persons who received an incident dementia diagnosis and were listed in a Dutch general practitioner database from 448 general practices in the Netherlands.

METHODS

Using multistate modeling analyses, we estimated the mean duration of care types (no/home/institutional care) for different ages based on simulations of transition rates and examined the influence of demographic and clinical factors on these durations.

RESULTS

From dementia diagnosis onward in 85-year-old men, the mean duration without formal care was 0.7 years, of home care 1.7, and institutional care 1.1 years. In 85-year-old women, the duration without formal care was 0.8 years, of home care 2.3, and institutional care 2.3 years. Total care duration was 3.5 years in 85-year-old men and 5.4 years in 85-year-old women. In men, the duration of home care was longer compared with no formal care and institutional care. The duration of no formal care was longer in persons not living alone, without prescribed dementia medication, with a non‒Western migration background, or with a higher income. The duration of home or institutional care was longer in women, persons without polypharmacy, in those living alone, or those with a Western background.

CONCLUSIONS AND IMPLICATIONS

Our findings help to increase understanding of long-term dementia care trajectories and show that demographic and clinical factors determine the duration of care types. Our results can contribute to the organization of healthcare resource planning and monitoring of the effects of healthcare policy and interventions.

Healthcare utilization and costs in primary care patients with dementia: baseline results of the DelpHi-trial

The objectives of this cross-sectional analysis were to determine healthcare resource utilization and cost for community-dwelling patients with dementia (PWD) from a payer's and societal perspective, and to analyze the associations between costs and sociodemographic and clinical variables. Analysis of healthcare costs from a payer's perspective was based on a sample of 425 PWD, analysis of healthcare costs from societal perspective on a subsample of 254 PWD and their informal caregivers. Frequency of healthcare resource utilization was assessed by means of questionnaires. Informal care and productivity losses were assessed by using the Resource Utilization in Dementia questionnaire (RUD). Costs were monetarized using standardized unit costs. To analyze the associations, multiple linear regression models were used. Total annual costs per PWD valued 7016€ from a payer's and 25,877€ from a societal perspective, meaning that societal cost is approximately three and a half times as much as payer's expenditures. Costs valuated 5456 € for medical treatments, 1559 € for formal care, 18,327€ for informal care. Productivity losses valued 1297€ for PWD caregivers. Informal care could vary substantially (-21%; +33%) concerning different valuation methods. Medical care costs decreased significantly with progression of dementia and with age. Costs of care double over the stages of dementia. Formal care costs were significantly higher for PWD living alone and informal care costs significantly lower for PWD with an employed caregiver. For all cost categories, deficits in daily living activities were major cost drivers.

Occupational Therapy in a Memory Clinic

Memory loss needs to be recognised as usually being the symptom of a disease, such as dementia, and not accepted merely as part of the normal ageing process. Memory clinics, developed to promote this concept, provide both an assessment resource for the increasing numbers of elderly people with memory problems and a focus for research into dementia. Although occupational therapists have not previously been included in such clinics' multidisciplinary assessment teams, experience at the Bath Memory Clinic identified this as a requirement. This article describes the main tasks of the occupational therapist and suggests that this is an essential role within a memory clinic setting.

Economic Analysis of Formal Care, Informal Care, and Productivity Losses in Primary Care Patients who Screened Positive for Dementia in Germany

BACKGROUND

The majority of people with dementia (PwD) live at home and require professional formal care and informal care that is generally provided by close relatives.

OBJECTIVE

To determine the utilization and costs of formal and informal care for PwD, indirect costs because of productivity losses of caregivers, and the associations between cost, socio-demographic and clinical variables.

METHODS

The analysis includes the data of 262 community-dwelling PwD and their caregivers. Socio-demographics, clinical variables, and the utilization of formal care were assessed within the baseline assessment. To evaluate informal care costs, the Resource Utilization in Dementia (RUD) questionnaire was used. Costs were calculated from a social perspective. Associations were evaluated using multiple linear and logistic regression models.

RESULTS

Formal care services were utilized less (26.3%) than informal care (85.1%), resulting in a cost ratio of one to ten(1,646 €; 16,473 €, respectively). In total, 29% of caregivers were employed, and every seventh (14.3%) experienced productivity losses, which corresponded to 1,258 € annually. Whereas increasing deficits in daily living activities were associated with higher formal and higher informal costs, living alone was significantly associated with higher formal care costs and the employment of a caregiver was associated with lower informal care costs.

CONCLUSION

Informal care contributes the most to total care costs. Living alone is a major cost driver for formal costs because of the lower availability of potential informal care. The availability of informal care is limited and productivity losses are increased when a caregiver is employed.

Variables influencing burden in spousal and adult child primary caregivers of persons with Alzheimer's disease in the home setting

The purpose of this study was twofold: to compare caregiver burden perceived by spouses and adult children providing care to a family member with Alzheimer's disease in the home, and to determine if functional ability of the Alzheimer's victim affects burden experienced by the caregiver.

Fifty-five primary caregivers providing care at home for a family member with Alzheimer's disease were invited to participate in this study and asked to complete the Caregiver Data Sheet, Burden Interview, Physical Self-Maintenance Scale (PSMS), and the Instrumental Activities of Daily Living Scale (IADL). Thirty caregivers (55 percent) responded.

The mean burden score for all participants was 67 (SD = 15), indicative of severe burden. A t-test performed to compare burden scores of spouse and adult child caregivers showed no significant difference between the two groups (t-value = 1.93, p> .05).

The mean scores for the PSMS (1.4; SD = 1.86) and IADL (1.4; SD = 1.59) indicated that the Alzheimer's victims were very dependent. This functional deficit, however, did not correlate significantly with caregiver burden. The Pearson Product Moment Correlation Coefficient (Pearson r) was -.339 for the PSMS and Burden Interview and -.203 for the IADL and Burden Interview. Neither were found significant at the .05 level of significance.

This study contributed to nursing knowledge by describing burden experienced by a specific population of primary caregivers; those spouses and adult children providing care for a family member with Alzheimer's disease in the home. A lack of a significant correlation between functional impairment of the Alzheimer's victim and caregiver burden was found. The researcher suggested that perhaps other factors, such as family and community support, had more of an impact on caregiver burden. Future nursing research to further delineate such factors would contribute to the understanding of caregiver burden.

Differences in caregivers of demented and lucid chronically ill family members

The relationship between social support, mood states, and burden was studied in 63 caregivers of chronically ill family members. These caregivers were categorized as providing care for either chronically ill demented or lucid family members. Contact was made with participating caregivers and their medical personnel so as to verify that reported illness did not overlap in both categories (e.g., AIDS with dementia). No differences were evident between caregivers of demented and lucid family members on age, gender, familial relationship, use of formal support, number of health problems or hours spent with the family member Caregivers of demented family members differ from caregivers of lucid chronically ill family members in the level of expressed emotional burden, and amount of revealed fatigue/inertia. However, differences between these caregivers were not evident on levels for time, social, developmental, or physical burden as measured by the Caregiver Burden Inventory (CRI); nor were differences evident on dimensions of tension-anxiety, depression-dejection, anger-hostility vigor activity, or confusion-bewilderment as measured by the Profile of Mood States (POMS).

Caring for Institutionalized Elders: Stress Among Nursing Assistants

The relationship between patient characteristics (dementia, other mental impairment, and a variety of difficult behaviors) and physical health among nursing assistants working in long-term care facilities is examined. Several sociodemographic characteristics of the worker, characteristics of the work environment, and social support were included as control variables. The number of residents cared for with Alzheimer's disease and with other mental impairment is empirically unrelated to any type of problem behavior. Both having more residents with gross mental impairment and having more residents exhibiting uncooperative behavior are related to several measures of physical health stress. Other problem behaviors related to specific indicators of physical health are identified. Few other factors emerge as significant predictors.

Psychogeriatrics in England: Its Route to Recognition by the Government as a Distinct Medical Specialty, c.1970-89

Demographic trends, and older people over 65 years disproportionately occupying beds in psychiatric hospitals, pointed to their increasing clinical needs. Clinical work with older people often required different skills from work with younger people. 'General psychiatrists', nominally working with adults of all ages, usually had little interest in working with older people. By 1977, it was clear to clinical leaders in the field of psychogeriatrics that official recognition of their specialty by the government was essential to ensure service development. Official recognition would provide the means to collect data to identify gaps in services, to obtain information on the implementation of government guidance and to advocate for resources, including ensuring high quality training posts for doctors wanting to specialise in the field. Doctors have traditionally taken the lead in creating new medical specialties, and psychogeriatrics was no exception. However, support fluctuated towards the specialty from the leadership of the Royal College of Psychiatrists. Health service leaders who did not undertake work with older people, were incredulous that others wished to do so. Negotiations between the Royal College of Psychiatrists and the Department of Health and Social Security about recognising psychogeriatrics were convoluted and prolonged. Recognition was achieved in 1989, following intervention by the Royal College of Physicians of London.

Psychiatrists, mental health provision and 'senile dementia' in England, 1940s-1979

Until around 1979, 'confused' or mentally unwell people over 65 years of age tended to be labelled as having 'senile dementia'. Senile dementia was usually regarded as a single, inevitably hopeless condition, despite gradually accumulating clinical and pathological evidence to the contrary. Specific psychiatric services for mental illness in older people began to emerge in the 1950s, but by 1969 there were fewer than 10 dedicated services nationally. During the 1970s, 'old age psychiatrists' established local services and campaigned nationally for them. By 1979, about 100 old age psychiatrists were leading multi-disciplinary teams in half the health districts in England. This paper explores the tortuous development of these new services, focusing on provision for people with dementia.

Age inclusive services or separate old age and working age services? A historical analysis from the formative years of old age psychiatry c.1940-1989

The Equality Act 2010 made it unlawful to discriminate in the provision of services on the grounds of age. This legislation is open to interpretation, but it is affecting the way older people's services are defined and provided. Historical evidence indicates that, since the 1940s, apart from psychiatrists working in dedicated old age services, most were unenthusiastic about working with mentally unwell older people and unsupportive of those who chose to do so. A historical analysis might shed light on current dilemmas about 'all age' or 'old age' services and inform decision-making on future mental health services.

Predictors of burnout in the family caregivers of Alzheimer's disease: evidence from Turkey

OBJECTIVE

The aim of this study was to investigate the factors related to burnout in the family caregivers of Alzheimer's disease.

METHODS

Subjects included in the study were 44 Alzheimer's disease patients and their primary caregivers. Patients were evaluated with Mini Mental State Examination, Brief Psychiatric Rating Scale, Physical Self-Maintenance Scale and Geriatric Depression Scale, and carers were administered Maslach Burnout Inventory, Ways of Coping Scale, Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale.

RESULTS

The emotional exhaustion of caregivers revealed a significant relationship with the caregivers' anxiety, submissive approach for coping and the patient's self-maintenance. Depersonalisation was found to be related to the depression score of the patient.

DISCUSSION

This study may serve to increase clinicians' awareness of burnout in relatives of dementia patients. It points to the fact that research for determining the causes and consequences of burnout in the family caregivers is warranted.

Mild Dementia: Perceptions and Problems

The focus of this paper is on the beginnings of dementia – on the grey area where normal and abnormal ageing seem to overlap, but where a diagnosis can be established. We look at a group of elderly people diagnosed as suffering from mild dementia and at the relatives most closely involved with them and whom we had assumed to be their carers. Our principal interest is in the relatives' perception of the deterioration in intellectual function, and in their awareness of and response to problems associated with it. Contrary to expectation, these relatives did not see themselves as carers, or the elderly person as demented. Spouses often saw their partner as no more disabled than themselves; and, more generally, the relationship between them often showed a high degree of reciprocity. Sons and daughters were usually aware of changes in their parents' behaviour but tended to explain them in terms of normal ageing. Improvement in the process of early identification and the creation of more appropriate services are generally seen as desirable. Questions are raised about the usefulness and justification for intervention in a situation which is not yet recognised by those involved as requiring it.

Continuing care of Old People—A Medical Viewpoint

Provision for old people who are in need of continuing care requires close co-operation between informal carers and different agencies and disciplines providing health and social care. In the United Kingdom, the present system of care has evolved from earlier patterns of care centred on the asylums and the poor law with its workhouse institutions. It lacks cohesion. Despite the designation of old people as a priority group, resources are still inadequate to provide a good quality of care. Organisational differences between health and social services can lead to inefficient use of existing resources. More specialised medical, psychiatric and social services for old people enhance the possibilities for co-operation even though they may appear to lead to greater fragmentation. The history of the development of these services in the UK, including the recent expansion of private sector care, is reviewed, with special attention from the medical perspective to the phenomenon of ‘bed blocking’. The recently published Griffiths Report on community care is briefly considered, and some principles for future developments are laid down.

Patient Turnover in a new Psychogeriatric Day Hospital: a Pluralistic Evaluation

Studies designed to evaluate the services of a health or welfare institution face the major difficulty of selecting evaluative criteria to serve as measures of successful performance. This paper explores that difficulty in the context of a study of a new psychogeriatric day hospital. The study and its methods of data collection are described. ‘Patient turnover’ features prominently as a measure of success within the hospital. Consultants, nurses, general practitioners, social workers, staff of a related hospital and patients’ relatives interpret this measure in different ways and adopt different strategies to pursue ‘success’ in their own interests. These differences are described. The paper concludes that a ‘pluralistic evaluation’ has several advantages as compared to other approaches.

The provision of mental health services in England for people over 65 years of age, 1970-78

The twentieth century saw an increasing number of people living into old age, and consequently a higher prevalence of age-related chronic degenerative brain disorders. By 1971 the mental hospitals were almost half full with people over 65 years of age. Thus plans to close the mental hospitals meant that the development of community mental health services for older people was a necessity. Although there was a multi-disciplinary focus on the care of older people, the lead in service development was largely taken by psychiatrists, both individually and through the Group for the Psychiatry of Old Age at the Royal College of Psychiatrists.

Time spent on informal and formal care giving for persons with dementia in Sweden

The purpose of this paper was to explore the time spent on caring by families of persons with dementia in Sweden. As part of a European Commission project, interviews were carried out on a sample of 92 carers, caring for persons with dementia. The interviews focused on time spent on caring, IADL, ADL and surveillance, as well as formal support received and used. Informal care, measured as hours spent caring, was about 8.5 times greater than formal services (299 and 35 h per month, respectively). Approximately 50% of the total informal care consisted of time spent on surveillance (day and night). Formal care input and informal support, in terms of ADL increased with dementia severity. A regression analysis showed that dementia severity, behavioural disturbances and coping were associated with the amount of informal care. This study gives some new perspectives on informal care giving for persons with dementia and support strategies in general. Some carers do carry a very heavy 24 h responsibility. This aspect of caring must be addressed by the development of well-targeted respite and relief support programmes.

Placements in psychiatric institutions, nursing homes, and homes for the elderly by Belgian general practitioners

This research is an epidemiological study of long-term care facility admissions to various types of institutions (homes for the elderly, nursing homes, psychiatric institutions) during 1994 in Belgium. Data were obtained from a network of 143 general practitioners, which acts as a reliable surveillance system for health-related data. For every patient who was institutionalized, physicians were asked to record the following information: (1) type of institution in which the patient was placed; (2) medical conditions; (3) current living situation; (4) reason for institutionalization; (5) length of the waiting time for institutionalization, and (6) whether or not the patient was hospitalized prior to the institutionalization. The overall incidence for institutionalization among older patients was 1%. The most common medical conditions upon placement were functional impairments and dementia. Over half the patients lived alone just prior to the placement and family members made the majority of requests for placements. Compared to placements in other types of institutions, those to psychiatric facilities were more likely to be 'urgent' and waiting times for admission to these institutions were shorter. Over half of all placements were preceded by an admission to a medical hospital. Few placements (16%) were made with the consultation of home care services. Finally, in about two thirds of the cases, patients were cared for by their general practitioner while they were institutionalized.

Care management, dementia care and specialist mental health services: an evaluation

OBJECTIVE

To evaluate a model of intensive case management for people with dementia based in a community-based mental health service for older people.

METHOD

Quasi-experimental design. Individuals in one community team setting received case management and were compared with those in a similar team without such a service. Forty-three matched pairs were identified. Eligible older people and their carers were interviewed at uptake and again at 6 and 12 months.

RESULTS

The impact of the scheme upon placement occurred in the second year at the end of which 51% of the experimental group remained at home compared with 33% of the comparison group. For the experimental group significant improvements in the social contacts of older people were noted; a decrease in the stress of their carers was observed, together with a reduction in their input to the care of the client; and there were significant improvements on ratings of overall need reduction, aspects of daily living and level of risk. Differences between the two groups based on service receipt showed higher costs for the experimental group.

DISCUSSION

The benefits to older people and their carers confirms previous findings that the most effective case management interventions are those targeted on a highly specific client group. Issues which influence the cost-effectiveness of intensive case management are discussed. The benefits of locating this service within a specialist mental health team are explored in the context of current initiatives to promote greater service integration between health and social services.

Revealing regional differences in the institutionalization of adult patients in homes for the elderly and nursing homes: results of the Belgian network of sentinel GPs

OBJECTIVES

The aim of this study was, firstly, to determine the number of institutionalizations in homes for the elderly and nursing homes and, secondly, to learn about regional differences in the placement procedure and the pre-existing problems and diseases.

METHODS

Data were recorded during 1994 by the 143 GPs of the network of sentinel practices, which is representative of Belgian GPs. All placements of adult patients in homes for the elderly and nursing homes were registered.

RESULTS

During 1994, Belgian sentinel GPs placed 297 patients in a nursing home or a home for the elderly. Most of them were women and patients who lived alone. At the time of institutionalization, motor function impairment and dementia were the most common diseases. The institutionalizations were motivated mostly by a need for assistance with daily living activities and nursing assistance. An interim hospitalization was necessary in 60% of all institutionalizations. Two-thirds of all patients were on a waiting list. The average length of these waiting lists was shorter in the southern (Walloon) region than in the northern (Flemish) region. Home care services were consulted in 16% of all institutionalizations. In the southern region, home care services were consulted more often than in the northern region.

CONCLUSIONS

Motor function impairment and dementia were the most common pre-existing impairments. Placements were often hampered by long waiting lists and interim hospitalization. In the southern region, waiting lists were shorter and home care services consulted more often. Some placements could be avoided or delayed by a better organization and promotion of the possibilities of professional home care services.

Helping the family carers of Alzheimer’s patients: from theory…to practice. A preliminary study

Alzheimer's disease (AD) represents one of the most important health issues in the western world. The ongoing care that the AD patient requires typically causes high stress levels, fatigue, irritation and depression in the caregiver, as well as socio-economical problems. The current study aimed to introduce a support program for carers of AD patients, in order to improve their quality of life. A Questionnaire for Carers and an Anxiety State Feature Questionnaire (STAI) was used to assess the carers. Results showed an overall improvement in the carers' health. Their subjective wellbeing increased, and though their situation had not changed, they nevertheless described feeling less trapped. It can be concluded that possibly the mere fact that the carers feel that they have help available is enough to endorse the value of the program.

Effects of caregiver communication on the outcomes of requests in spouses with dementia of the Alzheimer type

Three clinical and three matched nonclinical couples were studied for the effectiveness of their discourse in eliciting outcomes to requests made. Caregivers in the clinical couples were less likely to achieve successful outcomes than dominant communicators in the nonclinical couples. In studying the context for the requests, differences could not be attributed to the degree of concreteness of reference that was used by caregivers of spouses with Dementia of the Alzheimer type. More abstract and less abstract references were equally likely to be responded to by two of the three clinical couples. Differences in the styles of communication by the caregivers contributed to outcomes and reflected a self-reported degree of strain or comfort in the couples' relationships. Suggested is a method of study of outcomes that could be used in clinical assessment and intervention for nonresponsiveness and noncompliance with dementia patients.

Level of burden: women with more than one co-occurring disorder

Utilizing an expanded concept of level of burden, the impact of multiple problems experienced by women in a residential drug abuse treatment program on treatment retention and outcomes is investigated. Level of burden is defined in this study as the number and severity of problems, including psychological problems, cognitive impairment, chronic health problems, HIV/AIDS status, as well as substance abuse. In the first study of 260 women, the ability to retain women in treatment as a function of their level of burden is examined using the technique of survival analysis. Results indicate that early in the course of treatment, high-burden clients tend to be the highest risks for early termination. In addition, there is a significant interaction between time in the program and level of burden. In the second study of 68 women, partial correlations between level of burden and ratings of outcomes by program staff at time of discharge are examined. Results show that many of the treatment outcomes are significantly negatively correlated with the initial levels of burden. Implications for treatment providers and directives for future studies are discussed.

Cognitive impairment, caregiver burden, and the utilization of home health services

This study addresses the relationship between caregiver burden and the use of home health services among older adults with cognitive impairment. Analyses draw on data from personal interviews conducted with 327 older adults with cognitive impairment and living in the community of their primary caregivers. Using the Andersen-Newman framework, the results of ordinary least squares and logistic regression analyses reveal that caregiver burden and formal home health service use are only weakly related. Possible explanations for the findings are discussed.

Spouses of individuals with laryngeal cancer: caregiver strain and burden

A major proportion of care for patients with laryngectomies is provided by their spouses. This study assessed caregiver strain and burden using two standardized measures. Questionnaires were completed by 75 spouses of individuals with laryngectomies. The correlates of perceived strain and burden, time since the diagnosis of cancer, the caregivers gender, the caregivers present health status, and the effects of current stressors were considerations in the analyses. The strain and burden of caregiving decreased as time from the diagnosis of cancer increased. Male caregivers reported less strain and burden than female caregivers. Subjects reported strain and burden independent of other current stressors in their lives. Implications for counseling and support groups for caregivers are discussed.

Caring for demented elderly in rural primary health care

In 1988, the demented in an elderly rural population (n = 851) were traced and assessed with the GBS geriatric rating scale. The aim of the study was to investigate the level of impairments of demented persons primary cared for and to relate their impairments to form of housing; to compare the distribution of care between not-demented and demented in an elderly population, and to establish the primary caregiver/patient ratio. The majority of the demented (44/50) were cared for in the studied primary health care area, despite the scarcity of staff. All received formal care. They consumed more formal care than the not-demented in the population. In relation to amount of elderly persons helped, the home-help personnel ratio was 0.30, in district care the ratio was 0.02, whereas the ratio of general practitioners was 0.002, estimated from the number of contacts and staff.

Quality of life and Economic Aspects of Community Support Programs for Caregivers of Dementia Patients

This economic analysis of community programs for caregivers of dementia patients first reviews the clinical data on caregiver stress and the effectiveness of a variety of intervention programs. The authors then discuss issues relevant to the measurement of the true costs of specific community support programs and their impact on the quality of life of caregivers. Using cost data derived from other published studies, the authors conducted a cost-utility analysis using incremental costs per quality-adjusted life-year (QALY) gained. A sensitivity analysis of cost: utility ratios reveals a range from $3,333 (1988 US. dollars) to $28,571 per QALY gained. Although this is comparable to other health care programs, community support programs for caregivers of dementia patients present special challenges for evaluation of outcome.

Dementia day care and its effects on symptoms and institutionalization--a controlled Swedish study

OBJECTIVE

To examine the effects of Day Care (DC) on demented patients.

DESIGN

A prospective non-randomized concurrent-control study.

PARTICIPANTS

55 demented patients in DC and 44 controls.

SETTING

Sundsvall, an industrial community in northern Sweden.

MAIN OUTCOME MEASURE

Cognition, ADL-functions, behaviour and institutionalization.

RESULTS

Measurements of cognition, ADL-functions, and behaviour showed no or only small differences between the groups. After one year, 24% of the patients in the DC-group were institutionalized, compared with 44% of the controls. In the control group, the exhaustion of spouse and supervision need were highly correlated to institutionalization (p < 0.001), while high physical nursing load was correlated to institutionalization in the DC-group (p < 0.01).

CONCLUSION

DC postpones institutionalization, probably because of less exhaustion of spouses and decreased supervision need.

Predictive validity of factors influencing the institutionalization of elderly people with psycho-geriatric disorders

The predictive validity of certain items was tested with respect to their influence on the institutionalization of elderly people with psycho-geriatric disorders (n = 69). Twelve items measuring both the patient's condition and the exhaustion around the patient were tested. Two outcome measurements were used, the first measuring the number of patients who were institutionalized after the end of 12 months and the second measuring the number of days at an institution during 12 months. The items "Exhaustion of spouse" and "Supervision need" showed the highest correlation with institutionalization and predicted institutionalization, better than items describing the degree of dementia.

Abilities and activities of patients with dementia in day hospitals

The proportion of individuals with dementia is increasing in all kinds of institutions. Specialised day hospitals are now being developed as an alternative to long term care for the demented. Twelve day hospital wards, with 312 individuals suffering from dementia, were included in a study aiming to assess functional abilities and frequencies of participation in different activities. Eighty-nine per cent of the day hospital patients could be classified as having a dementia disease. Seventy-eight per cent of the population were dependent on some kind of help from a caregiver in the performance of ADL activities. The most common occupations that could be seen in the programmes were physical activities, entertainment, and personal care activities. The activities were often undertaken as large group activities, often including more than ten patients. The functional abilities that characterise the population are comparable with those of the population living in pensioners' service blocks with full board.

Regionalization of psychiatric services for the elderly

This overview addresses issues related to psychiatric services for the elderly in Canada. The author reviews the developments in the United Kingdom that have led to the establishment of guiding principles which may be applied to the Canadian health care system. These include the clear definition of a target population, a comprehensive approach to services, availability and accessibility, and clear accountability. A model for the establishment of regionalized psychiatric services is proposed, including the integration of hospital-based and community-based services with clearly defined areas of responsibility. In light of the changing demographics in Canada and the prevalence of psychiatric illness in the elderly, this is a matter of growing urgency for the health care system.

The emotional impact of caring for the chronically ill

Thirty-two family caregivers of persons with Alzheimer's disease and 30 caregivers of persons with cancer were compared cross-sectionally to determine whether the type of illness cared for affected the emotional state of the caregiver and to identify correlates of both undesirable and desirable emotional outcomes. No prominent differences in negative or positive emotional states were found between the two groups. Correlates of negative and positive emotional status were identified. They include caregiver personality variables, the feeling that one is supported by one's religious faith, and the number of social supports.

The effectiveness of services and treatment in psychogeriatrics

The future development of new psychogeriatric services in Australia may well depend upon the demonstration of their potential effectiveness and efficiency. Descriptive accounts of effective services provide ample guidelines, although formal evaluation is lacking. Examining the major psychiatric disorders of the elderly shows that most are functional. Effective acute psychiatric treatment is available for these. In dementia cases, effective therapies exist for the reduction of secondary behavioural disabilities in the sufferer and the stress on carers. Adequately resourced comprehensive psychogeriatric services would be best equipped to deliver such treatments.

The TAPS project. I: Previous psychiatric diagnosis and current disability of long-stay psychogeriatric patients. A pilot study

Of all 89 long-stay residents in four psychogeriatric wards at a large London psychiatric hospital, 18 had a previous functional psychiatric diagnosis. Although the total group was markedly impaired overall, male sex, younger age, and a previous functional diagnosis were independently associated with better cognitive performance. Males and those with previous functional disorders also had less behavioural disability. These subgroups within the psychogeriatric in-patient population must be recognised if an in-built distortion in community reprovision of hospital psychogeriatric services is to be avoided.

The social psychiatry of later life

Throughout the two million years of human existence, it is without precedent that the elderly should now constitute such a large proportion of the world's population. Although it is already trite to emphasise this remarkable change in the global population structure, the increase is nothing less than an awesome imperative for public health as a socially responsible science. By the year 2025 AD, the United Kingdom will have 14 million persons aged over 60, which would be 26% of the population. Just under two million of them will be over 80 years old (United Nations, 1985). In Australia and New Zealand, 24.8% of the population will be aged 60 years or more. About one million Australians will be 80 years or over. West Germany will have 2.4 million aged over 80, the USA 7.7 million. The People's Republic of China will have 19.3% of its 1.5 billion people who will be aged over 60, and over 25 million will be over 80 years.

Psychotropic drug use among caregivers of patients with dementia

The majority of research on "caregiver burden" focuses on mental health consequences. These stresses are associated with psychotropic drug use among some caregivers. The purposes of this paper are to identify the correlates of psychotropic drug use among caregivers of demented older adults and to determine whether or not certain types of psychotropics (ie, antianxiety, antidepressant, and sedative/hypnotic agents) have common or unique correlates. The prevalence of psychotropic drug use among caregivers in the sample (n = 510) is substantially higher than previously reported prevalence rates in the general population and among community-dwelling elderly. Using logistic regression techniques, caregiver characteristics (eg, gender, health, relationship to the patient) rather than severity of the patient's condition emerge as predictors of antianxiety, antidepressant, and sedative/hypnotic use. The caregiver's perception of how well he or she is supported in the caregiving role emerges as an important correlate of psychotropic drug use in general and especially of antidepressant consumption. Results suggest that caregivers are a high-risk group for the development of emotional symptoms such as nervousness, exhaustion, decreased appetite, and difficulty sleeping, symptoms that may or may not constitute a psychiatric disorder. Characteristics of the caregiver, especially aspects of the support system, should be important considerations in decisions to prescribe psychotropic drugs.

Day care for demented patients in general nursing homes. Effects on admissions to institutions and mental capacity

A day centre programme for demented patients aged 75 years and over was evaluated in a controlled trial, emphasizing its effect on the use of institutional care and mental capacity. A cost-benefit analysis of the programme was also performed. Thirty-eight patients were offered day care, thirty-nine served as controls. The programme was cost-effective in the sense that it reduced the frequency of the admissions to the acute units of the City hospitals and the cost of care. However, admission to permanent stay in nursing home was not delayed. The mental capacity deteriorated at the same rate in the two groups.

Adult day care: how families of the dementia patient respond

1. The experience of caring for a family member with dementia in the home is a physical, emotional, and financial strain for the majority of caregivers. 2. The availability of community as well as family supports are variables which will influence how well a caregiver will cope. 3. Though the use of adult day care did not significantly decrease the reported stress for caregivers as a group, some did experience less strain. 4. Caregiver response to adult day care is variable and complex. Gerontological nurses who counsel caregivers should help them be realistic about their expectations for adult day care.

Factors affecting the emotional wellbeing of the caregivers of dementia sufferers

Recent research on the factors that mediate the emotional wellbeing of the caregivers of dementia sufferers is reviewed. The roles of such factors as the caregiver's attributional style and coping strategies, the caregiver's relationship with the dementia sufferer, and levels of formal and informal support are discussed with reference to identifying those caregivers who are particularly vulnerable to emotional disorder or strain.

Expressed emotion and perceived family interaction in the key relatives of elderly patients with dementia

Four groups of families were investigated using an interview designed to assess expressed emotion (EE) in relatives of psychiatric patients and a family interaction questionnaire (FIQ) based upon the Leary and Benjamin schemes for coding interpersonal behaviour. The families included 25 containing a psychiatric patient aged between 18 and 46, and three groups of 12 families each, all containing a patient over 60 (patients with dementia, a functional psychiatric disorder, or a chronic physical disorder respectively). In all cases data were obtained from key relatives. The FIQ clearly separated out the group of dementia relatives who reported the most dominant and protective behaviours and the highest levels of hostile-dominance and the lowest levels of affection. EE was not found to be so sensitive to interactions occurring in families with a member with dementia, and the possible reasons for this are discussed.

Reality orientation and reminiscence therapy. A controlled cross-over study of elderly confused people

We compared reality orientation with reminiscence therapy for elderly people in a large residential home, using a controlled cross-over design. Both kinds of therapy group were enjoyed by both staff and residents, and enabled staff to get to know moderately and severely confused residents. The group that received reality orientation followed by reminiscence therapy showed improvement in cognitive and behavioural measures which was not found in the other two groups. It may be important to use reality orientation techniques with confused residents before involving them in a reminiscence group.

The mental health of elderly couples. II. Concordance for psychiatric morbidity in spouses

A community sample of elderly married couples completed the 60-item General Health Questionnaire and the Leeds General Scales for the Self-Assessment of Depression and Anxiety. Significant concordance was demonstrated between the spouses' scores on these scales. Concordance was higher for depression than for anxiety. There was little to support previous findings that wives are more likely than husbands to be concordant with an ill spouse. The spouse concordance rates for psychiatric morbidity were similar to those found in studies of younger married couples.

Pharmacologic treatment of agitation associated with dementia

Pharmacotherapy of aggressive or agitated behaviors in the dementia patient has not been studied extensively, despite the prevalence of this problem. Neuroleptics have the most support for efficacy, with shorter acting benzodiazepines demonstrating benefit on occasion. However, studies done to date indicate that these drugs are effective only for a minority of patients and that side effects frequently make patients worse. Other medications, such as propranolol, carbamazepine, or lithium, may be helpful, but their efficacy in dementia patients has not been demonstrated in placebo-controlled studies. Until such studies are done, their use is most appropriate in special patient groups or in patients who have failed neuroleptic or benzodiazepine treatment. More studies are needed in elderly patients evaluating effectiveness of pharmacologic agents in specific types of dementia, particularly Alzheimer's disease. Most studies done to date have been of relatively short duration, usually two months or less. Because these medications often are given to dementia patients for prolonged periods, studies are needed to define the long-term clinical efficacy of these agents. In the clinical setting, these agents should be reduced periodically or discontinued to determine ongoing need. In addition, environmental, social, or behavioral methods of reducing agitated behaviors need to be explored as an adjunct to any medication trial.