Non-pharmacological interventions for adults with mild cognitive impairment and early stage dementia: An updated scoping review

The purpose of this scoping review was to examine the science related to non-pharmacological interventions designed to slow decline for older adults with Mild Cognitive Impairment or early-stage dementia. We reviewed 32 unique randomized controlled trials that employed cognitive training (remediation or compensation approaches), physical exercise, or psychotherapeutic interventions that were published before November 2014. Evidence suggests that cognitive training focused on remediation and physical exercise interventions may promote small improvements in selected cognitive abilities. Cognitive training focused on compensation interventions and selected psychotherapeutic interventions may influence how cognitive changes impact daily living. However, confidence in these findings is limited due to methodological limitations. To better assess the value of non-pharmacological interventions for this population, we recommend: (1) adoption of universal criteria for "early stage cognitive decline" among studies, (2) adherence to guidelines for the conceptualization, operationalization, and implementation of complex interventions, (3) consistent characterization of the impact of interventions on daily life, and (4) long-term follow-up of clinical outcomes to assess maintenance and meaningfulness of reported effects over time.

Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis

OBJECTIVES

To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults.

DESIGN

A systematic review and metaanalysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun before discharge on healthcare cost and resource use outcomes. MEDLINE, EMBASE, and the Cochrane Library databases were searched for all English-language articles published between 1990 and April 2016.

SETTING

Hospital or skilled nursing facility.

PARTICIPANTS

Older adults with informal caregivers discharged to a community setting.

MEASUREMENTS

Readmission rates, length of and time to post-discharge rehospitalizations, costs of postdischarge care.

RESULTS

Of 10,715 abstracts identified, 15 studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control participants. Discharge planning interventions with caregiver integration were associated with a 25% fewer readmissions at 90 days (relative risk (RR) = 0.75, 95% confidence interval (CI) = 0.62-0.91) and 24% fewer readmissions at 180 days (RR = 0.76, 95% CI = 0.64-0.90). The majority of studies reported statistically significant shorter time to readmission, shorter rehospitalization, and lower costs of postdischarge care among discharge planning interventions with caregiver integration.

CONCLUSION

For older adults discharged to a community setting, the integration of caregivers into the discharge planning process reduces the risk of hospital readmission.

Role of social support in predicting caregiver burden

OBJECTIVE

To examine the unique contribution of social support to burden in caregivers of adults aging with spinal cord injury (SCI).

DESIGN

Secondary analyses of cross-sectional data from a large cohort of adults aging with SCI and their primary caregivers.

SETTING

Multiple community locations.

PARTICIPANTS

Caregivers of community-dwelling adults aging with SCI (n=173) were interviewed as part of a multisite randomized controlled trial. The mean age ± SD of caregivers was 53±15 years and of care-recipients, 55±13 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome was caregiver burden measured with the Abridged Version of the Zarit Burden Interview. A hierarchical multiple regression analysis examined the effects of social supports (social integration, received social support, and negative social interactions) on burden in caregivers of adults aging with SCI while controlling for demographic characteristics and caregiving characteristics.

RESULTS

After controlling for demographic characteristics and caregiving characteristics, social integration (β=-.16, P<.05), received social support (β=-.15, P<.05), and negative social interactions (β=.21, P<.01) were significant independent predictors of caregiver burden.

CONCLUSIONS

Findings demonstrate that social support is an important factor associated with burden in caregivers of adults aging with SCI. Social support should be considered for assessments and interventions designed to identify and reduce caregiver burden.

Can performance on daily activities discriminate between older adults with normal cognitive function and those with mild cognitive impairment?

OBJECTIVES

To examine whether preclinical disability in performance of cognitively focused instrumental activity of daily living (C-IADL) tasks can discriminate between older adults with normal cognitive function and those with mild cognitive impairment (MCI) and, secondarily, to determine the two tasks with the strongest psychometric properties and assess their discriminative ability so as to generate diagnosis-relevant information about cognitive changes associated with MCI and mild neurocognitive disorder according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria.

DESIGN

Secondary analyses of cross-sectional data from a cohort of individuals diagnosed with normal cognitive function or MCI.

SETTING

Pittsburgh, Pennsylvania.

PARTICIPANTS

Older adults with remitted major depression (N = 157).

MEASUREMENTS

Diagnosis of cognitive status was made at the Alzheimer's Disease Research Center, University of Pittsburgh. Performance on eight C-IADLs was measured using the criterion-referenced, observation-based Performance Assessment of Self-Care Skills (PASS).

RESULTS

Ninety-six older adults with normal cognitive function (mean age 72.5 ± 5.9) and 61 with MCI (mean age 75.5 ± 6.3) participated. The eight C-IADLs demonstrated 81% accuracy in discriminating cognitive status (area under the receiver operating characteristic curve (AUC) = 0.81, P < .001). Two tasks (shopping and checkbook balancing) were the most discriminating (AUC = 0.80, P < .001); they demonstrated similar ability as all eight C-IADLs in determining cognitive status. Assessing performance on these two C-IADLs takes 10 to 15 minutes.

CONCLUSION

This is the first demonstration of the discriminative ability of preclinical disability to distinguish older adults with MCI from cognitively normal older adults. These findings highlight potential tasks that, when measured using the observation-based PASS, demonstrate greater effort for individuals with MCI. These tasks may be considered when attempting to diagnose MCI or mild neurocognitive disorder in clinical practice and research.

Changing Structures and Processes to Support Family Caregivers of Seriously Ill Patients

BACKGROUND

Although family caregivers provide a significant portion of health and support services to adults with serious illness, they are often marginalized by existing healthcare systems and procedures.

OBJECTIVE

We examine the role of caregivers in existing systems of care, identify needed changes in structures and processes, and describe how these changes might be monitored and assessed and who should be accountable for implementing them.

DESIGN

Based on a broad assessment of the caregiving literature, the recent National Academy of Sciences Report on family caregiving, and descriptive data from two national surveys, we describe structural and process barriers that limit caregivers' ability to provide effective care.

SUBJECTS

To describe the unique challenges and impacts of caring for seriously ill patients, we report data from a nationally representative sample of older adults and their caregivers (National Health and Aging Trends Study [NHATS]; National Study of Caregiving [NSOC]) to identify the prevalence and impact on family caregivers of seriously ill patients who have high needs for support and are high cost to the healthcare system.

MEASUREMENTS

Standardized measures of patient status and caregiver roles and impacts are used.

RESULTS

Multiple structural and process barriers limit the ability of caregivers to provide effective care. These issues are exacerbated for the more than 13 million caregivers who provide care and support to 9 million seriously ill older adults.

CONCLUSIONS

Fundamental changes are needed in the way we identify, assess, and support caregivers. Educational and workforce development reforms are needed to enhance the competencies of healthcare and long-term service providers to effectively engage caregivers.

Adverse Consequences of Unmet Needs for Care in High-Need/High-Cost Older Adults

OBJECTIVES

We explore adverse consequences of unmet needs for care among high-need/high-cost (HNHC) older adults.

METHOD

Interviews with 4,024 community-dwelling older adults with ADL/IADL/mobility disabilities from the 2011 National Health and Aging Trends Study (NHATS). Reports of socio-demographics, disability compensatory strategies, and adverse consequences of unmet needs in the past month were obtained from older adults with multiple chronic conditions (MCC), probable dementia (DEM), and/or near end-of-life (EOL) and compared older adults not meeting these criteria.

RESULTS

Older adults with MCC (31.6%), DEM (39.6%), and EOL (48.7%) reported significantly more adverse consequences than low-need older adults (21.4%). Persons with MCC and DEM (53.4%), MCC, and EOL (53.2%), and all three (MCC, DEM, EOL, 65.6%) reported the highest levels of adverse consequences. HNHC participants reported more environmental modifications, assistive device, and larger helper networks. HNHC status independently predicted greater adverse consequences after controlling for disability compensatory strategies in multivariate models.

DISCUSSION

Adverse consequences of unmet needs for care are prevalent among HNHC older adults, especially those with multiple indicators, despite more disability-related compensatory efforts and larger helper networks. Helping caregivers provide better informal care has potential to contain healthcare costs by reducing hospitalization and unplanned readmissions.

Effects of music participation for mild cognitive impairment and dementia: A systematic review and meta-analysis

OBJECTIVES

To examine randomized controlled trials with active music-making interventions, in which older adults with probable mild cognitive impairment (MCI) or dementia physically participate in music, and their effects on cognitive functioning, emotional well-being, and social engagement. Participating in music-making is engaging and has shown diverse benefits. Additionally, this review categorized the music activities of each intervention.

DESIGN

Systematic review and meta-analysis.

SETTING

Long-term care facilities, day centers, specialty outpatient units, and community.

METHODS

Published randomized controlled trials of active music-making interventions to support older adults with probable MCI or dementia were identified (to March 15, 2021) using searches on Medline (Ovid), APA PsycInfo (Ovid), CINAHL (Ebsco), and Embase (Elsevier). The outcomes were cognitive functioning, emotional well-being, and social engagement, including self- and clinician-reported measures such as the Mini-Mental State Examination, Positive and Negative Affect Schedule, and the Beck Depression Inventory. Studies were critically appraised and studies with similar methodology were meta-analyzed.

PARTICIPANTS

Older adults with probable MCI and mild or moderate dementia.

RESULTS

A total of 21 studies with 1472 participants were analyzed for potential effect sizes and intervention activities. Of the 21 studies, nine studies recruiting a total of 495 participants were used to produce a random-effects meta-analytic model for cognitive functioning. Music showed a small, positive effect on cognitive functioning; the combined standard mean difference for the experimental and control group was 0.30 (95% confidence interval [CI] 0.10, 0.51). There was low study heterogeneity, with an I² of 24% (p = 0.004). Individual studies for emotional well-being in terms of quality of life and mood showed positive effect sizes, d = 1.08 and d = 1.74, respectively. [Corrections added on July 8, 2021, after first online publication: The preceding sentences were revised from: "… control group was 0.31 (95% confidence interval [CI] 0.10,0.52). There was low study heterogeneity, with an I2 of 25% (p = 0.004)."] CONCLUSION: This review shows that music-making has a small but statistically significant effect on cognitive functioning for older adults with probable MCI or dementia. Future music interventions can benefit from rigorous intervention protocols that isolate specific activities.

Does social support impact depression in caregivers of adults ageing with spinal cord injuries?

OBJECTIVE

The objective of this study was to examine the role of social support in predicting depression in caregivers of adults aging with spinal cord injuries.

DESIGN

Cross-sectional secondary data analyses were conducted for this study.

SETTING

Participants were recruited from multiple community locations in Pittsburgh, PA and Miami, FL.

SUBJECTS

Community-dwelling caregivers of aging adults with spinal cord injuries (N = 173) were interviewed as part of a multisite randomized controlled trial.

MAIN MEASURES

The Center for Epidemiological Studies Depression Scale measured caregiver depression symptom levels. A hierarchical multiple regression analysis examined the effect of social support (social integration, received social support, and negative social interactions) on depressive symptom levels for the caregivers of adults aging with spinal cord injuries, controlling for demographic characteristics, and caregiving characteristics.

RESULTS

Caregivers were, on average, 53 years old (SD = 15) and care-recipients were 55 years old (SD = 13). Average Center for Epidemiological Studies Depression Scale scores indicated that 69 (40%) of caregivers had significant depressive symptoms (mean 8.69, SD = 5.5). Negative social interactions (β = 0.27, P< 0.01) and social integration ( β = -0.25, P< 0.01) were significant independent predictors of depressive symptom levels in caregivers of adults aging with spinal cord injuries.

CONCLUSIONS

Findings demonstrate that negative social interactions and social integration are associated with the burden in caregivers of adults aging with spinal cord injuries. Negative social interactions and social integration should be investigated in assessments and interventions intended to target caregiver depressive symptom levels.

Caregiver health literacy predicting healthcare communication and system navigation difficulty

INTRODUCTION

The role of caregiver health literacy in predicting difficulty communicating with health care professionals and navigating services and supports for older adults was examined and informed by the health literacy skills framework (Squiers, Peinade, Berkman, Boudewyns, & McCormack, 2012).

METHOD

Secondary analyses of cross-sectional data from the Pittsburgh Regional Caregivers Survey in 2017 were conducted. A total of 761 caregivers of older adults reported communicating with health care providers and accessing services and supports. Health care provider communication and navigation of services and supports (HCNS) was assessed through self-report questions on communication about needs of the care recipient and caregiver, and the ability to locate and arrange services and supports for the care recipient. Health literacy was assessed with self-report questions on confidence filling out forms, need for help with reading information, and comprehension with written information. A logistic regression was conducted to determine the relationship between health literacy and high HCNS difficulty while controlling for demographic and contextual caregiving characteristics.

RESULTS

A fifth of the caregivers demonstrated low health literacy (n = 150, 19.7%). For a caregiver with low health literacy, the odds of having high levels of difficulty with HCNS was 2.52 times larger than the odds for a caregiver with adequate health literacy while controlling for demographic and contextual caregiving factors (odds ratio = 2.52, 95% confidence interval [1.57, 4.06]; p < .001).

DISCUSSION

Findings demonstrate that poor caregiver health literacy is an important factor associated with HCNS difficulty. The health literacy of caregivers should be considered for assessments and interventions designed to identify and reduce the difficulty caregivers experience with HCNS. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Deconstructing Chronic Low Back Pain in the Older Adult--Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part V: Maladaptive Coping

OBJECTIVE

As part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on maladaptive coping--a significant contributor of psychological distress, increased pain, and heightened disability in older adults with CLBP.

METHODS

A modified Delphi technique was used to develop a maladaptive coping algorithm and table providing the rationale for the various components of the algorithm. A seven-member content expert panel and a nine-member primary care panel were involved in the iterative development of the materials. While the algorithm was developed keeping in mind resources available within the Veterans Health Administration (VHA) facilities, panelists were not exclusive to the VHA, and therefore, materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors' clinical practice.

RESULTS

We present a treatment algorithm and supporting table to be used by providers treating older adults who have CLBP and engage in maladaptive coping strategies. A case of an older adult with CLBP and maladaptive coping is provided to illustrate the approach to management.

CONCLUSIONS

To promote early engagement in skill-focused treatments, providers can routinely evaluate pain coping strategies in older adults with CLBP using a treatment algorithm.

Systematic review of dyadic and family-oriented interventions for late-life depression

OBJECTIVE

Supportive behaviors (both instrumental and emotional) from spouses and close family members can impact the trajectory of older adults' depressive symptoms. Interventions that target both the patient and support person may be more effective than interventions that target the patient only, in terms of alleviating mood symptoms in the identified patient. The purpose of this paper was to review the characteristics and findings of dyadic and family-oriented interventions for late-life mood disorders to determine if they are effective and beneficial.

METHODS

Following PRISMA guidelines, we conducted a systematic review of reports in the literature on dyadic or family-oriented interventions for late-life mood disorders. We searched PubMed, OVID PsycINFO, and EMBASE for peer-reviewed journal articles in English through October 2014.

RESULTS

We identified 13 articles, representing a total of 10 independent investigations. Identified studies focused on spouses and close family members as support persons. Effect sizes for dyadic interventions that treated major depressive disorder were, on average, moderately strong, while effect sizes for dyadic interventions that reduced depressive symptoms were generally small. We did not identify any dyadic studies that treated bipolar disorder.

CONCLUSIONS

This review showed that dyadic interventions are feasible and that these interventions can decrease symptomatology in individuals who have major depressive disorder. Research is needed to understand the relative efficacy of a dyadic approach over a single-target approach in treating depression. Copyright © 2016 John Wiley & Sons, Ltd.

Additive effect of age on disability for individuals with spinal cord injuries

OBJECTIVE

To examine the additive effect of age on disability for adults with spinal cord injury (SCI).

DESIGN

Prospective cohort study.

SETTING

SCI Model Systems.

PARTICIPANTS

Individuals with SCI (median age at injury, 32 y; range, 6-88 y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI.

RESULTS

When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant (P=.07). Age at the time of SCI was significantly associated with motor FIM (F1,238=22.49, P<.001). Two sensitivity analyses found significant interactions for both age × time (P=.03, P=.02) and age × time-square (P=.01, P=.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years.

CONCLUSIONS

These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia.

METHODS

A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm.

RESULTS

We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management.

CONCLUSIONS

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Trajectory of Disability in Older Adults With Newly Diagnosed Diabetes: Role of Elevated Depressive Symptoms

OBJECTIVE

We examined whether the trajectory of disability differed between older adults with and without elevated depressive symptoms before and after the onset of diabetes mellitus (DM) over 10 years (2004-2014) and explored difficulties in basic and instrumental activities of daily living between the two groups.

RESEARCH DESIGN AND METHODS

A generalized linear mixed-model analysis was conducted using five waves (8th-12th) of Health and Retirement Study (HRS) data. We included 419 older adults who self-reported new DM diagnosis within the previous 2 years and used the Center of Epidemiologic Studies Depression Scale to measure elevated depressive symptoms. Disability was measured by 10 items defined in the HRS data set.

RESULTS

The trajectory of disability differed between older adults with and without elevated depressive symptoms after newly diagnosed DM over time. Significant and clinically meaningful between-group differences were found in disability after the onset of DM (waves 10 and 11) but not before the onset of DM (waves 8 and 9). Among older adults with elevated depressive symptoms, disability at pre-DM waves (8 and 9) was significantly less than post-DM waves (10-12). Difficulties with shopping, walking, and dressing were mostly reported by older adults with elevated depressive symptoms.

CONCLUSIONS

Older adults with newly diagnosed DM and elevated depressive symptoms have a clinically meaningful and faster disablement trajectory than those without elevated depressive symptoms. Future interventions may take an indicated approach to disability prevention in older adults with newly diagnosed DM, especially in those with a change in depression severity.

Developing a Non-Pharmacological Intervention for Individuals With Mild Cognitive Impairment

The purpose of this study is to describe one potential intervention model that is designed to slow decline to disability for individuals at-risk for dementia due to Mild Cognitive Impairment. Strategy training is a treatment model that focuses on behavioral activation through addressing barriers to daily activities. Strategy training encourages development of goals and plans to address self-identified impaired processes, and it maintains or improves individuals' ability to perform desired activities. Progression to dementia may be slowed due to the link between engagement in daily activities and production of biological factors associated with neurocognitive health. We demonstrated that an older adult with mild cognitive impairment is able to develop goals, establish effective plans, and engage in daily activities through the strategy training intervention model.

Evidence for the Effectiveness of Interventions for Caregivers of People With Chronic Conditions: A Systematic Review

IMPORTANCE

Caregivers are pivotal in supporting the growing population of people with chronic conditions. Yet, engaging in the caregiver role involves the risk of poor outcomes. Caregiver interventions are needed that address poor outcomes while fostering engagement in role-related activities.

OBJECTIVE

To evaluate the evidence for interventions to support caregivers of adults with chronic conditions.

DATA SOURCES

Five databases were searched for studies of interventions for caregivers and patient-caregiver dyads published between 1995 and 2019. Study Selection and Data Collection: We reviewed the titles, abstracts, and full-text articles of the initial search results (N = 12,216 studies) according to a predetermined protocol.

FINDINGS

Forty-eight studies met the inclusion criteria. Psychoeducation and education with skills training were the two caregiver intervention themes. Studies evaluating psychoeducation (n = 28) provided low strength of evidence for improved psychosocial outcomes. Within this theme, problem-solving and coping skills training were common intervention components associated with significant improvements in depression and quality of life. Studies evaluating education with skills training (n = 20) provided moderate strength of evidence for improved knowledge and low strength of evidence for improved psychosocial outcomes. Dyadic self-management education and hands-on training were common components associated with significant improvements in knowledge, quality of life, and burden or strain.

CONCLUSIONS AND RELEVANCE

We found low strength of evidence to support the use of psychoeducation and education with skills training. Within these approaches, problem-solving and coping skills training, dyadic self-management education, and hands-on training show promise for improving caregiver outcomes. What This Article Adds: Findings of this systematic review are inconclusive with respect to psychoeducation and education with skills training leading to improved caregiver well-being. Within these broad approaches, the findings support the use of problem-solving and coping skills training, dyadic self-management education, and hands-on training to improve knowledge and well-being among caregivers of people with chronic conditions.

Relationship Consensus and Caregiver Burden in Adults with Cognitive Impairments 6 Months Following Stroke

BACKGROUND

Caregiver burden is commonly experienced in caregivers of adults with cognitive impairment after stroke. This burden can be associated with caregiver-centered factors, including caregiver-perceived relationship quality.

OBJECTIVE

To examine the role of caregiver-perceived relationship quality on caregiver burden at 6 months following stroke.

DESIGN

Prospective observational study.

SETTING

Community settings.

PARTICIPANTS

Adults enrolled in two randomized controlled trials after stroke (n = 60) and their caregivers (n = 60).

METHODS

Three constructs of relationship quality (relationship consensus, cohesion, and satisfaction) were examined as predictors of caregiver burden (the Abbreviated Dyadic Adjustment Scale). A hierarchical logistic regression and a Poisson regression with robust standard errors were used to examine the effect of relationship quality on caregiver burden while controlling for characteristics of stroke survivors and caregivers.

MAIN OUTCOME MEASUREMENTS

Caregiver burden was measured with the abridged version of the Zarit Burden Interview.

RESULTS

Poor relationship consensus (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.06-2.07; P = .02) increased the odds of high caregiver burden after controlling for characteristics of stroke survivors (age, comorbidity, cognitive fluency) and caregivers (gender, self-reported health). Relationship cohesion (OR  = 1.03; 95% CI = .84-1.25; P = .81) and relationship satisfaction (OR  = 1.53; 95% CI = .75-3.10; P = .24) did not predict caregiver burden.

CONCLUSION

Meaningful and agreeable goals and expectations between dyads are essential to reduce caregiver burden after stroke. Collaborative goal-setting between stroke survivors and their caregivers may be a promising intervention strategy to increase relationship consensus and reduce caregiver burden.

LEVEL OF EVIDENCE

III.

Subjective Sleep Quality and Trajectories of Interleukin-6 in Older Adults

BACKGROUND

We aimed to identify trajectories of inflammation in older adults at elevated risk for syndromal depression and anxiety and to determine whether baseline physical, cognitive, and psychosocial factors could distinguish 15-month longitudinal trajectories.

METHODS

Older adults (N = 195, mean age (±SD) = 74.4 years (9.0) participating in three depression and anxiety prevention protocols completed a comprehensive battery of psychosocial assessments and provided blood samples for analysis of interleukin-6 (IL-6) every 3 months over a maximum of 15 months. Group-based trajectory modeling identified trajectories. Adjusted logistic regression examined associations between baseline factors and trajectory groups.

RESULTS

Two 15-month trajectories were identified: stable lower IL-6 levels (84%; mean (±SD) = 3.2 (2.1) pg/mL); and consistently higher IL-6 levels (16%; mean = 9.5 (7.4) pg/mL). Poor sleep quality predicted consistently higher levels of IL-6 (OR = 1.9, 95% CI = 1.03-3.55).

CONCLUSION

Poor sleep quality may represent a therapeutic target to reduce inflammation.

Activity-Based Goals Generated by Older Adults With Mild Cognitive Impairment

Client-centered care is one promising rehabilitation model that may support the unique needs of older adults with mild cognitive impairment (MCI). This secondary analysis examined (a) whether older adults with MCI generated activity-based goals using a client-centered model and (b) the types of goals generated. Thirteen older adults with MCI addressed 55 goals. Using client-centered care, the participants generated goals despite subtle limitations in activities and participation. Participants generated the greatest number of goals related to instrumental activities of daily living. This study demonstrated that older adults with MCI generated goals through a client-centered model. This is important because older adults with MCI are at risk for disability, and they may benefit from early rehabilitation care models that minimize activity limitations and participation restrictions despite underlying cognitive impairments.

Assessments for Caregivers of Hospitalized Older Adults

A systematic review was conducted to characterize assessments for caregivers of hospitalized older adults. Electronic literature searches of Medline, PsycINFO, and CINAHL of articles on caregiver assessments published in English between 2006 and present were completed. Thirty-three articles underwent full-text review; four included assessments designed to capture caregiver needs in hospital settings. Original articles on the development of these assessments were reviewed for quality appraisal. Four findings emerged from our review. Existing assessments (a) focus on caregivers of specific conditions of older adults, (b) contain a singular caregiving domain, (c) measure caregiver outcomes or simply describe caregiving experiences, and (d) neglect psychometric properties. Health care providers are limited in their selection of assessments with caregivers of hospitalized older adults. This barrier is problematic if we are to equip caregivers to be successful at providing care to older adults. Future research should develop a hospital assessment for caregivers.

Treatment Considerations for Depression Research in Older Married Couples: A Dyadic Case Study

OBJECTIVE

Critical gaps remain in understanding optimal approaches to intervening with older couples. The focus of this report is to describe the pros and cons of incorporating spousal dyads into depression-prevention research.

METHODS

In an intervention development study, the authors administered problem-solving therapy (PST) dyadically to participants with mild cognitive impairment (MCI) and their caregivers. Dyads worked with the same interventionist in the same therapy session. The dyadic PST (highlighted in a case example of a husband with MCI and his wife/support person) and the potential feasibility of the program are described.

RESULTS

The authors found that the wife of the individual with MCI could be trained as a PST coach to help her husband learn and use problem-solving skills. A decrease in depressive symptom severity was observed for the individual with MCI, which was sustained over 12 months of follow-up. Neither the husband nor wife experienced an incident episode of major depression over the course of the study.

CONCLUSION

Dyadic interventions need to be further developed in geriatric psychiatry; proven methods such as PST can be modified to include patients' support persons. Recommendations are offered for developing randomized controlled trials that aim to recruit dyads and prevent depression in at-risk older married couples.

Caring for Family Caregivers: Perceptions of CARE Act Compliance and Implementation

BACKGROUND

The Caregiver Advise, Record, Enable (CARE) Act encourages inclusion of family caregivers in the hospitalization process for patients. Translating the state laws into meaningful changes within the health care delivery system can be challenging and requires time. This study sought to examine early compliance with and implementation of the CARE Act reported by hospitals in the Commonwealth of Pennsylvania.

METHODS

We sent an online survey to hospital executives in Pennsylvania in 2017. Descriptive statistics were computed to examine hospital characteristics and used to assess compliance and implementation of the CARE Act tenets.

RESULTS

Most hospitals reported that changes have been and are being made to comply with the CARE Act (90.9%). Hospital executives reported that the family caregiver designation is available in 63.6% of the hospitals and notification of patient discharge is available in 45.5%. Hospital executives reported that family caregiver education and instruction is occurring in 31.8% of all inpatient stays. Hospital executives indicated that they are still developing processes to comply with the legislation and to integrate family caregivers into hospital systems and processes.

CONCLUSIONS

Our findings suggest that hospitals are complying with the legislation, while fully operationalizing the components of the CARE Act is a work in progress.

Work Performance Among Informal Caregivers: A Review of the Literature

Objectives: To examine the association between informal caregiving and caregiver work performance. Method: A systematized review of the literature. Results: We found that caregiving has an adverse impact on work performance: caregivers experience substantial work disruptions and negative work performance outcomes, and these findings were consistent across measures. Our synthesis suggests that caregivers miss a significant amount of work and have reductions in productivity due to their caregiving responsibilities. However, significant methodological limitations with the reviewed studies make systematic interpretations and causal determinations challenging. Discussion: Examining the effect of caregiving on work performance is critical to better understand the full impact of caregiving, especially as demand for caregivers increases as the population ages. This comprehensive review suggests that caregiving has a significant negative impact on work performance, although methodological challenges remain in this area of science. These findings should inform both public policy development and workplace benefits design.

Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers

BACKGROUND AND OBJECTIVES

Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie.

RESEARCH DESIGN AND METHODS

A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature.

RESULTS

Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed.

DISCUSSION AND IMPLICATIONS

The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.

Unpaid Caregiving and Aging in Place in the United States: Advancing the Value of Occupational Therapy

Unpaid caregivers are often expected to help family members or friends overcome activity limitations and participation restrictions to successfully age in place. Caregivers assume multiple responsibilities, such as managing their own physical and psychosocial needs and navigating a complex health care system, and many feel ill equipped to fulfill the necessary health care responsibilities for their care recipients. Underprepared caregivers may cause poor outcomes for care recipients. Federal and state policy proposals call attention to the need to better support caregivers, especially as their numbers increase. Occupational therapy practitioners are well positioned to effectively engage caregivers as they navigate the health care system. The occupational therapy process looks broadly at the functional abilities, environmental contexts, and occupational demands that play a pivotal role in successful aging in place for clients and better outcomes for their caregivers. Now is the time to define occupational therapy's distinct value to this area.