Enhancing caregiver health: findings from the resources for enhancing Alzheimer's caregiver health II intervention

A web-based program for informal caregivers of persons with Alzheimer's disease: an iterative user-centered design

BACKGROUND

Web-based programs have been developed for informal caregivers of people with Alzheimer's disease (PWAD). However, these programs can prove difficult to adopt, especially for older people, who are less familiar with the Internet than other populations. Despite the fundamental role of usability testing in promoting caregivers' correct use and adoption of these programs, to our knowledge, this is the first study describing this process before evaluating a program for caregivers of PWAD in a randomized clinical trial.

OBJECTIVE

The objective of the study was to describe the development process of a fully automated Web-based program for caregivers of PWAD, aiming to reduce caregivers' stress, and based on the user-centered design approach.

METHODS

There were 49 participants (12 health care professionals, 6 caregivers, and 31 healthy older adults) that were involved in a double iterative design allowing for the adaptation of program content and for the enhancement of website usability. This process included three component parts: (1) project team workshops, (2) a proof of concept, and (3) two usability tests. The usability tests were based on a mixed methodology using behavioral analysis, semistructured interviews, and a usability questionnaire.

RESULTS

The user-centered design approach provided valuable guidelines to adapt the content and design of the program, and to improve website usability. The professionals, caregivers (mainly spouses), and older adults considered that our project met the needs of isolated caregivers. Participants underlined that contact between caregivers would be desirable. During usability observations, the mistakes of users were also due to ergonomics issues from Internet browsers and computer interfaces. Moreover, negative self-stereotyping was evidenced, when comparing interviews and results of behavioral analysis.

CONCLUSIONS

Face-to-face psycho-educational programs may be used as a basis for Web-based programs. Nevertheless, a user-centered design approach involving targeted users (or their representatives) remains crucial for their correct use and adoption. For future user-centered design studies, we recommend to involve end-users from preconception stages, using a mixed research method in usability evaluations, and implementing pilot studies to evaluate acceptability and feasibility of programs.

Calidad de vida en cuidadores informales de personas con enfermedades crónicas

Objetivo: evaluar la calidad de vida de cuidadores informales de personas que viven en situación de enfermedad crónica determinando si la misma se relaciona con las características sociodemográficas de los participantes. Materiales y métodos: se evaluaron 127 cuidadores informales residentes en Montería (Córdoba, Colombia), durante el segundo semestre de 2012, por medio de un diseño ex post facto con el cuestionario WHOQOL-Bref de la Organización Mundial de la Salud (OMS). Para la evaluación de calidad de vida se consideraron cuatro dominios: a) salud física, b) salud psicológica, c) relaciones sociales y d) medioambiente. Los datos se analizaron con SPSS 18,0 aplicando chi cuadrado de Pearson y pruebas de diferencias entre grupos. Resultados: se observaron bajos niveles de salud física y psicológica, deterioro de los procesos de participación social y niveles moderados de interacción con el medioambiente. Condiciones como el género del cuidador, su ocupación y la relación con el paciente tuvieron una correspondencia significativa (p < 0,05) con la calidad de vida en relación con los dominios de medioambiente, vida social y salud psicológica. Conclusiones: los cuidadores informales presentan un deterioro general de su calidad de vida con déficit marcado en la esfera relacional.

A secondary data analysis of Internet use in caregivers of persons with dementia

AIM

This paper is a secondary data analysis to investigate relationships among caregiver stress appraisal, self-rated health and health-related Internet use.

DESIGN

Cross-sectional correlation design.

METHODS

National Alliance for Caregiving telephone survey conducted in the USA was a primary data source collected in 2009 from 258 caregivers of persons with dementia, who used the Internet to perform care-giving tasks. Based on Pearlin's Stress Process Model, structural equation modelling was conducted.

RESULTS

Caregivers with poor health reported higher levels of caregiver stress appraised, which was associated with more Internet use for health-related purposes. It is required to develop effective Internet-based resources to meet the needs of highly stressed caregivers of persons with dementia. However, there was no relationship between self-rated health and health-related Internet use in dementia caregiver.

A typology of care-giving across neurodegenerative diseases presenting with dementia

The purpose of this study is to develop and extend our understanding of dementia care-giving by introducing a typology of informal care-giving across four different diseases. Care-giving factors were examined with respect to specific dementia presentation in mild cognitive impairment, Alzheimer's disease, dementia with Lewy bodies and Parkinson's disease-associated dementia. Informal care-giving literature in the four diseases was systematically searched to identify specific disease symptoms and resultant care-giving strains and outcomes. Key concepts were extracted and grouped thematically. The first classification, ‘role-shift’, reflects care-giving where cognitive deterioration results in changing roles, uncertainty and relational deprivation among married partners. The second classification, ‘consumed by care-giving’, refers to those caring for persons with dementia-motor decline that greatly increases worry and isolation. Finally, in the ‘service use’ classification, formal support is needed to help care-givers cope with daily responsibilities and behaviour changes. In each case, the dementia presentation uniquely impacts care-giver strains. A major conclusion is that the same support to all care-givers under the umbrella term ‘dementia’ is unwarranted; the development of targeted support is required.

The Effectiveness of a Culturally Sensitive Cognitive Behavioral Group Intervention for Latino Alzheimer's Caregivers

PURPOSE OF THE STUDY

Demographic projections suggest that the older Latino population will experience the fastest growth among all racial/ethnic groups; and by 2050 will constitute 20% of the nation's seniors. Yet, Latino Alzheimer's elders and their families remain underrepresented in the health care system and caregiver intervention studies. To address this gap, this study tested the effectiveness of Circulo de Cuidado, a culturally-sensitive, cognitive behavioral (CBT) group intervention, in supporting Latino families' ability to manage the disease's neuropsychiatric symptoms and improve caregiver well-being.

DESIGN AND METHODS

Using a randomized controlled trial design, 67 caregivers were assigned to the CBT experimental condition or the psychoeducational (PED) control condition and interviewed at baseline, post-group, and 3 months follow-up. The 2 manualized interventions had the same structure: 5 weekly 90-minute group sessions, followed by telephone coaching at 3, 6, 9 and 12 weeks post-group.

RESULTS

Repeated measures analysis of covariance revealed significant group by time interaction effects. Compared with the PED participants, CBT participants reported lower neuropsychiatric symptoms in their relative, less caregiver distress about neuropsychiatric symptoms, a greater sense of caregiver self-efficacy, and less depressive symptoms over time.

IMPLICATIONS

Our findings offer preliminary evidence that a culturally tailored, CBT group intervention targeted toward neuropsychiatric symptom management has positive psychological benefits for Latino caregivers.

Culture, Caregiving, and Health: Exploring the Influence of Culture on Family Caregiver Experiences

Ethnic minorities are expected to experience a greater demand for family caregiving than non-Latino Whites due to their projected population growth. Although the consensus of researchers on caregiving and culture finds that the caregiving experience differs significantly among cultural/ethnic groups, the question remains as to how cultural values and norms influence the caregiver experiences. We conducted an interpretative, phenomenological qualitative analysis of focus group transcripts from four groups (African American, Asian American, Hispanic American, and European American) for cultural influences on caregiving. Data were collected in Nevada between December 7, 2009, and August 20, 2010. Thirty-five caregivers participated in this study. We found commonalities among all of the cultural/ethnic groups in their experiences of the difficulties of caregiving. However, there were some significant differences in the cultural values and norms that shaped the caregiving experience. We categorized these differences as: (a) cultural embeddedness of caregiving, (b) cultural determinants of caregiving responsibilities or taxonomy of caregiving, and (c) cultural values and norms underlying the decision to provide care. The significance of this study is that it highlights the culturally perceived mandate to provide care in the African, Asian, and Hispanic American cultures.

Impact of a community based implementation of REACH II program for caregivers of Alzheimer's patients

BACKGROUND

In 2009 an estimated 5.3 million people in the United States were afflicted with Alzheimer's disease, a degenerative form of dementia. The impact of this disease is not limited to the patient but also has significant impact on the lives and health of their family caregivers. The Resources for Enhancing Alzheimer's Caregiver Health (REACH II) program was developed and tested in clinical studies. The REACH II program is now being delivered by community agencies in several locations. This study examines the impact of the REACH II program on caregiver lives and health in a city in north Texas.

STUDY DESIGN

Family caregivers of Alzheimer's patients were assessed using an instrument covering the multi-item domains of Caregiver Burden, Depression, Self-Care, and Social Support upon enrollment in the program and at the completion of the 6 month intervention. The domain scores were analyzed using a multivariate paired t-test and Bonferroni confidence interval for the differences in pre- and post-service domain scores.

RESULTS

A total of 494 families were enrolled in the program during the period January 1, 2011 through June 30, 2012. Of these families 177 completed the 6 month program and have pre - and post service domain scores. The median age for the caregivers was 62 years. The domain scores for Depression and Caregiver Burden demonstrated statistically significant improvements upon program completion.

CONCLUSION

The REACH II intervention was successfully implemented by a community agency with comparable impacts to those of the clinical trial warranting wider scale implementation.

Linking family dynamics and the mental health of Colombian dementia caregivers

This cross-sectional, quantitative, self-report study examined the relationship between family dynamics (cohesion, flexibility, pathology/ functioning, communication, family satisfaction, and empathy) and mental health (depression, burden, stress, and satisfaction with life [SWL]) in 90 dementia caregivers from Colombia. Hierarchical multiple regressions controlling for caregiver demographics found that family dynamics were significantly associated with caregiver depression, stress, and SWL and marginally associated with burden. Within these regressions, empathy was uniquely associated with stress; flexibility with depression and marginally with SWL; and family communication marginally with burden and stress. Nearly all family dynamic variables were bivariately associated with caregiver mental health variables, such that caregivers had stronger mental health when their family dynamics were healthy. Family-systems interventions in global regions with high levels of familism like that in the current study may improve family empathy, flexibility, and communication, thereby producing better caregiver mental health and better informal care for people with dementia.

Does becoming an ADL spousal caregiver increase the caregiver's depressive symptoms?

This study investigated whether transitioning into the role of activities of daily living (ADL) spousal caregiver is associated with increased depressive symptoms for older husbands and wives among a sample of coresiding community-dwelling older couples. Using data from the Health and Retirement Study, we estimated a two-level linear model to examine the association between change in caregiver status and respondents' depressive symptoms at follow-up, controlling for other factors identified in Pearlin's stress process model (PSPM). Results indicate that both husbands and wives who become ADL caregivers have more follow-up depressive symptoms than noncaregivers. Furthermore, wives continuing as caregivers have more follow-up depressive symptoms than wives who do not provide care. Finally, the physical health of the spousal caregiver is related to depressive symptoms at follow-up. We conclude with policy and practice implications of these three main findings.

Dementia behavioural and psychiatric symptoms: effect on caregiver's sleep

AIMS AND OBJECTIVES

To examine caregiver sleep quality, especially in relation to the daytime and night-time behaviours and psychological symptoms exhibited by persons with dementias.

BACKGROUND

Caregivers of persons with dementias experience poorer sleep in comparison with noncaregivers, and poor sleep is related to negative health outcomes. The reasons for caregivers' poor sleep are complex, and it is known that the night-time behaviours of the persons with dementia contribute to caregiver sleep disruption. However, the frequency of behavioural and psychological symptoms of dementia has hitherto not been sufficiently explored as a contributing factor to poor caregiver sleep.

DESIGN

A nonexperimental cross-sectional design.

METHODS

Eighty caregivers completed questionnaires on the frequency of behavioural and psychological symptoms of the persons with dementia, the Dementia Severity Rating Scale, the Pittsburgh Sleep Quality Index and the Center for Epidemiologic Studies Depression Scale.

RESULTS

Poor sleep was reported with awakenings by the persons with dementia occurring for more than half of the caregivers. The frequency of behaviours and symptoms did not make a unique contribution to the variance of caregivers' global sleep. The frequency of behaviours, and specifically of agitation and apathy, contributed to the variance in subjective sleep quality, as defined by the caregivers' appraisal of their sleep.

CONCLUSIONS

The findings demonstrate the relationship between (1) daytime and night-time behaviours of persons with dementias and (2) their caregivers' sleep quality and emphasise the complexity of the factors that contribute to caregiver sleep quality.

RELEVANCE TO CLINICAL PRACTICE

These findings suggest that nurses should be cognizant of the relationship between daytime behaviours of the persons with dementia and the caregivers' appraisal of their sleep, realising that appraising one's sleep as poor can be a contributing factor to perpetuating sleep problems. Interventions aimed at helping the caregiver manage the persons with dementia's agitation or the caregiver's emotional response to persons with dementia apathy may improve caregivers' perception of their sleep.

The Impact of the REACH II Intervention on Caregivers’ Perceived Health

The primary goal of the current study was to examine the impact of a caregiving support program on caregivers’ perceived health at 6 months following baseline assessment in the Resources for Enhancing Alzheimer’s Caregiver Health II (REACH II) intervention. A composite measure of perceived health was established and incorporated self-rated health, change in self-rated health, and improvement in physical health. A total of 494 participants receiving the REACH II intervention or an education-only intervention were included in this study. Mixed effect linear regression analysis was performed to examine the effect of the intervention and the factors that mediate this relationship. Findings suggest that the enhanced supportive intervention led to significant improvement in caregivers’ overall perceived health at 6 months. This effect remains significant after controlling for positive satisfaction with caregiving. Improving caregivers’ stress and burden while fostering positive rewards and appraisals may provide indirect health benefits and maintain overall health in dementia caregivers.

Mindfulness-based stress reduction for family caregivers: a randomized controlled trial

PURPOSE

Caring for a family member with dementia is associated with chronic stress, which can have significant deleterious effects on caregivers. The purpose of the Balance Study was to compare a mindfulness-based stress reduction (MBSR) intervention to a community caregiver education and support (CCES) intervention for family caregivers of people with dementia.

DESIGN AND METHODS

We randomly assigned 78 family caregivers to an MBSR or a CCES intervention, matched for time and attention. Study participants attended 8 weekly intervention sessions and participated in home-based practice. Surveys were completed at baseline, postintervention, and at 6 months. Participants were 32- to 82-year-old predominately non-Hispanic White women caring for a parent with dementia.

RESULTS

MBSR was more effective at improving overall mental health, reducing stress, and decreasing depression than CCES. Both interventions improved caregiver mental health and were similarly effective at improving anxiety, social support, and burden.

IMPLICATIONS

MBSR could reduce stress and improve mental health in caregivers of family members with dementia residing in the community.

The UP-TECH project, an intervention to support caregivers of Alzheimer's disease patients in Italy: study protocol for a randomized controlled trial

BACKGROUND

The epidemic of Alzheimer's disease (AD) represents a significant challenge for the health care and social service systems of many developed countries. AD affects both patients and family caregivers, on whom the main burden of care falls, putting them at higher risk of stress, anxiety, mortality and lower quality of life. Evidence remains controversial concerning the effectiveness of providing support to caregivers of AD patients, through case management, counseling, training, technological devices and the integration of existing care services. The main objectives of the UP-TECH project are: 1) to reduce the care burden of family caregivers of AD patients; and 2) to maintain AD patients at home.

METHODS/DESIGN

A total of 450 dyads comprising AD patients and their caregivers in five health districts of the Marche region, Italy, will be randomized into three study arms. Participants in the first study arm will receive comprehensive care and support from a case manager (an ad hoc trained social worker) (UP group). Subjects in the second study arm will be similarly supported by a case manager, but in addition will receive a technological toolkit (UP-TECH group). Participants in the control arm will only receive brochures regarding available services. All subjects will be visited at home by a trained nurse who will assess them using a standardized questionnaire at enrollment (M0), 6 months (M6) and 12 months (M12). Follow-up telephone interviews are scheduled at 24 months (M24). The primary outcomes are: 1) caregiver burden, measured using the Caregiver Burden Inventory (CBI); and 2) the actual number of days spent at home during the study period, defined as the number of days free from institutionalizations, hospitalizations and stays in an observation unit of an emergency room.

DISCUSSION

The UP-TECH project protocol integrates previous evidence on the effectiveness of strategies in dementia care, that is, the use of case management, new technologies, nurse home visits and efforts toward the integration of existing services in an ambitious holistic design. The analysis of different interventions is expected to provide sound evidence of the effectiveness and cost of programs supporting AD patients in the community.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01700556.

Positive effects of a cognitive-behavioral intervention program for family caregivers of demented elderly

OBJECTIVE

It was to examine the effects of a Cognitive-Behavioral Therapy (CBT) program administered to family caregivers of dementia patients.

METHODS

Forty family caregivers were enrolled in a CBT intervention across eight weekly sessions. Cognitive, functional and behavioral status of patients were evaluated, as well as their own and their family caregivers' perceptions of quality of life. Specific instruments were also applied to evaluate caregiver stress level, coping, anxiety and depression.

RESULTS

At the end of the program, family caregivers reported fewer neuropsychiatric symptoms among patients and an improvement in patients' quality of life. In addition, caregivers changed their coping strategies, whereas a significant decrease was observed in their anxiety levels.

CONCLUSION

The CBT program employed appears to be a promising and useful tool for clinical practice, displaying positive effects on quality of life and neuropsychiatric symptoms of dementia, as well as proving beneficial for alleviating anxiety and stress in family caregivers.

A home-based training program improves Taiwanese family caregivers' quality of life and decreases their risk for depression: a randomized controlled trial

OBJECTIVES

Little is known about the longitudinal effects of training programs on family caregivers' health-related quality of life (HRQoL) and depressive symptoms over time. Therefore, the purpose of this study was to examine the effects of a home-based caregiver training program on HRQoL and depressive symptoms for family caregivers of older persons with dementia.

METHODS

Outcomes (caregivers' HRQoL and depressive symptoms) were assessed before the training program (baseline), and at 2 weeks, 3 months, and 6 months afterwards. HRQoL was measured using the Medical Outcomes Study 36-item Short Form Survey, Taiwan version. Depressive symptoms were measured using the Chinese version Center for Epidemiologic Studies Depression Scale.

RESULTS

Family caregivers who received the individualized home-based training program had better health outcomes in bodily pain (b = 12.37, p < 0.013), role disability due to emotional problems (b = 17.74, p < 0.013), vitality (b = 12.40, p < 0.001), better mental summary score (b = 5.14, p < 0.003), and decreased risk for depression (odds ratio = 0.15, confidence interval = 0.04-0.65, p < 0.013) than those in the control group during the 6 months following the training program.

CONCLUSION

Our home-based caregiver training program improved caregivers' HRQoL, especially role limitations due to emotional problems, and decreased their risk for depression.

Evaluating a Community-Based Family Caregiver Training Program

This mixed-methods, time series study investigated the effectiveness of a Family Caregiver Training Program offered by a community-based agency. The training program and the impact of the training program on the family caregivers of older community dwelling adults were evaluated using quantitative and qualitative measures. Program evaluation results were used to revise and develop a Family Caregiver Training Program responsive to needs of the caregivers. There was a significant difference on the overall Adapted Revised Caregiving Appraisal Scale that measured caregiver burden, satisfaction, mastery, impact, and demand among three survey points. These positive results demonstrated effectiveness of the Family Caregiver Training Program. An added benefit was the socialization that occurred through meeting with other family caregivers who shared the same experiences.

Psychometric evaluation of the surrogate decision making self-efficacy scale

Currently, no instrument exists to assess self-efficacy for surrogate decision making. This study assessed the psychometric properties of the Surrogate Decision Making Self-Efficacy Scale (SDM-SES). Interview data from surrogate decision makers (SDMs) were used to generate the items. Items were assessed for face validity by expert gerontological nurses. Responses from a sample of 155 SDMs for nursing home residents with dementia were analyzed to assess the psychometric properties of the scale scores. Internal consistency was calculated using Cronbach's alpha coefficient, and construct validity was evaluated using confirmatory factor analysis. The Cronbach's alpha coefficient suggested high internal consistency, and results of the confirmatory factor analysis supported the construct validity of the instrument. The SDM-SES may be useful as an assessment instrument, as well as an outcome measure for interventions aimed at increasing the capacity of SDMs. Future validations are suggested to optimize its utility.

Depression interventions among racial and ethnic minority older adults: a systematic review across 20 years

While there is strong evidence in support of geriatric depression treatments, much less is available with regard to older U.S. racial and ethnic minorities. The objectives of this review are to identify and appraise depression treatment studies tested with samples of U.S. racial and ethnic minority older adults. We include an appraisal of sociocultural adaptations made to the depression treatments in studies meeting our final criteria. Systematic search methods were utilized to identify research published between 1990 and 2010 that describe depression treatment outcomes for older adults by racial/ethnic group, or for samples of older adults who are primarily (i.e., >50%) racial/ethnic minorities. Twenty-three unduplicated articles included older adults and seven met all inclusion criteria. Favorable depression treatment effects were observed for older minorities across five studies that took place in different types of settings and with varying levels of sociocultural adaptations. The effectiveness of depression care remains mixed, although collaborative or integrated care shows promise for African Americans and Latinos. The degree to which the findings generalize to non-English-speaking, low acculturated, and low-income older persons, and to other older minority groups (i.e., Asian and Pacific Islanders, and American Indian and Alaska Natives), remains unclear. Given the high disease burden among older minorities with depression, it is imperative to provide timely, accessible, and effective depression treatments. Increasing their participation in behavioral health research should be a national priority.

Reducing Health Care Costs for Dementia Patients

Objective: Estimating cost savings based on limited health care events within a short time span for a dementia care program. Method: Data on health care utilization of persons with dementia (PWDs) and caregivers were gathered in the Dementia Care Services Program in North Dakota from January 2010 to January 2012. Data were aggregated into 3-month intervals and compared to 3 months before program intervention. Paired and cross-time models were used to estimate cost savings. Results: Health care cost savings for PWDs were estimated at US$143,118 to US$180,102 during the first 3 months after intervention, then decreased over time. Only the first 9 months could be used in the paired model due to small N and low power. Discussion: For programs with short time spans and limited health care events, a cross-time model can be used to estimate cost savings while producing results similar to paired models.

[Maintenance of health and relief for caregivers of elderly with dementia by using "initial case management": experiences from the Lighthouse Project on Dementia, Ulm, ULTDEM-study]

BACKGROUND

When facing the well-known demographic development with an increasing number of people suffering from dementia, there is a need of programmes to support nursing relatives and care at home. Many support services have been established in the past few years but they are rarely used by the relatives and the patients. The purpose of the Lighthouse Project Ulm (ULTDEM Study) was to prove the effectiveness of a single advisory approach in order to provide support services after care level classification and to relieve the burden placed on relatives caring for family members suffering from dementia ("initial case management").

METHODS

The ULTDEM Study is a prospective, open, randomized, controlled, interventional study with different parallel outcome measures (burden of caring, quality of life and mood). After the randomization, the interventional group was given comprehensive, individual advice about available treatment possibilities for dementia patients. Control group participants received standard treatment. Inclusion criteria were application of a care level (0 or 1) as well as dementia diagnosis. All participants (patients/relatives) underwent an initial and a 6 month comprehensive assessment.

RESULTS

Our results show that a single advisory approach does not lead to a significant difference in outcome measures in interventional and control groups. Those tendencies described have to be interpreted as clinically not relevant. Although utilization of support services increases, it remains similar in both study groups. A confirmatory interpretation has not been possible due to a lack of adjustment to the findings regarding multiple testing and an insufficient degree of recruitment. Possible causes will be discussed such as premature intervention during the course of the disease, a lack of intervention blinding, recruitment bias and lack of an influence on adherence with regard to the use of support services.

IMPLICATIONS

The study demonstrates that there is a substantial information deficit for persons affected by dementia and their relatives. Innovative ways still have to be developed to ensure that this information actually reaches the target audience.

The Northern Manhattan Caregiver Intervention Project: a randomised trial testing the effectiveness of a dementia caregiver intervention in Hispanics in New York City

OBJECTIVES

Dementia prevalence and its burden on families are increasing. Caregivers of persons with dementia have more depression and stress than the general population. Several interventions have proven efficacy in decreasing depression and stress in selected populations of caregivers. Hispanics in New York City tend to have a higher burden of dementia caregiving compared to non-Hispanic whites (NHW) because Hispanics have a higher prevalence of dementia, tend to have high family involvement, and tend to have higher psychosocial and economic stressors. Thus, we chose to test the effectiveness of a dementia caregiving intervention, the New York University Caregiver Intervention (NYUCI), with demonstrated efficacy in spouse caregivers in Hispanic relative caregivers of persons with dementia. Including the community health worker (CHW) intervention in both arms alleviates general psychosocial stressors and allows the assessment of the effectiveness of the intervention. Compared to two original efficacy studies of the NYUCI, which included only spouse caregivers, our study includes all relative caregivers, including common law spouses, children, siblings, a nephew and nieces. This study will be the first randomised trial to test the effectiveness of the NYUCI in Hispanic caregivers including non-spouses.

METHODS AND ANALYSIS

The design of the study is a randomised controlled trial (RCT). Participants are randomised to two arms: case management by a CHW and an intervention arm including the NYUCI in addition to case management by the CHW. The duration of intervention is 6 months. The main outcomes in the trial are changes in the Geriatric Depression Scale (GDS) and the Zarit Caregiver Burden Scale (ZCBS) from baseline to 6 months.

ETHICS AND DISSEMINATION

This trial is approved by the Columbia University Medical Center Institutional Review Board (AAAI0022), and funded by the National Institute on Minority Health and Health Disparities. The funding agency has no role in dissemination.

TRIAL REGISTRATION

 www.ClinicalTrials.gov NCT01306695.

2012 Alzheimer's disease facts and figures

This report provides information to increase understanding of the public health impact of Alzheimer's disease (AD). Topics addressed include incidence, prevalence, mortality rates, health expenditures and costs of care, and effect on caregivers and society. The report also explores issues that arise when people with AD and other dementias live alone. The characteristics, risks, and unmet needs of this population are described. An estimated 5.4 million Americans have AD, including approximately 200,000 age <65 years who comprise the younger-onset AD population. Over the coming decades, the aging of the baby boom generation is projected to result in an additional 10 million people with AD. Today, someone in America develops AD every 68 seconds. By 2050, there is expected to be one new case of AD every 33 seconds, or nearly a million new cases per year, and AD prevalence is projected to be 11 million to 16 million. Dramatic increases in the number of "oldest-old" (those age ≥85 years) across all racial and ethnic groups are expected to contribute to the increased prevalence of AD. AD is the sixth leading cause of death in the United States and the fifth leading cause of death in Americans age ≥65 years. Although the proportions of deaths due to other major causes of death have decreased in the last several years, the proportion due to AD has risen significantly. Between 2000 and 2008, the proportion of deaths due to heart disease, stroke, and prostate cancer decreased by 13%, 20%, and 8%, respectively, whereas the proportion due to AD increased by 66%. In 2011, more than 15 million family members and other unpaid caregivers provided an estimated 17.4 billion hours of care to people with AD and other dementias, a contribution valued at more than $210 billion. Medicare payments for services to beneficiaries age ≥65 years with AD and other dementias are three times as great as payments for beneficiaries without these conditions, and Medicaid payments are 19 times as great. In 2012, payments for health care, long-term care, and hospice services for people age ≥65 years with AD and other dementias are expected to be $200 billion (not including the contributions of unpaid caregivers). An estimated 800,000 people with AD (one in seven) live alone, and up to half of them do not have an identifiable caregiver. People with dementia who live alone are exposed to risks that exceed the risks encountered by people with dementia who live with others, including inadequate self-care, malnutrition, untreated medical conditions, falls, wandering from home unattended, and accidental deaths.

Deciding when to put grandma in the nursing home: measuring inclinations to place persons with dementia

For caregivers of persons with dementia, estimating when that person should be placed in long-term care is difficult. Health care providers also find it hard to give an exact time as to when the person should be placed. Using data from 197 caregivers working with the Dementia Care Services Project in North Dakota, we show that asking the caregiver about their inclination to place can be equated to asking them for a specific time to place (κ = .616). Using the probability density function of time to place we were able to translate it into inclination. This inclination is easier information for the caregiver to provide and places fewer burdens on the caregiver and patient. It also provides the health care provider with a measure of time to help advise caregivers and recommend interventions and provide service organizations with measures of cost savings to support the impact of outreach and intervention.

Systematic review of services providing information and/or advice to people with dementia and/or their caregivers

BACKGROUND

Information is a key part of service provision to people with dementia and their carers, but there is no systematic review of the evidence. This study aimed to determine whether information services confer significant benefit for quality of life, neuropsychiatric symptoms and carer burden.

METHOD

A systematic review of intervention studies in people with dementia was carried out, focussing predominantly on the provision of information and/or advice.

RESULTS

Thirteen randomised controlled trials were identified. Two of the three studies measuring quality of life indicated benefit. Significant benefits were also evident for neuropsychiatric symptoms (points difference, -1.48; confidence interval, -2.11 to 0.86), but not carer burden. Most interventions included other key elements such as skills training, telephone support and direct help to navigate the medical and care system.

CONCLUSION

There is some support for the value of information services, but studies are needed to determine the specific elements that are effective.

Cost-effectiveness of magnetic resonance imaging with a new contrast agent for the early diagnosis of Alzheimer's disease

Background

Used as contrast agents for brain magnetic resonance imaging (MRI), markers for beta-amyloid deposits might allow early diagnosis of Alzheimer's disease (AD). We evaluated the cost-effectiveness of such a diagnostic test, MRI+CLP (contrastophore-linker-pharmacophore), should it become clinically available.

Methodology/Principal Findings

We compared the cost-effectiveness of MRI+CLP to that of standard diagnosis using currently available cognition tests and of standard MRI, and investigated the impact of a hypothetical treatment efficient in early AD. The primary analysis was based on the current French context for 70-year-old patients with Mild Cognitive Impairment (MCI). In alternative “screen and treat” scenarios, we analyzed the consequences of systematic screenings of over-60 individuals (either population-wide or restricted to the ApoE4 genotype population). We used a Markov model of AD progression; model parameters, as well as incurred costs and quality-of-life weights in France were taken from the literature. We performed univariate and probabilistic multivariate sensitivity analyses.

The base-case preferred strategy was the standard MRI diagnosis strategy. In the primary analysis however, MRI+CLP could become the preferred strategy under a wide array of scenarios involving lower cost and/or higher sensitivity or specificity. By contrast, in the “screen and treat” analyses, the probability of MRI+CLP becoming the preferred strategy remained lower than 5%.

Conclusions/Significance

It is thought that anti-beta-amyloid compounds might halt the development of dementia in early stage patients. This study suggests that, even should such treatments become available, systematically screening the over-60 population for AD would only become cost-effective with highly specific tests able to diagnose early stages of the disease. However, offering a new diagnostic test based on beta-amyloid markers to elderly patients with MCI might prove cost-effective.

Functional analysis-based interventions for challenging behaviour in dementia

BACKGROUND

Functional analysis (FA) for the management of challenging behaviour is a promising behavioural intervention that involves exploring the meaning or purpose of an individual's behaviour. It extends the 'ABC' approach of behavioural analysis, to overcome the restriction of having to derive a single explanatory hypothesis for the person's behaviour. It is seen as a first line alternative to traditional pharmacological management for agitation and aggression. FA typically requires the therapist to develop and evaluate hypotheses-driven strategies that aid family and staff caregivers to reduce or resolve a person's distress and its associated behavioural manifestations.

OBJECTIVES

To assess the effects of functional analysis-based interventions for people with dementia (and their caregivers) living in their own home or in other settings.

SEARCH METHODS

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 3 March 2011 using the terms: FA, behaviour (intervention, management, modification), BPSD, psychosocial and Dementia.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with reported behavioural outcomes that could be associated with functional analysis for the management of challenging behaviour in dementia.

DATA COLLECTION AND ANALYSIS

Four reviewers selected trials for inclusion. Two reviewers worked independently to extract data and assess trial quality, including bias. Meta-analyses for reported incidence, frequency, severity of care recipient challenging behaviour and mood (primary outcomes) and caregiver reaction, burden and mood were performed. Details of adverse effects were noted.

MAIN RESULTS

Eighteen trials are included in the review. The majority were in family care settings. For fourteen studies, FA was just one aspect of a broad multi-component programme of care. Assessing the effect of FA was compromised by ill-defined protocols for the duration of component parts of these programmes (i.e. frequency of the intervention or actual time spent). Therefore, establishing the real effect of the FA component was not possible.Overall, positive effects were noted at post-intervention for the frequency of reported challenging behaviour (but not for incidence or severity) and for caregiver reaction (but not burden or depression). These effects were not seen at follow-up.

AUTHORS' CONCLUSIONS

The delivery of FA has been incorporated within wide ranging multi-component programmes and study designs have varied according to setting - i.e. family care, care homes and hospital, with surprisingly few studies located in care homes. Our findings suggest potential beneficial effects of multi-component interventions, which utilise FA. Whilst functional analysis for challenging behaviour in dementia care shows promise, it is too early to draw conclusions about its efficacy.

Living with an aging parent: "It was a beautiful invitation"

In the United States and globally, increasing numbers of older parents are living with their adult children. Making the decision to live together requires careful thought and planning; particularly when the decision means the children will be responsible for their elder parents' care, the physicians of all parties should be consulted. More than one-third of caregivers state that they seek advice from their physician or other clinician when information is needed about this transition. Using the case of a couple receiving care from their daughter in her own home, we review the prevalence and epidemiology of adult children caring for a parent in the adult child's home, important issues to consider, and a framework for clinicians to help guide their patients through this transition. We describe the physician's ongoing role in caring for and advising both the older parent and the adult children during common stages of multigenerational living: before the move and during coresidency and subsequent care transitions.

2011 Alzheimer's disease facts and figures

Alzheimer's disease (AD) is the sixth leading cause of all deaths in the United States and is the fifth leading cause of death in Americans aged ≥65 years. Although other major causes of death have been on the decrease, deaths because of AD have been rising dramatically. Between 2000 and 2008 (preliminary data), heart disease deaths decreased by 13%, stroke deaths by 20%, and prostate cancer-related deaths by 8%, whereas deaths because of AD increased by 66%. An estimated 5.4 million Americans have AD; approximately 200,000 people aged <65 years with AD comprise the younger-onset AD population. Every 69 seconds, someone in America develops AD; by 2050, the time is expected to accelerate to every 33 seconds. Over the coming decades, the baby boom population is projected to add 10 million people to these numbers. In 2050, the incidence of AD is expected to approach nearly a million people per year, with a total estimated prevalence of 11 to 16 million people. Dramatic increases in the numbers of "oldest-old" (those aged ≥85 years) across all racial and ethnic groups will also significantly affect the numbers of people living with AD. In 2010, nearly 15 million family and other unpaid caregivers provided an estimated 17 billion hours of care to people with AD and other dementias, a contribution valued at more than $202 billion. Medicare payments for services to beneficiaries aged ≥65 years with AD and other dementias are almost 3 times higher than for beneficiaries without these conditions. Total payments in 2011 for health care, long-term care, and hospice services for people aged ≥65years with AD and other dementias are expected to be $183 billion (not including the contributions of unpaid caregivers). This report provides information to increase understanding of the public health effect of AD, including incidence and prevalence, mortality, health expenditures and costs of care, and effect on caregivers and society in general. The report also examines the current state of AD detection and diagnosis, focusing on the benefits of early detection and the factors that present challenges to accurate diagnosis.

Descriptive study of partners' experiences of living with severe heart failure

PURPOSE

This qualitative study sought to describe the experiences of living with severe heart failure (HF) from the perspective of the partner.

METHODS

In-depth, semistructured interviews were conducted with 14 partners of individuals diagnosed with severe HF. Content analysis was performed to derive the main themes and subthemes of responses.

RESULTS

Three main themes were derived from the data: (1) My Experience of HF in My Loved One, (2) Experience With Healthcare Providers, and the (3) Patient's Experience of HF as Perceived by the Partner.

CONCLUSION

The severity of the patient's disease limited the partner's lifestyle, resulting in social isolation and difficulties in planning for the future for both the patient and the partner. The partners were unprepared to manage the disease burden at home without consistent information and assistance by healthcare providers. Moreover, end-of-life planning was neither encouraged by healthcare providers nor embraced by patients or partners.

Quality-of-life outcomes among Alzheimer's disease family caregivers following community-based intervention

This study sought to determine how community-based interventions such as adult day programs and caregiver support groups affected the quality of life (QOL) of caregivers of Alzheimer's disease clients. The authors hypothesized that using community-based interventions would increase the QOL of caregivers of Alzheimer's disease clients. They conducted a pilot study employing a cross-sectional comparative design involving 62 caregivers in the Durham region, Ontario, Canada. Individuals were recruited at five adult day programs and at six caregiver support groups, involving primary data collection consisting of a self-report questionnaire and a 13-item QOL scale. The authors' findings show that caregivers of Alzheimer's disease clients who used community-based interventions enjoyed similar levels of QOL as caregivers of non-Alzheimer's disease clients. These findings suggest that community-based interventions may be beneficial and should target the multiple needs of caregivers, including their knowledge of community resources and coping strategies.

Benefits of a poetry writing intervention for family caregivers of elders with dementia

This pilot clinical trial tested effectiveness of a poetry writing intervention for family caregivers of elders with dementia. This paper presents findings from a larger study using mixed methods to examine outcome variables of self-transcendence, resilience, depressive symptoms, and subjective caregiver burden. Findings reported here focus on qualitative analysis of in-depth interviews conducted with participants following their poetry writing experience. A grounded theory approach was used. Themes that arose from the data support a mid-range theory of self-affirmation in caregivers with subthemes of achievement, catharsis, greater acceptance, empathy, self-awareness, reflection, creative and fun, positive challenge, and helping others.

Effects of Alzheimer caregiving on allostatic load

This study aimed to determine if Alzheimer caregivers have increased allostatic load compared to non-caregivers. Potential psychological moderators (mastery, depression, and role overload) of the relationship between caregiving status and allostatic load were also explored. Eighty-seven caregivers and 43 non-caregivers underwent biological assessment of allostatic load and psychological assessments. Caregivers had significantly higher allostatic load compared to non-caregivers ( p < .05). Mastery, but not depression or overload, moderated the relationship between caregiving status and allostatic load. In conclusion, allostatic load may represent a link explaining how stress translates to downstream pathology, but more work is necessary to understand the role of psychological factors.

Gerontologic biostatistics: the statistical challenges of clinical research with older study participants

The medical and personal circumstances of older persons present challenges for designing and analyzing clinical research studies in which they participate. These challenges that elderly study samples present are not unique, but they are sufficiently distinctive to warrant deliberate and systematic attention. Their distinctiveness originates in the multifactorial etiologies of geriatric health syndromes and the multiple morbidities accruing with aging at the end of life. The objective of this article is to identify a set of statistical challenges arising in research with older persons that should be considered conjointly in the practice of clinical research and addressed systematically in the training of biostatisticians intending to work with gerontologists, geriatricians, and older study participants. The statistical challenges include design and analytical strategies for multicomponent interventions, multiple outcomes, state transition models, floor and ceiling effects, missing data, and mixed methods. The methodological and pedagogical themes of this article will be integrated by a description of a proposed subdiscipline of "gerontologic biostatistics" and supported by the introduction of new set of statistical resources for researchers working in this area. These conceptual and methodological resources have been developed in the context of several collaborating Claude D. Pepper Older Americans Independence Centers.