A randomized controlled trial to examine the effectiveness of case management model for community dwelling older persons with mild dementia in Hong Kong

[DemStepCare: Risk-stratified support for primary care-based dementia care - evaluation from general practitioner's view]

OBJECTIVE

The innovation fund project DemStepCare aimed to optimize multi-professional care through case management, risk stratification, and crisis outpatient clinic. Here, the evaluation results from the perspective of the general practitioners are presented.

METHODS

A quantitative survey was carried out at three time points regarding acceptance, benefit assessment and sensitivity to dementia of the general practitioners. In addition, qualitative interviews were conducted.

RESULTS

Satisfaction with the overall project was high. Added value and relief factors were perceived and more effective and stable dementia care was achieved through collaboration with case management. Physicians reported increased subjective competence in diagnostics and disease management.

CONCLUSIONS

The results confirm the benefit and effectiveness of DemStepCare from general practitioner's perspective.

What is well-being? A scoping review of the conceptual and operational definitions of occupational well-being

Well-being is a multifaceted construct that is used across disciplines to portray a state of wellness, health, and happiness. While aspects of well-being seem universal, how it is depicted in the literature has substantial variation. The aim of this scoping review was to identify conceptual and operational definitions of well-being within the field of occupational health. Broad search terms were used related to well-being and scale/assessment. Inclusion criteria were (1) peer-reviewed articles, (2) published in English, (3) included a measure of well-being in the methods and results section of the article, and (4) empirical paper. The searches resulted in 4394 articles, 3733 articles were excluded by reading the abstract, 661 articles received a full review, and 273 articles were excluded after a full review, leaving 388 articles that met our inclusion criteria and were used to extract well-being assessment information. Many studies did not define well-being or link their conceptual definition to the operational assessment tool being used. There were 158 assessments of well-being represented across studies. Results highlight the lack of a consistent definitions of well-being and standardized measurements.

Case management for people with dementia living at home and their informal caregivers: A scoping review

Case management is a complex intervention aimed at addressing a variety of health needs of people in their social environment. Case management for people with dementia is often poorly defined and insufficiently described. The crucial process steps are often not well understood. We aim to map and compare the key components, processes and contextual factors of case management programmes for dementia and to explore aspects of the interventions' generalisability. Our search covered the databases PubMed, CINAHL, Cochrane and GeroLit, as well as policy papers from international organisations. We included qualitative, quantitative and mixed-methods studies in the English or German language that was published between 1999 and 2020. The programmes were analysed according to programme characteristics, case management intervention and the structural and processing conditions. We identified 67 studies dealing with 25 programmes. Approximately half of the programmes were investigated in randomised controlled trials, two programmes used a mixed-methods design and the remaining were the subject of pre-post cohort studies. Participants in the studies were predominantly dyads of people with dementia and their informal caregivers. About half of the programmes reported a theoretical framework. All the programmes were derived from case management approaches or referred to such approaches. Despite huge differences in implementation, all the programmes covered the case management steps. In 14 out of 25 programmes, case management was carried out without additional intervention, the other programmes provided mainly education and training for informal caregivers. Costs of the case management interventions were stated in more than half of the programmes.The effectiveness and generalisability of dementia-specific case management interventions could be enhanced if the framework introduced in the review was used in the future by policy, practice and research.

Occupational therapy interventions for adult informal carers and implications for intervention design, delivery and evaluation: A systematic review

Introduction

Informal carers provide vital support for patients, reducing strain on health and social care services. However, caring can detrimentally affect carers’ health and wellbeing, thus policy advocates for improved carer support. Objective: to establish the published international evidence base regarding interventions for carers delivered by occupational therapists.

Method

English language studies published January 2010–January 2021 were identified against predetermined inclusion/exclusion criteria via searches of MEDLINE, EMBASE, CINAHL, PsychINFO, OTSeeker, Scopus, Web of Science and the Cochrane Library. Supplemental strategies: database alerts, hand-searching, searching of included papers’ reference lists and citations, and contacting key authors. Two reviewers completed critical appraisal and produced a textual narrative synthesis of data using a convergent integrated method.

Results

38 papers were included, reporting 21 interventions. Most were dyadic, home-based interventions for carers of people living with dementia. Common intervention components included: assessment and goal-setting, skill training, education, coping strategies, equipment provision, environmental adaptation and signposting. Interventions improved outcomes for carers, however, intervention design and evaluation require careful consideration to maximise carer benefits and capture intervention effects.

Conclusion

Occupational therapist delivered carer interventions enhance support and improve carer outcomes. Intervention and evaluation designs should include careful selection of outcome measures, avoidance of increased carer burden in dyadic interventions and acknowledgement of known barriers and facilitators to both carer and therapist intervention engagement.

What long-term care interventions have been published between 2010 and 2020? Results of a WHO scoping review identifying long-term care interventions for older people around the world

OBJECTIVE

The global population is rapidly ageing. To tackle the increasing prevalence of older adults' chronic conditions, loss of intrinsic capacity and functional ability, long-term care interventions are required. The study aim was to identify long-term care interventions reported in scientific literature from 2010 to 2020 and categorise them in relation to WHO's public health framework of healthy ageing.

DESIGN

Scoping review conducted on PubMed, CINHAL, Cochrane and Google Advanced targeting studies reporting on long-term care interventions for older and frail adults. An internal validated Excel matrix was used for charting.Setting nursing homes, assisted care homes, long-term care facilities, home, residential houses for the elderly and at the community.

INCLUSION CRITERIA

Studies published in peer-reviewed journals between 1 January 2010 to 1 February 2020 on implemented interventions with outcome measures provided in the settings mentioned above for subjects older than 60 years old in English, Spanish, German, Portuguese or French.

RESULTS

305 studies were included. Fifty clustered interventions were identified and organised into four WHO Healthy Ageing domains and 20 subdomains. All interventions delved from high-income settings; no interventions from low-resource settings were identified. The most frequently reported interventions were multimodal exercise (n=68 reports, person-centred assessment and care plan development (n=22), case management for continuum care (n=16), multicomponent interventions (n=15), psychoeducational interventions for caregivers (n=13) and interventions mitigating cognitive decline (n=13).

CONCLUSION

The identified interventions are diverse overarching multiple settings and areas seeking to prevent, treat and improve loss of functional ability and intrinsic capacity. Interventions from low-resource settings were not identified.

Predicting the burden of family caregivers from their individual characteristics

This study examined the association between caregivers' burdens and their individual characteristics and identified characteristics that are useful for predicting the level of caregiver burden. We successfully surveyed 387 family caregivers, having them complete the caregiver burden inventory scale (CBI) and an individual characteristic questionnaire. When we compared the average CBI scores between groups with a particular individual characteristic (including caring for older adult(s), educational level, employment status, place of birth, marital status, financial status, need for family support, need for friend support, and need for nonprofit organizational support), we found a significant difference in the average scores. From a logistic regression model, with burden level as the outcome, we found that caring for older adult(s), educational level, employment status, place of birth, financial situation, and need for nonprofit organizational support were significant predictors of the burden level of caregivers. The research findings suggest that certain individual characteristics can be adopted for identifying and quantifying caregivers who may have a higher level of burden. The findings are useful to uncover caregivers who may need prompt support and social care.

Effectiveness of interventions for people living with dementia and their carers in Chinese communities: protocol for a systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

As the largest and most rapidly ageing population, Chinese people are now the major driver of the continued growth in dementia prevalence globally. The need for evidence-based interventions in Chinese communities is urgent. Although a wide range of pharmacological and non-pharmacological interventions for dementia have been trialled in Chinese populations, the evidence has not been systematically synthesised. This systematic review and meta-analysis aims to map out the interventions for people living with dementia and their carers in Chinese communities worldwide and compare the effectiveness of these interventions.

METHODS AND ANALYSIS

This protocol followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist. We will search Chinese (China National Knowledge Infrastructure, WanFang DATA) and English bibliographical databases (MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Global Health, WHO Global Index Medicus, Virtual Health Library, Cochrane CENTRAL, Social Care Online, BASE, MODelling Outcome and cost impacts of interventions for DEMentia (MODEM) Toolkit, Cochrane Database of Systematic Reviews), complemented by hand searching of reference lists. We will include studies evaluating the effectiveness of interventions for dementia or mild cognitive impairment in Chinese populations, using a randomised controlled trial design, and published between January 2008 and June 2020. We will use a standardised form to extract data and Version 2 of the Cochrane risk-of-bias tool for randomised trials to assess the risk of bias of the included studies. Collected data will be fully interpreted with narrative synthesis and analysed using pairwise and network meta-analyses to pool intervention effects where sufficient information is available. We will perform subgroup analysis and meta-regression to explore potential reasons for heterogeneity.

ETHICS AND DISSEMINATION

No formal ethics approval is required for this protocol. The findings will facilitate the development of studies on interventions for dementia and timely inform dementia policymaking and practice. Planned dissemination channels include peer-reviewed publications, conference presentations, public events and websites.

PROSPERO REGISTRATION NUMBER

CRD42019134135.

Utilization of occupational therapy services and relation to survival in people taking dementia-specific medication in Austria-A retrospective population-based study with a 13-year observation period

OBJECTIVES

Evidence-based treatment of dementia includes pharmacological and non-pharmacological methods of which psycho-social interventions are an important component, commonly administered by occupational therapists. The aim of this study was to investigate the utilization of occupational therapy (OT) services and its association with survival in people taking dementia-specific medication in a population-based Austrian dataset compared to a two times as large control group without dementia-specific medication.

METHODS/DESIGN

A retrospective study with a 13-year observation period (2003-2016) was conducted on real-world data. Two stratifications were done and we used descriptive statistics, Chi-squared/Fisher's Exact Tests and survival analyses including three Cox models.

RESULTS

Data from 286,553 participants were analysed. Only 4.5% (n = 12,950) received OT services. In the dementia-medication group (n = 111,033), participants who received OT services (3.6%; n = 4032) had significantly more comorbidities (4.7%) compared to those without OT (3.5%; p < 0.001) and were also more likely to be male (4 vs. 3.5%; p < 0.001). While persons taking dementia-specific medication showed a slightly reduced survival with OT (p < 0.001) compared to those without, the result in the control group without dementia-specific medication showed a slightly better result of the participants who received OT (p < 0.001). The reduced survival in the dementia-medication group with OT is likely to be related to the higher number of comorbidities in this group.

CONCLUSION

People receiving dementia-specific medication were more likely to receive OT if they had additional comorbidities, however our analysis showed that utilization of OT services in Austria was very low indicating an overall insufficient accessibility of OT services for patients who needed it.

Effects of case management intervention for people with dementia and their carers: A systematic review and meta-analysis of experimental studies

BACKGROUND

Case management has been developed and suggested as a method for improving the quality of dementia care by optimising care service and delivery using a feasible and cost-effective approach. However, the effects of case management for improving dementia care remain inconclusive.

AIM

To analyse the efficacy of case management interventions for people with dementia and their carers.

DESIGN

Systematic review and meta-analysis.

METHODS

This study conducted a systematic review of the literature from January 1, 2002, to March 15, 2021, indexed in the following databases: Academic Search Complete, CINAHL, Cochrane Library, EMBASE, MEDLINE, PubMed, OVID, and Web of Science. Intervention studies examining patients with dementia and their carers published in the English language were included. The methodological quality of included studies was evaluated using the PEDro scale. The meta-analysis was performed using a random-effects model to calculate the pooled standardised mean difference (SMD) of case management intervention outcomes for both people with dementia (cognitive function, neuropsychiatric symptoms, and quality of life) and their carers (carer burden). Stata 16.0 was used for statistical analysis.

RESULTS

A total of eight studies met the eligibility criteria for this study. The results of the quantitative analysis, ranging from 6 to 18 months, showed no significant effect on cognitive function, quality of life over 12 months and longer, and carer burden over time between groups with and without intervention. However, significant improvements were observed for neuropsychiatric symptoms over 12 months and longer and quality of life at six months in the case management group.

CONCLUSION

Case management appears to have the potential to improve the health outcomes among people with dementia. However, these conclusions are limited due to the lack of conducted studies. Future work examining intervention outcomes remains necessary to explore the effects of interventions on the mental and physical wellbeing of carers.

The Effectiveness of Community Occupational Therapy Interventions: A Scoping Review

Background: This review aims to evaluate the level of scientific evidence for the effectiveness of Community Occupational Therapy interventions. Methods: A systematic review was used to analyze and synthesize the studies collected. The databases of Cochrane, OTseeker, OTCATS, Web of Science, Scielo and Scopus were used in order to collect articles published between 2007 and 2020. PRISMA recommendations were followed. Results: A total of 12 articles comprised part of the study (7 randomized controlled studies, 4 systematic reviews and 1 meta-analysis). The main areas of practice were geriatric gerontology (22.1%) and mental health (19.7%), which were statistically significant (χ²; p < 0.005) compared to the rest. Regarding the studies analyzed, all of them had scores of >7 on the PEDro and AMSTAR scales. Conclusions: Research on Community Occupational Therapy constitutes a consolidated line of research but the objectives and areas of research were limited. Descriptive qualitative methodology predominated and studies on the effectiveness of Community Occupational Therapy interventions showed a medium–low level of evidence.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews

BACKGROUND

With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

METHODS

We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

RESULTS

Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

DISCUSSION

Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Outcomes tested in non-pharmacological interventions in mild cognitive impairment and mild dementia: a scoping review

OBJECTIVES

Non-pharmacological treatments are an important aspect of dementia care. A wide range of interventions have been trialled for mild dementia and mild cognitive impairment (MCI). However, the variety of outcome measures used in these trials makes it difficult to make meaningful comparisons. The objective of this study is to map trends in which outcome measures are used in trials of non-pharmacological treatments in MCI and mild dementia.

DESIGN

Scoping review.

DATA SOURCES

EMBASE, PsychINFO, Medline and the Cochrane Register of Controlled Trials were searched from inception until February 2018. An additional search was conducted in April 2019 ELIGIBILITY: We included randomised controlled trials (RCTs) testing non-pharmacological interventions for people diagnosed with MCI or mild dementia. Studies were restricted to full RCTs; observational, feasibility and pilot studies were not included.

CHARTING METHODS

All outcome measures used by included studies were extracted and grouped thematically. Trends in the types of outcome measures used were explored by type of intervention, country and year of publication.

RESULTS

91 studies were included in this review. We extracted 358 individual outcome measures, of which 78 (22%) were used more than once. Cognitive measures were the most frequently used, with the Mini-Mental State Examination being the most popular.

CONCLUSIONS

Our findings highlight an inconsistency in the use of outcome measures. Cognition has been prioritised over other domains, despite previous research highlighting the importance of quality of life and caregiver measures. To ensure a robust evidence base, more research is needed to highlight which outcome measures should be used over others.

PROSPERO REGISTRATION NUMBER

CRD42018102649.

The relationship between comorbidities in dementia patients and burden on adult-child primary caregivers: Does having a secondary caregiver matter?

Primary family caregivers of patients with dementia often experience high caregiver burden and significant decline in a range of health outcomes. The current study examined the relationship between medical comorbidities of inpatients with dementia and caregiver burden in adult-child primary caregivers, and the buffering effect of having a secondary caregiver on the relationship between patients' comorbidities and caregiver burden. The study is a secondary analysis of data from a cross-sectional observational study design. The sample comprised 477 dyads of inpatients with dementia and adult-child primary caregivers attending the neurological department of two grade A hospitals. All the inpatients were assessed with the Charlson Comorbidity Index (CCI) and the Mini-Mental State Examination (MMSE). All the adult-child primary caregivers were assessed with the Zarit Burden Interview (ZBI) and completed the questionnaires on socio-demographic data, caring hours, presence of secondary caregiver, and the level of impairment of the patient. Higher burden was associated with higher scores on the CCI and having a spouse of the patient as the secondary caregiver. A significant interaction occurred between the CCI and caregiver burden when having a spouse as the secondary caregiver, indicating the negative effect of the CCI on caregiver burden was greater when the spouse of the patient served as the secondary caregiver. In summary, the negative impact of patients' comorbidities on caregiver burden in adult-child primary caregivers was heightened when the secondary caregiver role was undertaken by the spouse of the patient with dementia. These results may inform programmes targeted to improve care arrangements for people with dementia and their caregivers.

Interventions for reducing levels of burden amongst informal carers of persons with dementia in the community. A systematic review and meta-analysis of randomised controlled trials

Objectives: Caregiver burden can lead to increased stress, depression and health difficulties for caregivers and care-recipients. This systematic review aimed to examine the published evidence, for interventions designed to reduce levels of carer burden, in those caring for a person with dementia. Methods: Three databases were searched (Medline, PsycINFO and CINAHL) for studies reporting on randomised controlled trials of non-pharmacological interventions for dementia-related caregiver burden. Data quality checks were completed for included papers and meta-analysis was performed to estimate the efficacy of individual interventions and different categories of non-pharmacological intervention. Results: Thirty studies were included in the analysis. Seven studies found a significant reduction in carer burden and a pooled effect found that intervening was more effective than treatment as usual (SMD = -0.18, CI = -0.30, -0.05). This result was small, but significant (p = 0.005). Multi-component interventions are more effective than other categories. High heterogeneity means that results should be interpreted with caution. Conclusions: Interventions that significantly reduced levels of burden should be replicated on a larger scale. The relative effectiveness of interventions targeting cognitive appraisals and coping styles suggests that future interventions might be informed by models theorising the role of these processes in carer burden.

Interventions to support family caregivers of people living with dementia in high, middle and low-income countries in Asia: a scoping review

INTRODUCTION

Despite increasing numbers of persons living with Alzheimer's disease and Alzheimer's-related dementias (AD/ADRD) in Asia, particularly in low-income countries (LIC) and middle-income countries (MIC), surprisingly little is known about the current state of the evidence for family caregiver interventions. The objectives of this scoping review were to: (1) describe the evidence for efficacy of family dementia-caregiver psychosocial interventions in Asian countries, (2) compare evidence across LIC, MIC, and high-income countries (HIC), and (3) characterise cultural adaptions to interventions developed outside Asia.

METHODS

The inclusion criteria included: (1) conducted in Asia (2) included an intervention delivered to a family caregiver of a person living with AD/ADRD, (3) reported quantitative outcomes for the family caregiver and (4) published in a peer-reviewed journal with full text available in English.

RESULTS

Thirty intervention trials were identified meeting inclusion criteria and all reported statistically significant (p<0.05) improvement in one or more caregiver outcomes. Interventions usually included multiple components. The most frequently reported outcomes (ie, by ≥20% of studies) were caregiver depression, burden, quality of life and self-efficacy. Overall, 26 (87%) of the studies were conducted in HIC in Asia, primarily in Hong Kong SAR-China and Taiwan, and only 4 (13%) in LIC and MIC in Asia. Seven studies (23%) used interventions developed in USA and several described cultural adaptations.

CONCLUSION

This scoping review found substantial evidence, particularly from high-income Asian countries, that a wide range of interventions improve AD/ADRD family caregiver outcomes. However, critical knowledge gaps exist, particularly for LIC and MIC in Asia, where the number of persons with dementia is numerically largest and projected to increase dramatically in coming decades. The field could also benefit from more detailed descriptions of the process and types of cultural adaptations to interventions.

Occupational therapy for people with dementia and their family carers provided at home: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of occupational therapy provided at home on activities of daily living, behavioural and psychological symptoms of dementia (BPSD) and quality of life (QOL) for people with dementia, and the effect on family carer burden, depression and QOL.

DESIGN

Systematic review and meta-analysis.

METHODS

Eight databases were searched to February 2018. Randomised controlled trials of occupational therapy delivered at home for people with dementia and their family carers that measured ADL, and/or BPSD were included. Two independent reviewers determined eligibility, risk of bias and extracted data.

RESULTS

Fifteen trials were included (n=2063). Occupational therapy comprised multiple components (median=8 sessions). Compared with usual care or attention control occupational therapy resulted in improvements in the following outcomes for people with dementia: overall ADL after intervention (standardised means difference (SMD) 0.61, 95% CI 0.16 to 1.05); instrumental ADL alone (SMD 0.22, 95% CI 0.07 to 0.37; moderate quality); number of behavioural and psychological symptoms (SMD -0.32, 95% CI -0.57 to -0.08; moderate quality); and QOL (SMD 0.76, 95% CI 0.28 to 1.24) after the intervention and at follow-up (SMD 1.07, 95% CI 0.58 to 1.55). Carers reported less hours assisting the person with dementia (SMD -0.33, 95% CI -0.58 to -0.07); had less distress with behaviours (SMD -0.23, 95% CI -0.42 to -0.05; moderate quality) and improved QOL (SMD 0.99, 95% CI 0.66 to 1.33; moderate quality). Two studies compared occupational therapy with a comparison intervention and found no statistically significant results. GRADE ratings indicated evidence was very low to moderate quality.

CONCLUSIONS

Findings suggest that occupational therapy provided at home may improve a range of important outcomes for people with dementia and their family carers. Health professionals could consider referring them for occupational therapy.

PROSPERO REGISTRATION NUMBER

CRD42011001166.

Reappraising the Efficacy and Acceptability of Multicomponent Interventions for Caregiver Depression in Dementia: The Utility of Network Meta-Analysis

Background

Previous meta-analyses have demonstrated the efficacy of interventions for caregiver depression in dementia. However, they generally lumped the interventions together without accounting for the multicomponent nature of most interventions. It is unknown which combination of components contributed to the efficacy and should be implemented in clinical practice.

Objectives

To reappraise the interventions for caregiver depression from a recent systematic review, and evaluate whether a network meta-analytic approach offers additional insight into the efficacy and acceptability of multicomponent interventions.

Research Design and Methods

This study built upon a recent systematic review which identified 33 RCTs on caregiver depression from multiple databases (Medline, EMBASE, CENTRAL, PsycINFO, PSYNDEX). The 33 RCTs had different combinations of components serving at least one of the three key functions: addressing the care needs of persons with dementia (“CN”), addressing caregiving competency (“CC”), and providing emotional support for loss and grief (“ES”). A Bayesian network meta-analysis was conducted to compare the efficacy and all-cause attrition across different combinations of interventions.

Results

CN–CC combination was significantly more efficacious than treatment-as-usual (standardized mean difference in depression scores, SMD = −0.25, 95% credible interval [CrI] = −0.41 to −0.08) and marginally better than CN (SMD = −0.43, 95% CrI = −0.85 to −0.00). While none of the interventions clearly had both high efficacy and acceptability, three combinations of interventions (CC, CN–CC, and CN–CC–ES) had a reasonable balance between efficacy and acceptability.

Discussion and Implications

Although interventions for caregiver depression in dementia are effective in general, the different components of interventions may not share the same efficacy and acceptability. In implementing interventions, policymakers may consider addressing CC first, introducing CN in a graded manner, and providing ES only when indicated. Future studies may also consider using network meta-analysis to gain additional insights on how to implement multicomponent interventions in geriatric care.

Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions

Background

Two-thirds of people living with dementia live at home in the UK and many experience distressing behavioural and psychological symptoms. This systematic review evaluates the effectiveness of non-pharmacological interventions for behavioural and psychological symptoms among community-dwelling people living with dementia.

Methods

This two-stage review undertook an initial mapping of the literature followed by a systematic review of relevant randomised controlled trials. We searched electronic databases for pertinent studies reporting outcomes from interventions from January 2000 to March 2015 and updated searches in October 2016. We included studies that considered behavioural and psychological symptom management for older people living with dementia who live at home and excluded studies conducted in long-term care settings. This paper presents findings from a narrative synthesis of 48 randomised controlled trials evaluating interventions for people living with dementia alone, family carers alone and patient-carer dyads.

Results

We retrieved 17,871 de-duplicated records and screened them for potential inclusion. Evidence from 48 randomised controlled trials suggests that family carer training and educational programmes that target problem behaviours and potential triggers can improve outcomes. Nurses and occupational therapists appear to help people with dementia with behavioural and psychological symptoms, but professional comparisons are lacking and there is no shared language about or understanding of behavioural and psychological symptoms amongst professionals, or between professionals and family carers.

Conclusions

Future research should focus on the effectiveness of components of multi-faceted programmes and their cost effectiveness and include qualitative data to better target interventions for behavioural and psychological symptoms. It is important to consider family carer readiness to use non-pharmacological strategies and to develop a shared language about the inherent needs and communications of behavioural and psychological symptoms.

Supporting carers of people with dementia: What is effective?

Carer stress is well documented, especially in those caring for individuals with dementia. A recommendation of all national dementia strategies is to provide excellent support and information to informal carers of people with dementia. NICE guidance suggests that a range of tailored interventions, including psychological input, psychoeducation and training courses, should be offered to reduce caregiver burden and stress, although good-quality outcome-based evidence is lacking. On the basis of a narrative review of the literature, we describe individual and multicomponent carer support packages and discuss their evidence base, reflecting on outcomes for carers. Multicomponent interventions have the best evidence for effectiveness.

Learning Objectives

• Consider the risks of both physical and psychological harm experienced by carers of people with dementia (often referred to as carer burden or caregiver burden)

• Be aware of the interventions available for the support of carers of people with dementia

• Consider the evidence for the effectiveness of these interventions and be aware of the limitations of the evidence

The effectiveness of community-based coordinating interventions in dementia care: a meta-analysis and subgroup analysis of intervention components

Background

Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to evaluate the effectiveness of community-based care coordinating interventions on health outcomes and investigate whether specific components of interventions influence their effects.

Methods

We searched four databases from inception to April 2017: Medline, The Cochrane Library, EMBASE and PsycINFO. This was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted meta-analyses and subgroup analyses.

Results

A total of 14 randomised controlled trials (RCTs) involving 10,372 participants were included in the review. Altogether we carried out 12 meta-analyses and 19 subgroup analyses. Meta-analyses found coordinating interventions showed a statistically significant improvement in both patient behaviour measured using the Neuropsychiatric Inventory (NPI) (mean difference (MD) = −9.5; 95% confidence interval (CI): −18.1 to −1.0; p = 0.03; number of studies (n) = 4; I² = 88%) and caregiver burden (standardised mean difference (SMD) = −0.54; 95% CI: -1.01 to −0.07; p = 0.02; n = 5, I² = 92%) compared to the control group. Subgroup analyses found interventions using a case manager with a nursing background showed a greater positive effect on caregiver quality of life than those that used case managers from other professional backgrounds (SMD = 0.94 versus 0.03, respectively; p < 0.001). Interventions that did not provide supervision for the case managers showed greater effectiveness for reducing the percentage of patients that are institutionalised compared to those that provided supervision (odds ratio (OR) = 0.27 versus 0.96 respectively; p = 0.02). There was little evidence of effects on other outcomes, or that other intervention components modify the intervention effects.

Conclusion

Results show that coordinating interventions in dementia care has a positive impact on some outcomes, namely patient behaviour and caregiver burden, but the evidence is inconsistent and results were not strong enough to draw definitive conclusions on general effectiveness. With the rising prevalence of dementia, effective complex interventions will be necessary to provide high quality and effective care for patients, and facilitate collaboration of health, social and third sector services.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2677-2) contains supplementary material, which is available to authorized users.

Cognitive Stimulation as a Therapeutic Modality for Dementia: A Meta-Analysis

OBJECTIVE

Although cognitive stimulation (CS) is one of the most popular non-pharmacological interventions for people with dementia, its efficacy is still debatable. We performed a meta-analysis of randomized controlled trials (RCTs) on the efficacy of CS in people with dementia.

METHODS

Data sources were identified by searching PubMed, MEDLINE, Embase, psychINFO, and Cochrane Reviews Library. A total of 7,354 articles were identified, and of these, 30 RCTs were selected based on the selection criteria. Of these 30 RCTs, 14 were finally included in our meta-analysis [731 participants with dementia; 412 received CS (CS group) and 319 received usual care (control group)].

RESULTS

We found that the people with dementia had a moderate benefit from CS. The mean difference between the CS and control groups was 2.21 [95% CI (0.93, 3.49), Z=3.38, p=0.00007] in the Alzheimer's Disease Assessment Scale-Cognition and 1.41 [95% CI (0.98, 1.84), Z=6.39, p<0.00001] in the Mini-Mental State Examination. CS also improved quality of life in people with dementia [95% CI (0.72, 3.38), Z=3.02, p=0.003].

CONCLUSION

CS is effective for improving cognition and quality of life in people with dementia; however, its effects were small to moderate.

Effectiveness of Interventions for Caregivers of People With Alzheimer’s Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE. The goal of the evidence review was to evaluate the effectiveness of interventions for caregivers of people with Alzheimer’s disease and related major neurocognitive disorders that facilitate the ability to maintain participation in the caregiver role.

METHOD. Scientific literature published in English between January 2006 and April 2014 was reviewed. Databases included MEDLINE, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews.

RESULTS. Of 2,476 records screened, 43 studies met inclusion criteria. Strong evidence shows that multicomponent psychoeducational interventions improve caregiver quality of life (QOL), confidence, and self-efficacy and reduce burden; cognitive reframing reduces caregiver anxiety, depression, and stress; communication skills training improves caregiver skill and QOL in persons with dementia; mindfulness-based training improves caregiver mental health and reduces stress and burden; and professionally led support groups enhance caregiver QOL.

CONCLUSION. Strong evidence exists for a spectrum of caregiver interventions. Translation of effective interventions into practice and evaluation of sustainability is necessary.

Consequences of clinical case management for caregivers: a systematic review

OBJECTIVE

Informal caregivers are deeply involved in the case management process. However, little is known about the consequences of such programs for informal caregivers. This systematic literature review, reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, addressed the consequences of clinical case management programs, whether positive or negative, for caregivers of frail older persons or persons with dementia.

METHODS

We systematically identified and analyzed published randomized trials and quasi-experimental studies comparing case management programs to usual care, which discussed outcomes concerning caregivers.

RESULTS

Sixteen studies were identified, and 12 were included after quality assessment. Seven identified at least one positive result for caregivers, and no negative effect of case management has been found. Characteristics associated with positive results for caregivers were a high intensity of case management and programs specifically addressed to dementia patients.

CONCLUSIONS

Despite the numerous methodological challenges in the assessment of such complex social interventions, our results show that case management programs can be beneficial for caregivers of dementia patients and that positive results for patients are achieved without increasing caregivers' burden. Copyright © 2017 John Wiley & Sons, Ltd.

Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial

OBJECTIVE

To investigate effects of a novel dementia care coordination program on health services utilization.

DATA SOURCES/STUDY SETTING

A total of 303 community-dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008-2011).

STUDY DESIGN

Single-blind RCT evaluating efficacy of an 18-month care coordination intervention delivered through community-based nonclinical care coordinators, supported by an interdisciplinary clinical team.

DATA COLLECTION/EXTRACTION METHODS

Study partners reported acute care/inpatient, outpatient, and home- and community-based service utilization at baseline, 9, and 18 months.

PRINCIPAL FINDINGS

From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community-based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005).

CONCLUSIONS

While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia-related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.

Development of a model of dementia support and pathway for culturally and linguistically diverse communities using co-creation and participatory action research

OBJECTIVE

To develop an inclusive model of culturally sensitive support, using a specialist dementia nurse (SDN), to assist people with dementia from culturally and linguistically diverse (CALD) communities and their carers to overcome barriers to accessing health and social care services.

DESIGN

Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and stakeholders.

SETTING

An SDN support model embedded within a home nursing service in Melbourne, Australia was implemented between October 2013 and October 2015.

PARTICIPANTS

People experiencing memory loss or with a diagnosis of dementia from CALD backgrounds and their carers and family living in the community setting and expert stakeholders.

DATA COLLECTION AND ANALYSIS

Reflections from the SDN on interactions with participants and expert stakeholder opinion informed the CALD dementia support model and pathway.

RESULTS

Interaction with 62 people living with memory loss or dementia from CALD backgrounds, carers or family members receiving support from the SDN and feedback from 13 expert stakeholders from community aged-care services, consumer advocacy organisations and ethnic community group representatives informed the development and refinement of the CALD dementia model of care and pathway. We delineate the three components of the 'SDN' model: the organisational support; a description of the role; and the competencies needed. Additionally, we provide an accompanying pathway for use by health professionals delivering care to consumers with dementia from CALD backgrounds.

CONCLUSIONS

Our culturally sensitive model of dementia care and accompanying pathway allows for the tailoring of health and social support to assist people from CALD backgrounds, their carers and families to adjust to living with memory loss and remain living in the community as long as possible. The model and accompanying pathway also have the potential to be rolled out nationally for use by health professionals across a variety of health services.

Acceptance and efficacy of interventions for family caregivers of elderly persons with a mental disorder: a meta-analysis

BACKGROUND

The aim of the present study was to conduct an extended meta-analysis of the efficacy and acceptance of supportive interventions for alleviating depressive symptoms in family caregivers of elderly relatives with a mental disorder, including dementia. The second aim was to analyze intervention characteristics as potential moderators of the efficacy and acceptance of these interventions.

METHODS

We searched electronic databases for randomized controlled trials (RCTs) published between 2005 and 2014. Thirty-three studies were included in the meta-analysis with a total of 5,980 participants.

RESULTS

No RCTs that tested interventions for caregivers of elderly patients with mental disorders other than dementia were found. The weighted pooled effect size of the interventions for caregivers of dementia patients was positive but small (standardized mean difference = 0.13; CI0.95 [0.03; 0.23], p = 0.01). Meta-regression analysis revealed higher effect sizes for interventions that were individually customized. Intervention discontinuation rates were low (mean 11%, SD = 6.3) and independent of most intervention characteristics. If the intervention was delivered via telecommunication intervention discontinuation rates tended to be higher (r = -0.39, p = 0.07).

CONCLUSIONS

Comparative research for caregivers of elderly patients with mental disorders other than dementia is lacking. RCTs of interventions for family caregivers of dementia patients of the last decade show good acceptance among intervention participants, but there is still a need to improve the efficacy of these interventions. Individual customization of intervention components might enhance efficacy. More research is needed on the acceptance of telecommunication interventions for family caregivers.

What is the effectiveness of the support worker role for people with dementia and their carers? A systematic review

BACKGROUND

Dementia is progressive in nature and the associated functional decline inevitably leads to increasing dependence on others in areas of daily living. Models of support have been developed and implemented to assist with adjusting to living with memory loss and functional decline; to navigate the health and aged care system; and to access services. We undertook a systematic review of international literature on key worker type support roles to identify essential components and ascertain how the role can be best utilised to assist community-dwelling people with dementia and their carers. This review of support roles is the first to our knowledge to include both quantitative and qualitative studies and all models of support.

METHOD

A systematic review of studies written in English and published between January 2003 and December 2014. Data sources were Medline, PsychInfo and CINAHL, internet, expert consultation and reference lists of included studies. After screening articles to ensure that they reported on a key worker type support role, involved carers and or people with dementia living at home and removing duplicates, eligible papers were appraised and evaluated.

RESULTS

Thirty six studies were eligible for inclusion in the review. Eligible studies were divided into type of support roles and study type. The heterogeneity of included studies and high risk of bias made a meta-analysis inappropriate and it was therefore difficult to draw overall conclusions. However, essential components shared across support worker models that demonstrated a positive impact on carer burden and improved quality of life included: long term intervention, face to face contact, individualised education and support based on needs, multi-disciplinary teams, collaborative input, health/clinical background of support workers, ongoing follow up and inter professional and inter-sectoral collaborations. There was a lack of studies assessing cost-effectiveness.

CONCLUSIONS

Studies that include a high quality evaluation of holistic, tailored models of support that identify which components of support produce the most valuable outcomes to assist people with dementia and their carers and families to continue to live meaningful lives are needed. There is also a need for a cost effectiveness evaluation of support worker roles.

TRIAL REGISTRATION

PROSPERO international prospective register of systematic reviews: PROSPERO 2014 CRD42014013992 .

The effectiveness of collaborative care for people with memory problems in primary care: results of the CAREDEM case management modelling and feasibility study

BACKGROUND

People with dementia and their families need support in different forms, but currently services are often fragmented with variable quality of care. Case management offers a way of co-ordinating services along the care pathway and therefore could provide individualised support; however, evidence of the effectiveness of case management for dementia is inconclusive.

OBJECTIVE

To adapt the intervention used in a promising case management project in the USA and test its feasibility and acceptability in English general practice.

DESIGN

In work package 1, a design group of varied professionals, with a carer and staff from the voluntary sector, met six times over a year to identify the skills and personal characteristics required for case management; protocols from the US study were adapted for use in the UK. The feasibility of recruiting general practices and patient-carer dyads and of delivering case management were tested in a pilot study (work package 2). An embedded qualitative study explored stakeholder views on study procedures and case management.

SETTING

Four general practices, two in the north-east of England (Newcastle) one in London and one in Norfolk, took part in a feasibility pilot study of case management.

PARTICIPANTS

Community-dwelling people with dementia and their carers who were not already being case managed by other services.

INTERVENTION

A social worker shared by the two practices in the north-east and practice nurses in the other two practices were trained to deliver case management. We aimed to recruit 11 people with dementia from each practice who were not already being case managed.

MAIN OUTCOME MEASURES

Numbers of people with dementia and their carers recruited, numbers and content of contacts, needs identified and perceptions of case management among stakeholders.

RESULTS

Recruitment of practices and patients was slow and none of the practices achieved its recruitment target. It took more than 6 months to recruit a total of 28 people with dementia. Practice Quality and Outcome Framework registers for dementia contained only 60% of the expected number of people, most living in care homes. All stakeholders were positive about the potential of case management; however, only one of the four practices achieved a level of case management activity that might have influenced patient and carer outcomes. Case managers' activity levels were not related solely to time available for case management. Delivery of case management was hindered by limited clarity about the role, poor integration with existing services and a lack of embeddedness within primary care. There were discrepancies between case manager and researcher judgements about need, and evidence of a high threshold for acting on unmet need. The practice nurses experienced difficulties in ring-fencing case management time.

CONCLUSIONS

The model of case management developed and evaluated in this feasibility study is unlikely to be sustainable in general practice under current conditions and in our view it would not be appropriate to attempt a definitive trial of this model. This study could inform the development of a case management role with a greater likelihood of impact. Different approaches to recruiting and training case managers, and identifying people with dementia who might benefit from case management, are needed, as is exploration of the scale of need for this type of working.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN74015152.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 52. See the NIHR Journals Library website for further project information.

Factors facilitating dementia case management: Results of online focus groups

To obtain insight into facilitating factors for case management in dementia care, we conducted a qualitative study with 13 online focus groups (OFGs). Participants were professionals involved in dementia case management ( N = 99). We used mind-maps and the method of constant comparison for analysis. Participants perceived OFGs as a useful tool to explore their perspectives. The perceived advantage of OFGs was the flexibility and convenience of logging in at any time or place preferred. Five facilitating factors for case management were identified in the OFGs: 1. Good cooperation between partners; 2. Organisational embedding with an independent position of case managers; 3. Structural funding; 4. Competent case managers; 5. Familiarity with case management in the region. Good cooperation was essential for successful dementia case management and should thus be a primary concern for care providers.

Occupational therapy for elderly. Evidence mapping of randomised controlled trials from 2004-2012

OBJECTIVE

Previous systematic reviews on occupational therapy for elderly included studies until 2003. The present evidence mapping summarizes recent evidence for the efficacy of occupational therapy with older persons based on randomised controlled trials from 2004-2012.

METHOD

An electronic search in Cochrane and Medline databases identified publications of randomised controlled trials on occupational therapy interventions for persons≥65 years old. Two raters independently extracted data and analysed the quality of samples, interventions and outcome evalutations according to PRISMA criteria.

RESULTS

In all, 136 abstracts were identified and 48 studies analysed, from these 12 on stroke, 15 on falls and mobility, 7 on dementia, 4 on prevention and 10 on other conditions. Reports of adverse events and evaluations of costs and long-term outcomes are frequently lacking.

CONCLUSION

The most promising fields for further research are primary and secondary prevention in persons with stroke, falls or mobility problems and tertiary prevention in persons with dementia. Future trials should be conducted and reported according to consented reporting guidelines of the equator network.

Would transcranial direct current stimulation (tDCS) enhance the effects of working memory training in older adults with mild neurocognitive disorder due to Alzheimer's disease: study protocol for a randomized controlled trial

BACKGROUND

There has been longstanding interesting in cognitive training for older adults with cognitive impairment. In this study, we will investigate the effects of working memory training, and explore augmentation strategies that could possibly consolidate the effects in older adults with mild neurocognitive disorder. Transcranial direct current stimulation (tDCS) has been demonstrated to affect the neuronal excitability and reported to enhance memory performance. As tDCS may also modulate cognitive function through changes in neuroplastic response, it would be adopted as an augmentation strategy for working memory training in the present study.

METHODS/DESIGN

This is a 4-week intervention double-blind randomized controlled trial (RCT) of tDCS. Chinese older adults (aged 60 to 90 years) with mild neurocognitive disorder due to Alzheimer's disease (DSM-5 criteria) would be randomized into a 4-week intervention of either tDCS-working memory (DCS-WM), tDCS-control cognitive training (DCS-CC), and sham tDCS-working memory (WM-CD) groups. The primary outcome would be working memory test - the n-back task performance and the Chinese version of the Alzheimer's Disease Assessment Scale - Cognitive Subscale (ADAS-Cog). Secondary outcomes would be test performance of specific cognitive domains and mood. Intention-to-treat analysis would be carried out. Changes of efficacy indicators with time and intervention would be tested with mixed effect models.

DISCUSSION

This study adopts the theory of neuroplasticity to evaluate the potential cognitive benefits of non-invasive electrical brain stimulation, working memory training and dual stimulation in older adults at risk of cognitive decline. It would also examine the tolerability, program adherence and adverse effects of this novel intervention. Information would be helpful for further research of dementia prevention studies.

TRIAL REGISTRATION

ChiCTR-TRC- 14005036 Date of registration: 31 July 2014.

Multicomponent intervention on enhancing dementia caregiver well-being and reducing behavioral problems among Hong Kong Chinese: a translational study based on REACH II

OBJECTIVE

This study examined the effectiveness of a translated version of Resources for Enhancing Alzheimer's Caregiver Health (REACH) II in Hong Kong's service delivery context.

METHOD

The localized intervention was adapted from REACH II with 12 individual-based sessions, which addressed multiple domains including disease education, safety, caregiver (CG) well-being, and care recipients' problem behavior. Two-hundred and one dementia family dyads completed the intervention.

RESULTS

The efficacy of the intervention was demonstrated by the significant improvement in the perception of positive aspects of caregiving, reduction in depressive symptoms, subjective burden, bother and caregiving risks among CGs, and abatement in behavioral problems among care recipients. Treatment implementation was reflected from the high rate of adoption of each intervention component by interventionists and satisfactory reception from CGs. Promises in reach and adoption were demonstrated by the participation of 85 interventionists from 11 NGOs across 18 districts and CGs of a variety of demographic characteristics.

DISCUSSION

This study is the first attempt to translate a highly successful evidence-based dementia CG intervention developed in the USA into the Hong Kong service delivery context. The current results echoed the success of REACH II. The values and challenges of translational research are discussed.

Case management approaches to home support for people with dementia

BACKGROUND

Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital.

OBJECTIVES

To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including 'treatment as usual', standard community treatment and other non-case management interventions.

SEARCH METHODS

We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated.

SELECTION CRITERIA

We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made 'Risk of bias' assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic.

MAIN RESULTS

We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 - 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services.

AUTHORS' CONCLUSIONS

There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.

Barriers to implementation of case management for patients with dementia: a systematic mixed studies review

PURPOSE

Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation.

METHODS

We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers.

CONCLUSIONS

Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.

The effects of mindfulness-based stress reduction program on the mental health of family caregivers: a randomized controlled trial

BACKGROUND

Caregivers of people with chronic conditions are more likely than non-caregivers to have depression and emotional problems. Few studies have examined the effectiveness of mindfulness-based stress reduction (MBSR) in improving their mental well-being.

METHODS

Caregivers of persons with chronic conditions who scored 7 or above in the Caregiver Strain Index were randomly assigned to the 8-week MBSR group (n = 70) or the self-help control group (n = 71). Validated instruments were used to assess the changes in depressive and anxiety symptoms, quality of life, self-efficacy, self-compassion and mindfulness. Assessments were conducted at baseline, post-intervention and at the 3-month follow-up.

RESULTS

Compared to the participants in the control group, participants in the MBSR group had a significantly greater decrease in depressive symptoms at post-intervention and at 3 months post-intervention (p < 0.01). The improvement in state anxiety symptoms was significantly greater among participants in the MBSR group than those of the control group at post-intervention (p = 0.007), although this difference was not statistically significant at 3 months post-intervention (p = 0.084). There was also a statistically significant larger increase in self-efficacy (controlling negative thoughts; p = 0.041) and mindfulness (p = 0.001) among participants in the MBSR group at the 3-month follow-up compared to the participants in the control group. No statistically significant group effects (MBSR vs. control) were found in perceived stress, quality of life or self-compassion.

CONCLUSIONS

MBSR appears to be a feasible and acceptable intervention to improve mental health among family caregivers with significant care burden, although further studies that include an active control group are needed to make the findings more conclusive.

Case management for dementia in primary health care: a systematic mixed studies review based on the diffusion of innovation model

Background

The purpose of this study was to examine factors associated with the implementation of case management (CM) interventions in primary health care (PHC) and to develop strategies to enhance its adoption by PHC practices.

Methods

This study was designed as a systematic mixed studies review (including quantitative and qualitative studies) with synthesis based on the diffusion of innovation model. A literature search was performed using MEDLINE, PsycInfo, EMBASE, and the Cochrane Database (1995 to August 2012) to identify quantitative (randomized controlled and nonrandomized) and qualitative studies describing the conditions limiting and facilitating successful CM implementation in PHC. The methodological quality of each included study was assessed using the validated Mixed Methods Appraisal Tool.

Results

Twenty-three studies (eleven quantitative and 12 qualitative) were included. The characteristics of CM that negatively influence implementation are low CM intensity (eg, infrequent follow-up), large caseload (more than 60 patients per full-time case manager), and approach, ie, reactive rather than proactive. Case managers need specific skills to perform their role (eg, good communication skills) and their responsibilities in PHC need to be clearly delineated.

Conclusion

Our systematic review supports a better understanding of factors that can explain inconsistent evidence with regard to the outcomes of dementia CM in PHC. Lastly, strategies are proposed to enhance implementation of dementia CM in PHC.

A home-based training program improves caregivers' skills and dementia patients' aggressive behaviors: a randomized controlled trial

OBJECTIVE

To investigate the effects of an individualized, home-based caregiver-training program for caregivers of elderly patients with dementia and behavioral problems.

METHODS

Using a randomized clinical trial in the neurologic clinics of two hospitals and a community care management center in northern Taiwan, we tested an individualized home-based caregiver-training program for managing behavioral problems, with referrals to community services and telephone consultation. Participants were patients with dementia and their caregivers (N = 129): 63 in the intervention group and 66 in the control group. The control group received only written instructions and social telephone follow-ups. Behavioral problems of elderly dementia patients were assessed by the Chinese version of the Cohen-Mansfield Agitation Inventory, community form. Family caregivers' outcomes were measured by the Agitation Management Self-efficacy Scale and the Preparedness and Competence Scales. These instruments were administered before the program and 2 weeks, 3 months, and 6 months afterward.

RESULTS

Family caregivers who received the individualized home-based training program had better preparedness (t = 2.72, df = 127, p <0.01), competence (t = 4.77, df = 126, p <0.001), and overall self-efficacy (t = 3.81, df = 127, p <0.001) at 3 months than those in the control group. Moreover, the growth rate by treatment interaction effect was significant for caregiver competence (t = 2.25, df = 127, p <0.05) and overall self-efficacy for managing behavioral problems (t = 2.16, df = 127, p <0.05). The probability of physically aggressive behavior for patients in the intervention group decreased from 0.27 to 0.12.

CONCLUSION

Our individualized home-based caregiver-training program improved caregivers' preparedness, competence, and self-efficacy for managing problematic behaviors and decreased physical aggressiveness of elderly patients with dementia.

Case managed community aged care: what is the evidence for effects on service use and costs?

OBJECTIVE

To evaluate the effects of case management in community aged care (CMCAC) interventions on service use and costs.

METHOD

Five databases were searched from inception to 2011 July to include randomized control trials and comparative observational English studies. Results were summarized by using the best-evidence synthesis approach.

RESULTS

Twenty-one studies were included. Available studies supported improvements in clients' use of case management services (all of the four studies), some community services (8 of the 10) and nursing home admission and stay (around one half), delay of nursing home placement (all of the two studies), and achieving cost neutrality (8 of the 11). The effects on medical care utilization were varying.

DISCUSSION

In general, these positive effects justify the further development and refinement of CMCAC programs. Result applicability is limited by only including English studies. Cost studies applying a societal perspective, and full economic appraisals where appropriate are warranted.

The social networks of Hong Kong Chinese family caregivers of Alzheimer's disease: correlates with positive gains and burden

PURPOSE

To examine the social networks of family caregivers of persons with Alzheimer's disease and the degree to which network characteristics were associated with satisfaction with social support, burden, and positive gains.

DESIGN AND METHODS

A total of 142 Chinese caregivers responded to measures of structural support, positive exchanges, and negative exchanges using the social convoy questionnaire, as well as to measures of social support satisfaction, burden, role overload, positive gains, self-rated health, and behavioral and psychological symptoms of dementia (BPSD) of the care recipient. Data were analyzed using multiple regression.

RESULTS

The caregivers had small networks (mean = 4.4 persons). They reported few negative exchanges with network members and higher emotional than instrumental support, while being rather satisfied with the social support obtained. Surprisingly, both spouse/sibling and adult child caregivers excluded many close kin, in particular ~40% of their children, from their networks. A larger network was associated with higher social support satisfaction and positive gains, and lower role overload. Controlling for network size and social support satisfaction, positive exchanges were associated with higher positive gains, whereas negative exchanges were associated with higher burden and overload. Caregivers who experienced more BPSD and poorer self-rated health also reported lower support satisfaction and positive gains, as well as higher burden and overload.

IMPLICATIONS

Under the influence of collectivism, individuals may shoulder the responsibilities of caregiving for the collective well-being of the family and end up being isolated and disappointed when expectations of family support were not forthcoming, to the extent that even ties with close kin may be severed.

The potential of case management for people with dementia: a commentary

BACKGROUND

A recent review of studies of case management in dementia argues that lack of evidence of cost-effectiveness should discourage the use of this approach to care. We argue that that this is too conservative a stance, given the urgent need throughout the world to improve the quality of care for people with dementia and their caregivers. We propose a research agenda on case management for people with dementia.

METHOD

A critical comparison was made of the studies identified in two systematic reviews of trials of case management for dementia, with selective inclusion of non-trial studies and economic evaluations.

RESULTS

Our interpretation of the literature leads us to four provisional conclusions. First, studies with long follow-up periods tend to show delayed relocation of people with dementia to care homes. Second, the quality of life of people with dementia and their caregivers may also influence the likelihood of relocation. Third, different understandings of what constitutes case management make interpretation of studies difficult. Fourth, we agree that the population most likely to benefit from case management needs to be characterised. Earlier intervention may be more beneficial than intervening when the condition has progressed and the individual's situation is highly complex. However, this runs counter to some definitions of case management as an administrative, professional, and systemic focus on people with high needs and where expensive support is accessed or in prospect.

CONCLUSIONS

More work needs to be carried out in a more focused way in order to establish the value of case management for people with dementia. Since care home residence is such a sizeable contributor to the costs of dementia care, studies need to be long enough to capture possible postponed relocation. However, case management studies with shorter follow-up periods can still contribute to our understanding, since they can demonstrate improved quality of life. Future research should be built around a common, agreed definition of types of case management.

Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies

BACKGROUND

Case management has been applied in community aged care to meet frail older people's holistic needs and promote cost-effectiveness. This systematic review aims to evaluate the effects of case management in community aged care on client and carer outcomes.

METHODS

We searched Web of Science, Scopus, Medline, CINAHL (EBSCO) and PsycINFO (CSA) from inception to 2011 July. Inclusion criteria were: no restriction on date, English language, community-dwelling older people and/or carers, case management in community aged care, published in refereed journals, randomized control trials (RCTs) or comparative observational studies, examining client or carer outcomes. Quality of studies was assessed by using such indicators as quality control, randomization, comparability, follow-up rate, dropout, blinding assessors, and intention-to-treat analysis. Two reviewers independently screened potentially relevant studies, extracted information and assessed study quality. A narrative summary of findings were presented.

RESULTS

Ten RCTs and five comparative observational studies were identified. One RCT was rated high quality. Client outcomes included mortality (7 studies), physical or cognitive functioning (6 studies), medical conditions (2 studies), behavioral problems (2 studies) , unmet service needs (3 studies), psychological health or well-being (7 studies) , and satisfaction with care (4 studies), while carer outcomes included stress or burden (6 studies), satisfaction with care (2 studies), psychological health or well-being (5 studies), and social consequences (such as social support and relationships with clients) (2 studies). Five of the seven studies reported that case management in community aged care interventions significantly improved psychological health or well-being in the intervention group, while all the three studies consistently reported fewer unmet service needs among the intervention participants. In contrast, available studies reported mixed results regarding client physical or cognitive functioning and carer stress or burden. There was also limited evidence indicating significant effects of the interventions on the other client and carer outcomes as described above.

CONCLUSIONS

Available evidence showed that case management in community aged care can improve client psychological health or well-being and unmet service needs. Future studies should investigate what specific components of case management are crucial in improving clients and their carers' outcomes.