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

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

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An Outpatient-Based Training Program Improves Family Caregivers' Preparedness in Caring for Persons With Mild Cognitive Impairment: A Randomized Controlled Trial

BACKGROUND

Little is known regarding the effects of training programs on family caregivers of older persons with mild cognitive impairment because of the significant differences in outcome variables measured in the various studies in the literature.

PURPOSE

This study was designed to examine the effects of an outpatient-based caregiver training program on the preparedness, health-related quality of life, and depressive symptoms of participants responsible for caring for older persons with mild cognitive impairment.

METHODS

A randomized clinical trial was implemented. Of the 54 family caregiver participants who provided complete and valid data, 28 and 26 were assigned to the experimental and control groups, respectively. The experimental group participated in a researcher-developed training program that provided information on mild cognitive impairment, strategies for maintaining and promoting cognitive function in persons with mild cognitive impairment, managing their own and their care recipients' healthcare, and managing their own emotional support and stress. Outcomes (caregiver preparedness, health-related quality of life, and depressive symptoms) were assessed before the start of the training program (baseline) and at 1, 3, and 6 months after completion of the program.

RESULTS

After controlling for baseline cognitive function of the care recipients and of caregiver preparedness, the experimental group was shown to be significantly less prepared than the control group at baseline (β = -1.41, p = .031) and better prepared than the control group at all three posttests (group differences: 1.3, 1.53, and 4.24, respectively), with the difference at the third posttest (6 months) reaching statistical significance (p = .008). No impact of the intervention on caregiver depressive symptoms or health-related quality of life was found at posttest.

CONCLUSIONS

The training intervention in this study was found to increase the perceived preparedness of the family caregiver participants to handle various aspects of providing care to persons with mild cognitive impairment. However, no changes were found in depressive symptoms or health-related quality of life.

Family Caregivers of People with Dementia Associate with Poor Health-Related Quality of Life: A Nationwide Population-Based Study

Despite the growing awareness of poor health-related quality of life (HRQoL) in family caregivers of people with dementia (PWD), their relationship has rarely been explored with population-based samples. The current cross-sectional study aimed to determine the detrimental impact of informal dementia caregiving on HRQoL by using nationally representative population-based samples from the Korean Community Health Survey. Demographics, socioeconomic, and physical and mental health-related characteristics as well as HRQoL measured by the Korean version of the European Quality of Life Questionnaire Five Dimension (EQ-5D) were compared between 9563 family caregivers of PWD and 186,165 noncaregivers. Caregivers had lower index scores and higher frequency of some/extreme problems in all five dimensions of the EQ-5D compared with noncaregivers. Logistic regression adjusting for potential confounding factors found that caregivers had a higher frequency of poor HRQoL (lowest quartile of EQ-5D index) than noncaregivers (adjusted odds ratio [95% confidence interval] = 1.46 [1.39-1.53]). Compared to noncaregivers, caregivers had a higher frequency of some/extreme problems in each dimension of the EQ-5D: mobility (1.30 [1.21-1.40]), self-care (1.62 [1.46-1.80]), usual activity (1.39 [1.29-1.51]), pain/discomfort (1.37 [1.31-1.45]), and anxiety/depression (1.51 [1.42-1.61]). A one-to-one propensity score matching analysis confirmed that poor HRQoL was more frequently found in caregivers compared to noncaregivers (1.38 [1.29-1.48]). Our results indicated that family caregivers of PWD are significantly associated with overall poor HRQoL, underscoring the detrimental impact of informal dementia caregiving on HRQoL. Given the high frequency of poor HRQoL in dementia caregivers and the important recognition of its serious consequences on physical and mental health, clinicians should take into consideration efficient interventions to improve health and HRQoL for family caregivers of PWD.

Occupational Therapy Interventions for Dementia Caregivers: Scoping Review

BACKGROUND AND PURPOSE

caregivers of people with dementia (PwD) often experience a significant caregiver burden. Occupational Therapy (OT) is a helpful discipline for improving quality of life and other health factors for these caregivers. We conducted a Scoping Review to describe OT interventions for caregivers of PwD.

METHODS

two authors searched PubMed, Scopus, EMBASE and Web of Science databases and OT journals indexed in the Journal Citation Reports. Terms included in the search strategy were: dementia, Alzheimer, Parkinson, caregivers and OT. We included articles with experimental design in which an OT intervention in caregivers of PwD was carried out, written in Spanish or English and with the full text available.

RESULTS

a total of 2121 articles were obtained, 31 of which were included; 22 of them described home-based OT interventions: Tailored Activity Program (TAP) (n = 5), Environmental Skill-Building Program (ESP) (n = 4) and Advancing Caregiver Training (ACT) (n = 3) and other household interventions (n = 10); the remaining studies described OT interventions in other settings (n = 9).

CONCLUSIONS

OT interventions for caregivers of PwD were mainly carried out at home. The most commonly used interventions were TAP focused on caregivers of people with Alzheimer's disease, aimed at lessening the burden, depression and stress experienced by caregivers.

Factors Influencing the Quality of Life of the Primary Caregiver of a Palliative Patient: Narrative Review

Introduction: Quality of life is a difficult concept to understand and therefore difficult to evaluate. From the general definition to the individuality of the person, there are factors that positively or negatively influence quality of life. Aim: The aim is to identify the factors that influence the quality of life of primary caregivers of patients with progressive life-threatening illnesses. Methodology: PUBMED was searched to retrieve the relevant literature for our research questions used the following keywords: "Quality of life and caregiver or caretaker and palliative care or life threatening disease." Only quantitative studies containing randomized trials were included using at least one caregiver's quality-of-life tool, not older than 10 years, written in English, and with subjects older than 18 years, who considered they were involved in the active care of a palliative patient. Results: A number of 687 articles were identified from which only 38 were analyzed in detail regarding the impact of different interventions over the quality-of-life of the caregiver. The factors that influence the quality-of-life can be distributed into four areas: social, psycho-emotional, financial, and physical. The disruption of daily routine, non-existential financial resources, multiple responsibilities and psychological tension are reduce the caregiver's quality-of-life. Family involvment, knowledge about disease and treatment, abilities to communicate patient and the team and optimistic atitude improve caregiver's quality-of-life. Conclusions: The quality of life of the caregiver be improved by social, and relaxation techniques, reduction of insecurity or anxiety. Furthermore, the caregiver's quality of increases through and adequate communication diagnosis, a proper conducted treatment and education over the care maneuvers.

Caregiving of children with Down syndrome: impact on quality of life, stress, mental and oral health

AIM

Parental caregivers of children with Down Syndrome (DS) have a greater burden of daily activities that may affect their health. The aim of this exploratory study was to evaluate the impact of caregiving of children with Down syndrome on parenting quality of life, stress, mental and oral health.

METHODS

Fifty-four parental caregivers of children with DS and 51 parents of children without physical or mental disabilities participated of this study. All participants were clinically examined to evaluate the presence of dental caries, gingival conditions and answered a sociodemographic questionnaire. Depression, anxiety, quality of life and coping strategies were assessed using specific instruments. Hair cortisol level was assessed as biological marker of chronic stress.

RESULTS

Psychological and quality of life parameters were similar between the groups of caregivers (p > .05). Caregivers of children with DS were older (48.6 vs. 41.5, p < .001), had longer caregiving period (> 10 vs < 10 years, p = .003), presented higher gingival bleeding index (6.1 vs. 4.7, p = .014) and higher cortisol levels (55.9 vs. 38.4, p = .07) as compared with parents of children without disabilities. Sociodemographic data has no influence on cortisol levels (p > .05).

CONCLUSIONS

These findings suggest that the caregiving of children with DS has an impact on parenting oral health and stress.

Influence of Nutritional Status on a Family-Centered Care Intervention for Older Adults with Cognitive Impairment following Hip-Fracture Surgery: Secondary Data Analysis of a Randomized Controlled Trial

OBJECTIVES

In Taiwan, older adults with cognitive impairment who undergo hip-fracture surgery are routinely cared for by family members. This study aimed to determine if nutritional status influenced the effects of a family-centered intervention for older adults with cognitive impairment recovering from hip-fracture surgery.

DESIGN

Secondary data analysis of data from a randomized controlled trial was conducted to examine the influences of nutritional status 1 month after hospital discharge on the effects of a family-centered care intervention model, which was designed for older adults with hip fracture and cognitive impairment. Outcomes were compared among participants according to nutrition status (well-nourished/poorly-nourished) and treatment approach (control/intervention).

SETTING

The original study was conducted at a 3000-bed medical center from July 2015 to October 2019.

PARTICIPANTS

Participants were older adults with cognitive impairment who had undergone hip-fracture surgery. Participants were assessed as poorly-nourished or well-nourished with the Mini-Nutritional Assessment (MNA) 1-month post-discharge and were then randomly assigned to either the intervention group or control group.

INTERVENTION

A family-centered intervention model for family caregivers of older adults with cognitive impairment recovering from hip-fracture surgery was implemented. The intervention was delivered by geriatric nurses, which included instructions for family caregivers in overseeing exercises for strengthening the hip, understanding dietary requirements, and managing behavioral problems associated with cognitive impairment.

MEASUREMENTS

Outcome measures included activities of daily living (ADLs), instrumental ADLs, hip range of motion, hip muscle strength, depression, measured with the Geriatric Depressive Scale, and physical and mental health related quality of life, measured with the Short Form Survey (SF-36), Taiwanese version. Participants were assessed at 1-, 3-, 6-, and 12-months post-discharge.

RESULTS

Most of the 134 participants were assessed as poorly nourished (n = 122); 57 were the control group and 65 received the intervention. For the well-nourished participants (n = 12), four were in the intervention group and eight were controls. There were no significant differences in any outcome variables for poorly nourished participants who received the intervention compared with controls. For the sample of well-nourished participants, those who received the intervention performed significantly better in outcomes of IADLs (b = 1.74, p < .05), hip muscle strength (b = 9.64, p < .01), and physical health related quality of life (b = 10.47, p < .01).

CONCLUSION

The family-centered care intervention was only effective for older adults with cognitive impairment recovering from hip-fracture surgery who were well-nourished at 1 month following hospital discharge, but not for those at risk of malnutrition. Interventions should focus on enhancing nutritional status following hip surgery which could allow the family-centered in-home intervention to be beneficial for more older adults with cognitive impairment recovering from hip-fracture surgery.

Health, social care and technological interventions to improve functional ability of older adults living at home: An evidence and gap map

Background

By 2030, the global population of people older than 60 years is expected to be higher than the number of children under 10 years, resulting in major health and social care system implications worldwide. Without a supportive environment, whether social or built, diminished functional ability may arise in older people. Functional ability comprises an individual's intrinsic capacity and people's interaction with their environment enabling them to be and do what they value.

Objectives

This evidence and gap map aims to identify primary studies and systematic reviews of health and social support services as well as assistive devices designed to support functional ability among older adults living at home or in other places of residence.

Search Methods

We systematically searched from inception to August 2018 in: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, CENTRAL, CINAHL, PsycINFO, AgeLine, Campbell Library, ASSIA, Social Science Citation Index and Social Policy & Practice. We conducted a focused search for grey literature and protocols of studies (e.g., ProQuest Theses and Dissertation Global, conference abstract databases, Help Age, PROSPERO, Cochrane and Campbell libraries and ClinicalTrials.gov).

Selection Criteria

Screening and data extraction were performed independently in duplicate according to our intervention and outcome framework. We included completed and on-going systematic reviews and randomized controlled trials of effectiveness on health and social support services provided at home, assistive products and technology for personal indoor and outdoor mobility and transportation as well as design, construction and building products and technology of buildings for private use such as wheelchairs, and ramps.

Data Collection and Analysis

We coded interventions and outcomes, and the number of studies that assessed health inequities across equity factors. We mapped outcomes based on the International Classification of Function, Disability and Health (ICF) adapted categories: intrinsic capacities (body function and structures) and functional abilities (activities). We assessed methodological quality of systematic reviews using the AMSTAR II checklist.

Main Results

After de-duplication, 10,783 records were screened. The map includes 548 studies (120 systematic reviews and 428 randomized controlled trials). Interventions and outcomes were classified using domains from the International Classification of Function, Disability and Health (ICF) framework. Most systematic reviews (n = 71, 59%) were rated low or critically low for methodological quality.The most common interventions were home-based rehabilitation for older adults (n = 276) and home-based health services for disease prevention (n = 233), mostly delivered by visiting healthcare professionals (n = 474). There was a relative paucity of studies on personal mobility, building adaptations, family support, personal support and befriending or friendly visits. The most measured intrinsic capacity domains were mental function (n = 269) and neuromusculoskeletal function (n = 164). The most measured outcomes for functional ability were basic needs (n = 277) and mobility (n = 160). There were few studies which evaluated outcome domains of social participation, financial security, ability to maintain relationships and communication.There was a lack of studies in low- and middle-income countries (LMICs) and a gap in the assessment of health equity issues.

Authors' Conclusions

There is substantial evidence for interventions to promote functional ability in older adults at home including mostly home-based rehabilitation for older adults and home-based health services for disease prevention. Remotely delivered home-based services are of greater importance to policy-makers and practitioners in the context of the COVID-19 pandemic. This map of studies published prior to the pandemic provides an initial resource to identify relevant home-based services which may be of interest for policy-makers and practitioners, such as home-based rehabilitation and social support, although these interventions would likely require further adaptation for online delivery during the COVID-19 pandemic. There is a need to strengthen assessment of social support and mobility interventions and outcomes related to making decisions, building relationships, financial security, and communication in future studies. More studies are needed to assess LMIC contexts and health equity issues.

A family care model for older persons with hip-fracture and cognitive impairment: A randomized controlled trial

BACKGROUND

Dementia and hip fracture are both associated with substantial disability and mortality. However, few studies have explored the effects of intervention programs on post-operative recovery of older persons with hip fracture and cognitive impairment.

OBJECTIVE

To examine the effects of a family-centered care model for older persons with hip fracture and cognitive impairment and their family caregivers.

DESIGN

Single-blinded clinical trial.

SETTING

A 3000-bed medical center in Taiwan.

PARTICIPANTS

Older persons hip fracture and cognitive impairment (N = 152); 76 in the intervention group, and 76 in the usual-care control group.

METHODS

A family-centered care model consisting of geriatric assessment, discharge planning, in-home rehabilitation, and family caregiver-training for dementia care. Outcomes were assessed 1-, 3-, 6- and 12-months following hospital discharge for older persons with hip fracture and cognitive impairment. Assessed outcomes were self-care ability (performance of activities of daily living and instrumental activities of daily living), nutritional status, self-rated health, health-related quality of life and self-efficacy, and competence of the family caregivers.

RESULTS

Relative to patients who received usual care, those who received the family-centered care intervention had a greater rate of improvement in self-rated health (β = 1.68, p < .05) and nutritional status (β = 0.23, p < .05), especially during the first 6 months following hospital discharge. Relative to family caregivers who received usual care, those who received family-centered care had a higher level of competence (β = 7.97, p < .01), a greater rate of improvement in competence (β = 0.57, p < .01), and a greater rate of improvement in self-efficacy (β = 0.74, p < .05) 3 months following hospital discharge.

CONCLUSIONS

A family-centered care model enhanced family caregivers' self-efficacy and competence but did not improve the physical recovery of the participants with hip fracture and dementia. We suggest adding an educational component to include geriatric assessment, discharge planning, in-home rehabilitation, and family caregiver-training for dementia care and assessing family caregiver outcomes in interventions for older persons with hip fracture and cognitive impairment.

TRIAL REGISTRATION

Registered with www.clinicaltrials.gov (NCT03894709) Tweetable abstract: A family-centered care model consisting of geriatric assessment, discharge planning, in-home rehabilitation, and family caregiver-training for dementia care of older persons with hip fracture and cognitive impairment enhanced family caregivers' self-efficacy and competence.

Components, impacts and costs of dementia home support: a research programme including the DESCANT RCT

Background

Over half of people with dementia live at home. We know little about what home support could be clinically effective or cost-effective in enabling them to live well.

Objectives

We aimed to (1) review evidence for components of home support, identify their presence in the literature and in services in England, and develop an appropriate economic model; (2) develop and test a practical memory support package in early-stage dementia, test the clinical effectiveness and cost-effectiveness of routine home support in later-stage dementia and design a toolkit based on this evidence; and (3) elicit the preferences of staff, carers and people with dementia for home support inputs and packages, and evaluate the cost-effectiveness of these approaches in early- and later-stage dementia.

Design

We undertook (1) an evidence synthesis, national surveys on the NHS and social care and an economic review; (2) a multicentre pragmatic randomised trial [Dementia Early Stage Cognitive Aids New Trial (DESCANT)] to estimate the clinical effectiveness and cost-effectiveness of providing memory aids and guidance to people with early-stage dementia (the DESCANT intervention), alongside process evaluation and qualitative analysis, an observational study of existing care packages in later-stage dementia along with qualitative analysis, and toolkit development to summarise this evidence; and (3) consultation with experts, staff and carers to explore the balance between informal and paid home support using case vignettes, discrete choice experiments to explore the preferences of people with dementia and carers between home support packages in early- and later-stage dementia, and cost–utility analysis building on trial and observational study.

Setting

The national surveys described Community Mental Health Teams, memory clinics and social care services across England. Recruitment to the trial was through memory services in nine NHS trusts in England and one health board in Wales. Recruitment to the observational study was through social services in 17 local authorities in England. Recruitment for the vignette and preference studies was through memory services, community centres and carers’ organisations.

Participants

People aged > 50 years with dementia within 1 year of first attendance at a memory clinic were eligible for the trial. People aged > 60 years with later-stage dementia within 3 months of a review of care needs were eligible for the observational study. We recruited staff, carers and people with dementia for the vignette and preference studies. All participants had to give written informed consent.

Main outcome measures

The trial and observational study used the Bristol Activities of Daily Living Scale as the primary outcome and also measured quality of life, capability, cognition, general psychological health and carers’ sense of competence.

Methods

Owing to the heterogeneity of interventions, methods and outcome measures, our evidence and economic reviews both used narrative synthesis. The main source of economic studies was the NHS Economic Evaluation Database. We analysed the trial and observational study by linear mixed models. We analysed the trial by ‘treatment allocated’ and used propensity scores to minimise confounding in the observational study.

Results

Our reviews and surveys identified several home support approaches of potential benefit. In early-stage dementia, the DESCANT trial had 468 randomised participants (234 intervention participants and 234 control participants), with 347 participants analysed. We found no significant effect at the primary end point of 6 months of the DESCANT intervention on any of several participant outcome measures. The primary outcome was the Bristol Activities of Daily Living Scale, for which scores range from 0 to 60, with higher scores showing greater dependence. After adjustment for differences at baseline, the mean difference was 0.38, slightly but not significantly favouring the comparator group receiving treatment as usual. The 95% confidence interval ran from –0.89 to 1.65 (p = 0.56). There was no evidence that more intensive care packages in later-stage dementia were more effective than basic care. However, formal home care appeared to help keep people at home. Staff recommended informal care that cost 88% of formal care, but for informal carers this ratio was only 62%. People with dementia preferred social and recreational activities, and carers preferred respite care and regular home care. The DESCANT intervention is probably not cost-effective in early-stage dementia, and intensive care packages are probably not cost-effective in later-stage dementia. From the perspective of the third sector, intermediate intensity packages were cheaper but less effective. Certain elements may be driving these results, notably reduced use of carers’ groups.

Limitations

Our chosen outcome measures may not reflect subtle outcomes valued by people with dementia.

Conclusions

Several approaches preferred by people with dementia and their carers have potential. However, memory aids aiming to affect daily living activities in early-stage dementia or intensive packages compared with basic care in later-stage dementia were not clinically effective or cost-effective.

Future work

Further work needs to identify what people with dementia and their carers prefer and develop more sensitive outcome measures.

Study registration

Current Controlled Trials ISRCTN12591717. The evidence synthesis is registered as PROSPERO CRD42014008890.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 6. See the NIHR Journals Library website for further project information.

Effects of a home-based exercise program on mental health for caregivers of relatives with dementia: a randomized controlled trial

OBJECTIVE

This study was aimed to evaluate the effectiveness of a home-based physical exercise program on participants' mental health: psychological symptoms, depression, and burden of female informal caregivers.

DESIGN AND PARTICIPANTS

In a randomized controlled trial, a sample of 48 female informal primary caregivers completed the entire study, 25 were randomly allocated to the intervention group (IG), and 23 participants to the control group (CG).

INTERVENTION

Participants in the IG performed two 60-minute-long physical exercise sessions per week (36 weeks) that were supervised by a personal trainer at caregivers' home during 9 months. The CG continued their habitual leisure-time activities.

MEASUREMENTS

Subjective burden was assessed by the Zarit Burden Interview. The risk of depression was measured by the Geriatric Depression Scale Short Form 15-item version, and psychological symptoms were evaluated by the Symptom Check List-90-Revised (SCL-90-R). All participants were evaluated at baseline and at the end of the intervention.

RESULTS

A promising positive impact of the intervention on caregivers' subjective burden and risk of depression was found in the IG. In addition, no significant between-group differences were found in any of nine subscales scores of the SCL-90-R. Finally, care recipients' level of functional independence and area of residence were found to be predictors of the promising positive impact on caregivers' subjective burden and risk of depression.

CONCLUSIONS

The present home-based physical exercise intervention that was individually implemented has shown promising results to reduce subjective burden and risk of depression in female caregivers of relatives with dementia. However, future research efforts should elucidate both the particular dose of physical exercise and the particular duration of the intervention that are required to obtain the expected significant positive impact. Finally, future inclusion of psychological approaches, besides physical exercise, might help reduce female caregivers' psychological symptoms.

An international systematic review of dementia caregiving interventions for Chinese families

OBJECTIVES

Older Asians and Chinese are among the least studied populations in the dementia caregiving literature. This review seeks to critically synthesize the literature on intervention characteristics, components and tailoring strategies for dementia family caregivers in Chinese communities globally.

METHODS

Five electronic databases (PsychINFO, PubMed, CINAHL, ScienceDirect and Google Scholar) were searched for articles published between 1980 and July 2018. The protocol of this review was registered with PROSPERO (CRD42019132800).

RESULTS

Twenty-nine unique interventions across 39 papers met inclusion criteria. Results from descriptive and thematic syntheses revealed that most interventions were psychoeducational, CBT-based, multicomponent, structured, and less than a year in duration. Disease education, management of behavioral and psychological symptoms of dementia, stress coping techniques, and referral to community resources were frequently included in interventions. Community-, culture- and language-focused strategies were used to tailor interventions. The most common tailoring strategies were: (a) using community networks and media for outreach and recruitment; (b) making translations and language adaptations to the intervention materials; and (c) focusing on trust and therapeutic alliance. Most interventions produced desired outcomes, particularly reducing caregiver burden and increasing self-efficacy.

CONCLUSIONS

To our knowledge, this is the first review to date that systematically synthesized the characteristics and tailoring of dementia caregiving interventions for Chinese families globally. Current findings suggest that most interventions are effective, although many only superficially address Chinese culture. Future research should incorporate Chinese values and cross-cultural challenges into caregiving interventions for deep-level adaptations that could potentially be more effective to engage and support Chinese caregivers.

Satisfaction with Health Care Interventions among Community Dwelling People with Cognitive Disorders and Their Informal Caregivers-A Systematic Review

Informal caregivers have a leading role when implementing health care services for people with cognitive disorders living at home. This study aims to examine the current evidence for interventions with dual satisfaction with health care services for people with cognitive disorders and their caregivers. Original papers with quantitative and mixed method designs were extracted from two databases, covering years 2009-2018. Thirty-five original papers reported on satisfaction with health care services. The International Classification of Health Interventions (ICHI) was used to classify the interventions. Most interventions had a home-based approach (80%). Reduction in caregiver depression was the outcome measure with the highest level of satisfaction. Interventions to reduce depression or increase cognitive performance in persons with cognitive disorders gave the least satisfaction. Satisfaction of both caregivers and persons with cognitive disorders increased their use of services. In the ICHI, nearly 50% of the interventions were classified as activities and participation. A limited number of interventions have a positive effect on satisfaction of both the persons with cognitive disorders and the caregiver. It is important to focus on interventions that will benefit both simultaneously. More research is needed with a clear definition of satisfaction and the use of the ICHI guidelines.

Psychosocial Interventions for Family Carers of People With Dementia: A Systematic Review and Meta-Analysis

Objective:This study aimed to review and synthesize findings of the effectiveness of psychosocial interventions aimed at improving outcomes for family carers of people with dementia. Method: A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically searched the following databases: Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Excerpta Medica Database (EMBASE), and Applied Social Sciences Index and Abstracts (ASSIA). RevMan 5 software was used to conduct meta-analysis and subgroup analysis using a random-effects model. Results: The search yielded 22 high-quality intervention articles that were suitable for further meta-analysis. Meta-analysis revealed that psychosocial interventions have a small to moderate significant effect on carer burden (standardized mean difference [SMD] = −0.34, confidence interval [CI] = [−0.59, −0.09]), depression (SMD = −0.36, CI = [−0.60, −0.13]), and general health (SMD = 0.34, CI = [0.18, 0.51]). Discussion: Psychosocial interventions had a positive impact on carer outcomes; however, these results should be interpreted with caution, given the significant level of heterogeneity in study designs. Future research could examine contextual and implementation mechanisms underlying psychosocial interventions to develop effective support systems for family carers of people with dementia.

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.

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.

Occupational Therapy Interventions for People With Alzheimer's Disease

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association's (AOTA's) Evidence-Based Practice Project. In this Evidence Connection article, we describe a case report of a person with Alzheimer's disease. The occupational therapy assessment and intervention process in the home setting is described. Findings from the systematic reviews on this topic were published in the November/December 2017 issue of the American Journal of Occupational Therapy and in AOTA's Occupational Therapy Practice Guidelines for Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders. Each article in this series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical reasoning.

[Factors influencing the quality of life of family caregivers of the elderly with dementia]

The progression of symptoms of dementia leads to loss of autonomy and independence of the elderly. This progression suggests that a family member will assume the functions of caregiver, which can adversely affect his/her quality of life (QOL). This research is an integrative review that sought to analyze the available evidence on the factors that influence quality of life of family caregivers of the elderly with dementia. Articles published in the BDENF, Lilacs and Medline databases were examined and 477 studies were selected, of which 11 met the inclusion criteria and comprised the sample of this review. It was found that the factors that influence quality of life of caregivers are: depression; poor sleep quality; dementia type and neuropsychiatric symptoms; support, social support and access to health services; leisure; pre-existing health problems; interventions for caregiver training and spirituality. It is suggested that the nursing professional identifies the needs of the caregivers, such that strategies of care can be defined.

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.

A randomized controlled trial of a home-based training programme to decrease depression in family caregivers of persons with dementia

AIMS

The aim of this study was to explore distinct trajectories of caregivers' depressive symptoms and the effects of a training programme on these trajectories over 18 months after the programme.

BACKGROUND

Overall effects of caregiver-training programmes on family caregivers' depressive symptoms have been reported, but few studies explored distinct courses of changes in caregivers' depressive symptoms and followed up intervention effects on these distinct courses.

DESIGN

Randomized clinical trial.

METHODS

Family caregivers (n = 116) were randomly assigned into experimental (n = 57) and control (n = 59) groups. The experimental group received the training programme with telephone consultation and the control group received written educational materials and social telephone follow-ups. Caregivers' depressive symptoms were assessed from June 2009 - March 2012 by self-completed questionnaires before, at 2 weeks and 3, 6, 12 and 18 months after the intervention. Groups of individual trajectories were distinguished using group-based trajectory modelling.

RESULTS

Caregivers' depressive symptoms fell into three stable trajectories: non-depressed, mildly blue and depressed. After controlling for covariates, caregivers who received the caregiver-training programme were less likely than those who did not experience persistent depressive symptoms (b = -1·92, odds ratio = 0·15, P < 0·05).

CONCLUSION

Depressive symptoms of family caregivers of persons with dementia were relatively stable and followed three distinct courses: non-depressed, mildly blue and depressed. Therefore, caregivers' depressive symptoms should be assessed as early as possible. Caregivers in the experimental group had a lower probability of persistent depressive symptoms than caregivers in the control group. Therefore, this training programme can be used by healthcare providers for persons with dementia and their caregivers.

TRIAL REGISTRATION NUMBER

NCT02667951.

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.

Pilot testing of the "First You Should Get Stronger" program among caregivers of older adults with dementia

OBJECTIVE

In this study, randomized controlled interventional study pattern was used to examine the effects of the "First You Should Get Stronger" program on the caregiving burden and healthy life style behavior of caregivers of dementia patients.

METHODS

"Zarit Caregiver Burden Scale" and "Healthy Life Style Behavior Scale" were used. The study was completed with 40 caregivers in total with 20 in the intervention group and 20 in the control group. A statistically significant difference was determined between the "Zarit Caregiving Burden Scale" and "Healthy Life Style Behavior Scale" score averages of the intervention group that participated in the "First You Should Get Stronger" program in comparison with those of the control group.

RESULTS

It is important for the healths of caregivers to include similar programs for the caregivers of dementia patients in continuous and regular applications.

DISCUSSION

The results highlight the importance of the "First You Should Get Stronger" program significantly decreased the caregiving burden and significantly developed the healthy lifestyle behaviors of caregivers in the intervention group. Since dementia is a difficult neurological syndrome with patients cared at home, it generally wears out the caregivers significantly. It is suggested that the nurses and healthcare professionals working with dementia patients are evaluated separately and that they carry out caregiving applications within the scope of the "First You Should Get Stronger" program.

A Systematic Review and Meta-Analysis Comparing Carer Focused and Dyadic Multicomponent Interventions for Carers of People With Dementia

Objective: The aim of this study was to compare the efficacy of two approaches: multicomponent interventions that focus on working with the carer and dyadic interventions that work with both the carer and the person with dementia. Method: A systematic review involving a search of Medline, EMBASE, and PsycINFO in October 2015 was performed. Randomized controlled trials involving carers of people with dementia and comparing multicomponent interventions with usual care were included. Results: Pooling of all studies demonstrated that multicomponent interventions can reduce depressive symptoms, improve quality of life, reduce carer impact, and reduce behavioral and psychological symptoms of dementia as well as caregiver upset with these symptoms. We were unable to find a significant difference in the effects of dyadic interventions in comparison with carer focused interventions for these outcomes. Discussion: Although effect sizes associated with intervention are small, multicomponent interventions are relatively inexpensive to deliver, acceptable, and widely applicable.

A telehealth behavioral coaching intervention for neurocognitive disorder family carers

OBJECTIVES

This study examined the differential impact of two telehealth programs for women caring for an older adult with a neurocognitive disorder. Outcomes examined were depressive symptoms, upset following disruptive behaviors, anxious and angry mood states, and caregiving self-efficacy.

METHODS

Women cohabitating with a family member diagnosed with a neurocognitive disorder were assigned via random allocation to either of the following: (1) a 14-week behavioral intervention using video instructional materials, workbook and telephone coaching in behavioral management, pleasant events scheduling, and relaxation or (2) a basic education guide and telephone support comparison condition. Telephone assessments were conducted by interviewers blind to treatment condition at pre-intervention, post-intervention, and 6 months following intervention.

RESULTS

For those providing in-home care at post-treatment, depressive symptoms, upset following disruptive behaviors, and negative mood states were statistically lower in the behavioral coaching condition than in the basic education and support condition. Reliable change index analyses for Beck Depression Inventory II scores favored the behavioral coaching condition. Caregiving self-efficacy scores for obtaining respite and for managing patient behavioral disturbances were significantly higher in the coaching condition. Effect sizes were moderate but not maintained at the 6-month follow-up.

CONCLUSIONS

This study provides some initial evidence for the efficacy of a telehealth behavioral coaching intervention compared with basic education and telephone support. Carers' abilities to maintain strategy use during progressive disorders such as Alzheimer's disease likely require longer intervention contact than provided in the current study. Dementia carers, including those living in rural areas, can benefit from accessible and empirically supported interventions that can be easily disseminated across distances at modest cost.

Health-related quality of life and self-efficacy of managing behavior problems for family caregivers of vascular dementia and Alzheimer's disease patients

BACKGROUND

Little is known about the differences in patients' behavioral problems and health outcomes of family caregivers of patients with vascular dementia (VaD) and Alzheimer's disease (AD).

METHODS

A secondary analysis of baseline data on a subsample of caregiver-dementia patient dyads in a randomized clinical trial.

RESULTS

Family caregivers of VaD patients reported higher self-efficacy than caregivers of AD patients in handling verbally nonaggressive and verbally aggressive behaviors. Caregivers of VaD patients had poorer health-related quality of life (HRQoL) than caregivers of AD patients considering role disability due to physical health problems, bodily pain, social function, and physical component summary. Greater self-efficacy was associated with better mental health-related outcomes for family caregivers of VaD patients, and better self-care ability of VaD patients was associated with better caregiver mental health-related outcomes. Caring for a patient with more severe dementia predicted poor physical health-related outcomes in role disability due to physical health problems, but better overall mental health (mental component summary) for caregivers.

CONCLUSION

This study is the first to examine and compare the behavioral problems of AD and VaD patients in a Chinese population, along with their family caregivers' self-efficacy and health outcomes. Family caregivers of patients with VaD might warrant specific attention to their HRQoL, with interventions developed to enhance their self-efficacy.