The process of a group intervention for caregivers of demented persons living at home: conceptual framework, components, and characteristics

Adaptation of a psycho-educational group programme to improve coping in dementia caregiving: a feasibility study with mixed-methods

BACKGROUND

As the number of people living with dementia rapidly increases worldwide, the support provided by their informal caregivers remains key to the sustainability of most healthcare systems, this voluntary contribution representing 40% of the costs of dementia worldwide. Informal caregiving in dementia, however, is linked to long periods of chronic stress with frequent and serious negative consequences on the health and quality of life of the caregiver. A psycho-educational group intervention focusing on coping with the daily stress of dementia caregiving ("Learning to feel better… to help better"), developed in French-speaking Canada and showing broad effects on quality of life, was selected with the aim of 1) adapting it to a new cultural context (French-speaking Switzerland) based on identified facilitators and barriers, using a participative approach; and 2) conducting a feasibility study to evaluate whether the adapted programme showed similar or improved feasibility and effects compared to the original Canadian programme.

METHODS

A mixed-methods concurrent nested design was used to evaluate the feasibility and the effects on five quantitative core outcomes. Additional qualitative data helped document in depth the acceptability and impact of the intervention.

RESULTS

We shortened the programme from 30 to 21 h in total, which resulted in increased accessibility, in terms of facilitated recruitment of participants and inclusion of a broader range of informal caregivers. There were significant reductions in subjective burden (effect size: d = -0.32) and psychological distress (d = -0.48), as well as decreases in the stress reactions of informal caregivers related to the behaviour problems of the persons with dementia (d = -0.57). The qualitative results emphasized the usefulness of providing informal caregivers with structured procedures for efficiently tackling everyday challenges, and of enabling learning through a variety of channels and activities.

CONCLUSIONS

Substantial improvements are associated with this 21-h group intervention, organised in 7 sessions of 3 h each, focused on learning more efficient strategies to cope with the daily stress of dementia caregiving. This intervention empowered informal caregivers to master their daily challenges with more confidence, satisfaction and calm.

TRIAL REGISTRATION

ISRCTN13512408 (registration date 17.05.2021, retrospectively registered).

Positive aspects of care in informal caregivers of community-dwelling dementia patients

WHAT IS KNOWN ON THE SUBJECT?: Positive aspects of care are considered an essential part of caregiving research. They have been related to a wide range of dimensions of the caregiving circumstances, but there are few valid, reliable and brief measures to assess them. One of the most frequently used internationally is the Positive Aspects of Caregiving (PAC) scale, whose psychometric properties have received little attention. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The present study analyses the psychometric properties of the Portuguese version of the PAC scale in a sample of informal caregivers of someone with dementia and further explores the association of different factors (e.g. caregiver health, sociodemographic variables) with the PAC. The Portuguese version of PAC scale presented good psychometric characteristics, and the factor analysis revealed the presence of two factors: affirming self and enriching life. Our study also verified that higher levels of PAC are more likely to be associated with better caregiver health perception, lower levels of psychological distress and burden, the care recipient's older age, providing care to more than one care recipient, not receiving social support services and not considering institutionalizing the care recipient. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings from this study can assist professionals, including mental health nurses, to develop and implement effective interventions that help dementia caregivers to maintain their emotional health by identifying and focusing specific positive aspects of care. The study stresses the Portuguese version of the PAC scale as a reliable and valid measure for practice. ABSTRACT: Introduction Positive aspects of care refer to the psychosocial benefits of caregiving. The Positive Aspects of Caregiving (PAC) scale is one of the instruments most frequently used internationally, but its psychometric properties and correlates within the caregiving experience have received limited attention. Aim To examine the factorial structure of the Portuguese version of PAC scale and to analyse background and contextual factors that are more likely to be associated with higher levels of PAC. Method The PAC scale, a sociodemographic questionnaire and measures assessing burden and physical and mental health were administered to 204 informal caregivers of dementia patients. Results Exploratory factor analysis revealed a two-factor structure; internal consistency was adequate. Higher scores were negatively correlated with caregiver burden and distress. Better health perception, care recipient's older age, providing care to more than one care recipient and overall self-reliance were correlated with higher levels of PAC. Discussion The PAC scale was found to be a reliable and valid measure. Dementia caregiving circumstances and caregivers' and care receivers' characteristics play an important role for the presence of PAC, but relate distinctively with its dimensions. Implications for Practice Findings can help mental health nurses to recognize distinctive relations between PAC and caregiving variables.

Developing the New Interventions for independence in Dementia Study (NIDUS) theoretical model for supporting people to live well with dementia at home for longer: a systematic review of theoretical models and Randomised Controlled Trial evidence

PURPOSE

To build an evidence-informed theoretical model describing how to support people with dementia to live well or for longer at home.

METHODS

We searched electronic databases to August 2018 for papers meeting predetermined inclusion criteria in two reviews that informed our model. We scoped literature for theoretical models of how to enable people with dementia to live at home independently, with good life quality or for longer. We systematically reviewed Randomised Controlled Trials (RCTs) reporting psychosocial intervention effects on time lived with dementia at home. Two researchers independently rated risk of bias. We developed our theoretical model through discussions with experts by personal, clinical and academic experiences, informed by this evidence base.

RESULTS

Our scoping review included 52 studies. We divided models identified into: values and approaches (relational and recovery models; optimising environment and activities; family carer skills and support); care strategies (family carer-focused; needs and goal-based; self-management); and service models (case management; integrated; consumer-directed). The 11 RCTs included in our systematic review, all judged at low risk of bias, described only two interventions that increased time people with dementia lived in their own homes. These collectively encompassed all these components except for consumer-directed and integrated care. We developed and revised our model, using review evidence and expert consultation to define the final model.

CONCLUSIONS

Our theoretical model describes values, care strategies and service models that can be used in the design of interventions to enable people with dementia to live well and for longer at home.

TRIAL REGISTRATION

PROSPERO 2018 registration number: CRD42018099693 (scoping review). PROSPERO 2018 registration number: CRD42018099200 (RCT systematic review).

Coping with dementia caregiving: a mixed-methods study on feasibility and benefits of a psycho-educative group program

Background

Persons with dementia experience a progressive decline associated with an increasing dependency. Most of the support they require to stay at home comes from their informal caregivers (IC). Dementia informal caregiving imposes high costs on IC’s health and quality of life, related to long periods of chronic stress. Based on evidence that more adequate coping strategies can reduce chronic stress and its negative consequences, and that psycho-educative interventions have the broadest effects on IC quality of life, the program “Learning to feel better… and help better” was developed in French-speaking Canada. This group intervention focusing on coping with the daily stress of dementia caregiving showed efficacy in decreasing the behavior problems of the person with dementia and the associated stress reactions in their IC. The objectives of our study were to examine within a one group pre- and post-test design 1) the feasibility of implementing the program in two regions of French-speaking Switzerland, 2) the effects of the program, and 3) the participants’ use of the trained strategies in daily life.

Method

A mixed-methods concurrent nested design was used to quantitatively evaluate the feasibility, the effects on five core outcomes, and strategy use in daily life. Additional qualitative data documented in depth the acceptability and impact of the intervention.

Results

We analyzed 18 complete data sets. Regarding feasibility, qualitative and quantitative results converged towards a very good acceptance of the program and a strong implication of the participants. Regarding effects, the program resulted in substantial and significant improvements in burden (d = 0.41, p < .05), psychological distress (d = 0.54, p < .05) and self-efficacy (d = 0.43, p < .05). The qualitative results emphasized the benefits of a group format: Participants felt understood by peers, could build new social bonds and experienced reduced social isolation. Data regularly collected in daily life showed that participants were using more and more over time the strategies they learned (β₀₁ = 0.55, p < .001), particularly reframing.

Conclusion

This study expands on the original one conducted by the developers of the program in French-speaking Canada, by showing the feasibility and the very promising effects of this intervention in two regions of French-speaking Switzerland.

Review of family therapy and dementia: twenty-five years on

BACKGROUND

We reviewed the literature on family therapy and dementia to investigate the following: what is known about the use of family therapy in the context of living with dementia; what are the challenges of working in this context; and what guidelines/models are available to guide family therapists working with families living with dementia.

METHODS

We searched English language literature from 1992 onwards, classified the resulting papers into broad categories of theoretical, expository, or research (descriptive, quantitative, or qualitative), and conducted a narrative review to draw learning points from the identified papers.

RESULTS

In total 31 papers were identified: five theoretical, 11 expository; and 15 research papers. Several papers described methodologies; psychotherapeutic interventions applied to family members; or complex intervention packages in which the role of family therapy could not be separately identified, rather than family therapy. A range of outcomes were investigated, often involving the caregiver. Several authors suggest areas in dementia care where family therapy is likely to be beneficial.

CONCLUSIONS

Although the literature on family therapy and dementia has grown over the past 25 years and suggests potentially useful roles for therapy, a number of challenges exist in terms of context, family, and therapy itself. There is a need for further research, particularly into the following fields: How to evaluate the success of therapy; how to ensure treatment integrity; how to make techniques from family therapy available more widely; and how to train the health and social care workforce in working with families.

Benefit-finding intervention for Alzheimer caregivers: conceptual framework, implementation issues, and preliminary efficacy

PURPOSE

To describe an intervention promoting benefit-finding in Alzheimer caregivers, to discuss key issues in implementation and ways to resolve them, and to examine whether the intervention reduced burden and depression in a small randomized trial.

DESIGN AND METHODS

Twenty-five caregivers were randomized into benefit-finding and psychoeducation groups. Both groups had eight weekly sessions. Outcome measures including role overload, Zarit Burden Interview, and Hamilton depression scale were collected at baseline and after treatment. Results were analyzed using analysis of covariance. Additionally, the challenges of implementing such interventions, some of which related to cultural issues, were analyzed qualitatively.

RESULTS

Controlling for pretest, the benefit-finding group had lower depression than the psychoeducation group at post-test, despite the fact that some caregivers found benefit-finding challenging. The two groups did not differ on overload and burden. However, within-group analysis suggested that both groups showed significant reductions in overload from pretest to post-test. In addition, we discussed participants' difficulties in grasping the technique of thought modification for benefit-finding, recording such exercises at home, and sharing their thoughts and experiences in groups. We described measures undertaken in the main trial to overcome these issues.

IMPLICATIONS

Cognitive approaches focusing on benefit-finding are feasible among Chinese caregivers, with preliminary evidence suggesting an effect on alleviating depression.

Ways of coping and biomarkers of an increased atherothrombotic cardiovascular disease risk in elderly individuals

Objective. To investigate the relationship between coping and atherothrombotic biomarkers of an increased cardiovascular disease (CVD) risk in the elderly. Methods. We studied 136 elderly caregiving and noncaregiving men and women who completed the Ways of Coping Checklist to assess problem-focused coping, seeking social support (SSS), blamed self, wishful thinking, and avoidance coping. They had circulating levels of 12 biomarkers measured. We also probed for potential mediator and moderator variables (chronic stress, affect, health behavior, autonomic activity) for the relation between coping and biomarkers. Results. After controlling for demographic and CVD risk factors, greater use of SSS was associated with elevated levels of serum amyloid A (P = 0.001), C-reactive protein (CRP) (P = 0.002), vascular cellular adhesion molecule (VCAM)-1 (P = 0.021), and D-dimer (P = 0.032). There were several moderator effects. For instance, greater use of SSS was associated with elevated VCAM-1 (P < 0.001) and CRP (P = 0.001) levels in subjects with low levels of perceived social support and positive affect, respectively. The other coping styles were not significantly associated with any biomarker. Conclusions. Greater use of SSS might compromise cardiovascular health through atherothrombotic mechanisms, including elevated inflammation (i.e., serum amyloid A, CRP, VCAM-1) and coagulation (i.e., D-dimer) activity. Moderating variables need to be considered in this relationship.

Support groups for caregivers of Alzheimer patients: A historical review

Support groups (SG) for family caregivers are an intervention frequently used by associations and institutions. But their extensive use does not correspond to the current scientific interest in them. The aim of this paper is to make a historical review of the use and study of SGs for family caregivers of Alzheimer patients, describing their main features and variations, with special emphasis on data about their efficacy. In this analysis, three stages were differentiated: an initial stage (late 1970s – 1985) with studies based on subjective impressions and questionnaires showing high satisfaction among caregivers; a second stage (1985–1995) with more rigorous methodology, which led to doubts about SGs’ efficacy; and a third stage (1995 – present) in which qualitative methodology focused on group process has led to renewed interest. At the end some proposals regarding the future of research on caregiver SGs are discussed.

Development of a conceptual framework of positive aspects of caregiving in dementia

Research on family caregivers usually focuses more on stress and burden, especially in the context of looking after a person with dementia. This leads to fewer considerations of positive aspects of caregiving. Thus enhancing these positive aspects represents an innovative approach to caregivers’ support. Furthermore, these aspects need more conceptualization to underpin the development of such an approach. This article proposes a conceptual framework of the positive aspects of caregiving based on an integrative literature review. This conceptual framework provides a comprehensive model that should improve understanding of positive aspects of caregiving. It could also contribute to the development of innovative support programs based on the positive aspects instead of the negative aspects of caregiving.

Improving depression and enhancing resilience in family dementia caregivers: a pilot randomized placebo-controlled trial of escitalopram

BACKGROUND

This study examined the potential of an antidepressant drug, escitalopram, to improve depression, resilience to stress, and quality of life in family dementia caregivers in a randomized placebo-controlled double-blinded trial.

METHODS

Forty family caregivers (43-91 years of age, 25 children and 15 spouses; 26 women) who were taking care of their relatives with Alzheimer disease were randomized to receive either escitalopram 10 mg/day or placebo for 12 weeks. Severity of depression, resilience, burden, distress, quality of life, and severity of care-recipient's cognitive and behavioral disturbances were assessed at baseline and over the course of the study. The Hamilton Depression Rating Scale scores at baseline ranged between 10 and 28. The groups were stratified by the diagnosis of major and minor depression.

RESULTS

Most outcomes favored escitalopram over placebo. The severity of depression improved, and the remission rate was greater with the drug compared with placebo. Measures of anxiety, resilience, burden, and distress improved on escitalopram compared with placebo.

DISCUSSION

Among caregivers, this small randomized controlled trial found that escitalopram use resulted in improvement in depression, resilience, burden and distress, and quality of life. Our results need to be confirmed in a larger sample.

Développement d’un programme d’éducation au loisir adapté comme moyen de soutien à l’implication d’aidants d’un proche atteint de démence,

Leisure represents a positive way to keep relationships satisfactory between caregivers and a person with dementia. Adapted leisure education is a promising approach to assist the family to discover new ways to share good times with their relatives. This study aimed to develop an adapted leisure education program. It included an evaluation of the caregivers’ needs, the program content development, and a pilot study to experiment with the content of the program. Three focus groups of dementia caregivers (n = 19) were conducted to investigate caregivers needs. Based on content analysis of these focus groups and a literature review, the content of the program was developed. The pilot study (n = 4) included a quasi-experimental trial and an implementation evaluation. This study led to the development of an adapted leisure education program that puts caregiver support in a new perspective, focusing on positive aspects rather than the burden of caregiving.

The Eating and Appraisal Due to Emotions and Stress (EADES) Questionnaire: Development and Validation

OBJECTIVE

To develop and validate the Eating and Appraisal Due to Emotions and Stress (EADES) Questionnaire that was created to measure how one uses food to cope with stress and emotions.

DESIGN

Data were collected from a cross-sectional study using the EADES Questionnaire.

SUBJECTS/SETTING

Convenience sample (response rate 22%) from a southeastern public university, including staff and faculty (n=854) with ages ranging from 18 to 83 years and a mean body mass index of 27.3+/-6.4.

STATISTICAL ANALYSIS PERFORMED

Exploratory factor analysis was completed on 54 items that were originally meant to describe constructs from the Transactional Model of Stress and Coping. Reliability of scales was estimated using Cronbach's alpha. Total sum scores were given to each factor. Pearson correlation coefficients assessed linear associations between factors.

RESULTS

Three factors accounting for 43.5% of the variance were retained with a total Cronbach's alpha=.949. The factors did not represent the theoretical constructs from the Transactional Model of Stress and Coping as anticipated. A new model was created, including Emotion- and Stress-Related Eating, Appraisal of Resources and Ability to Cope, Appraisal of Outside Stressors and Influences with Cronbach's alpha being .949, .869, and .652, respectively. These factors were significantly correlated with one another.

CONCLUSIONS

The EADES model provides a viable conceptual model to help explain variables that may contribute to overeating, whereas the EADES Questionnaire provides a measurement tool for evaluating these variables that have not traditionally been explored in weight management efforts.

Stress and depression in informal family caregivers of patients with Alzheimer’s disease

Family caregiving of older individuals with Alzheimer’s disease is becoming widespread in the USA and around the world because of the aging of the population. As a result, family members are increasingly being asked to perform complex tasks similar to those carried out by paid health or social service providers. Dementia caregiving presents unique and extreme challenges associated with caring for someone with cognitive and behavioral impairment. This article summarizes the extensive literature on dementia caregiving, identifies key issues and major findings regarding the definition and prevalence of caregiving, and reviews the epidemiological, cultural, individual and biological factors contributing to caregiver stress and depression. The author describes the psychiatric and physical health effects of caregiving and reviews various intervention approaches to improving caregiver burden, depression and quality of life. The author offers a perspective on future directions in dementia caregiver research and development of more effective interventions.

Understanding the outcomes of a psycho-educational group intervention for caregivers of persons with dementia living at home: a process evaluation

This qualitative process evaluation study aimed to identify the primary processes of a psycho-educational group for caregivers of persons with dementia, in order to better understand intervention outcomes. Semi-structured interviews were conducted with 30 participants recruited from the experimental group of a randomised controlled trial. At pre-test, participants reported their expectations of the group. At post-test, they described their group experience, the most/least helpful aspects of the intervention, their most useful learning and their responses during a recent episode of disturbing behaviour by their relative. Results showed that the group delivered both educational and support processes. Support processes complemented educational processes. Participants learned coping strategies, with reframing playing a more important role than problem-solving or seeking social support. Daughters benefited more than spouses from educational processes. This study of group processes contributes to our understanding of the reported reduction in frequency of disturbing behaviours and of the change in caregivers' behaviours.

[Health promotion of the elderly: a conceptual matter]

Although community health nurses have to face the increasing needs in curative and palliative care, they still engage in health promotion activities for the elderly, mainly cognitive and behavioural ones. The Quebec community health nurses who choose the McGill model of nursing, are able to integrate health promotion interventions in their daily practice with old aged people. In fact, this model helps these nurses consider the elderly, health, sickness and nursing care in a way that makes them promote self-esteem, empowerment, development and coping through most of their interventions. Moreover, the elderly population would benefit from an increased implication of nurses in ecological, environmental and community health promotion projects.

Perceived Helpfulness of Telephone Calls

The purpose of this study was to determine the perceived helpfulness of telephone calls to 83 caregivers of family members with dementia. Study participants were assigned by groups to experimental (n = 41) or attention-only control (n = 42) conditions. Initial baseline interview data and narrative transcripts of telephone calls were used in this study. Major perceived reasons for helpfulness were that participants were assisted in sharing thoughts and feelings, expressing feelings of being overwhelmed, discussing physical and psychosocial problems, forgetting the situation, seeking reassurance, and asking for information; several participants perceived the telephone calls to be lacking in helpfulness. Results from this study suggest family caregivers can be helped through a variety of social support mechanisms.

Efficacy of a psychoeducative group program for caregivers of demented persons living at home: a randomized controlled trial

OBJECTIVES

To test the efficacy of a psychoeducative group program for informal caregivers of persons with dementia.

METHODS

The study was a multicenter randomized controlled trial. Randomization was stratified according to sex and kinship. Participants randomized to the control group were referred to the traditional support groups. Participants in the study group had fifteen 2-hr weekly sessions focusing on stress appraisal and coping. Eligible participants (primary caregivers of community-dwelling persons with dementia) were blindly assessed before the randomization and after 16 weeks on the following measures: frequency and reactions to behavioral problems (primary outcome), burden, psychological distress, anxiety, perceived social support, and personal efficacy.

RESULTS

A total of 158 participants were randomized to the study (n = 79) and control (n = 79) groups in 12 successive waves. Results show that study participants presented a 14% decrease in their reactions to the behavioral problems of the care-receivers as opposed to a 5% decrease in the control group ( p =.04). The frequency of behavior problems also decreased ( p =.06), as did the cross-product frequency/reaction ( p =.02). There was no significant effect on the secondary outcome variables.

DISCUSSION

This is one of the first studies showing a significant effect of this type of support group program on the caregivers of participants with dementia.