The Caregiver Activity Survey (CAS): longitudinal validation of an instrument that measures time spent caregiving for individuals with Alzheimer's disease

Family members incur substantial financial costs during the course of caring for an individual with Alzheimer's disease. Much of this cost is associated with time spent in caregiving tasks, including supervision and communication with the patient, and assisting with activities of daily living. We have previously reported on the cross sectional reliability and validity of a scale that measures time spent caregiving, the Caregiver Activity Survey (CAS). This study extends our results to a longitudinal study of the validity of the instrument. Forty-four outpatients with Alzheimer's disease who lived with a primary caregiver were followed over a period of 1 year 6 months. At six month intervals, the patients were administered the Mini Mental State Exam (MMSE), Alzheimer's Disease Assessment Scale (ADAS), and the Physical Self Maintenance Scale (PSMS). Caregivers completed the CAS. Over time, the CAS correlated significantly with the MMSE (r=-0.58, p=0.000), ADAS cognitive subscale (r=0.56, p=0. 000) and PSMS (r=0.49, p=0.000). As patients declined, caregivers spent less time communicating with and more time supervising the patient. Excluding the communication item, time spent caregiving increased significantly over time. This prospective study longitudinally validates the CAS with Alzheimer's patients.     

A pilot study of the reliability and validity of the Caregiver Activity Survey – Intellectual Disability (CAS-ID)

Background People with Down's syndrome (DS) are at increased risk of Alzheimer‐type dementia (AD) when compared to the general population. Despite AD being a serious progressive disorder, little attention has been paid to the impact of the illness on formal caregivers. In the general population, the Caregiver Activity Survey (CAS) is used to measure time spent by family caregivers assisting people with AD in their day‐to‐day activities of living. In order to plan appropriate models of health and social care effectively for people with AD and DS, it is imperative that the care requirements of individuals at different stages of dementia are realized. An amended version of this survey, the Caregiver Activity Survey – Intellectual Disability (CAS‐ID), was developed and tested for use by professional caregivers in the present study. Methods The CAS‐ID was administered to 30 people with DS and their caregivers. Convergent validity was tested by comparing the results of the CAS‐ID to other validated tests for cognitive and functional impairment in individuals with DS. Test–retest and inter‐rater reliability were investigated. Results The final version of the CAS‐ID consists of eight items: dressing, bathing/showering, grooming, toileting, eating and drinking, housekeeping, nursing care‐related activities, and supervision/ behaviour management. The scale had excellent test–retest reliability, and correlated strongly with the Down Syndrome Mental Status Examination (DSMSE; r = ?0.770), the Test for Severe Impairment (TSI; r = ?0.881) and the Daily Living Skills Questionnaire (DLSQ; r = ?0.855). Conclusions The present authors provide preliminary evidence for the validity and reliability of the CAS‐ID. This instrument offers a means of identifying and measuring care and resources requirements as this population experiences symptoms of dementia. Such information may help assist healthcare professionals in planning supports and services to address the care challenges evidenced at different stages of the disease process.     

Gender roles and caregiving stress: An examination of subjective appraisals of specific primary stressors in Alzheimer's caregivers

Family caregivers of patients with dementia face numerous, severe stressors in the course of caring for their relatives. While women are more likely than men to take on the caregiving role, evidence is mixed concerning how traditional gender roles influence response to caregiving. In the present study, male (n with Alzheimer's disease reported on their appraisals of the subjective stressfulness of 44 common primary caregiving stressors, including patient memory and behavior problems and self-care deficits. Male and female caregivers did not differ in length of caregiving service or hours per week spent in caring for their relatives, and there were no differences in terms of overall impairment in patients cared for by males and females. Males and females showed no differences in their stressfulness appraisals of any of the 44 primary caregiving stressors. Memory and self-care deficits, while relatively common, were rated as less stressful by male and female caregivers than behavioral problems. It appears that in the context of caregiving in Alzheimer's disease, gender roles may be less important than the nature of the stressor in determining reaction to primary stressors. Interventions to alleviate caregiver distress should target behavioral problems, such as dangerous behavior and agitation, which are most stressful to caregivers. =67) and female (n=130) primary caregivers of patients     

THE CLOCK DRAWING TEST FOR DEMENTIA OF THE ALZHEIMER'S TYPE: A COMPARISON OF THREE SCORING METHODS IN A MEMORY DISORDERS CLINIC

Objectives. To examine the reliability and validity of the Clock Drawing Test when used as a cognitive screening instrument for mild to moderate dementia, and to compare different scoring mechanisms. Design. Retrospective analysis of clock drawing performance using three published scoring methods (Shulman, Sunderland and Wolf-Klein). Setting. Hospital-based memory disorders clinic. Participants. A sample of 28 consecutive patients attending the memory clinic for assessment who were given a diagnosis of Alzheimer's disease (mild or moderate) and 28 age- and sex-matched control subjects comprising 17 memory clinic attenders found to be normal and 11 community volunteers. Measurements. Sensitivity and specificity of the three clock rating scales against memory clinic diagnoses of dementia using DSM-III-R; their respective interrater reliabilities; and comparisons of each with measures of cognitive impairment (the Mini-Mental State Examination and the Blessed Orientation–Information–Memory–Concentration Test), daily performance of basic and instrumental activities (the Blessed Dementia Scale) and depression (the Hamilton Rating Scale for Depression). Results. All methods of scoring the Clock Drawing Test correlated well with measures of cognitive impairment (r=0.57–0.73) and daily performance (r=0.38–0.48), were independent of mild depression and demonstrated high sensitivity, specificity and interrater reliability. While all clock scales identified mild to moderate dementia reasonably well, the Shulman method performed best. In screening for dementia, clock drawing proved superior to the MMSE: 24/28 vs 20/28 cases identified. When compared with the MMSE, clock drawing provided additional diagnostic discrimination, identifying 7/8 AD patients with MMSE scores ≥24. Conclusions. In a clinic population, clock drawing, especially if scored according to the Shulman scale and combined with the MMSE, is an extremely efficient test screening measure for mild to moderate dementia of the Alzheimer's type with low false negative and false positive rates. This may have implications for screening elderly populations.     

MRI Temporal Lobe Volume Measures and Neuropsychologic Function in Alzheimer's Disease

The authors performed quantitation of the temporal lobes using magnetic resonance imaging in 20 patients with mild-tomoderate Alzheimer's disease, 20 age-matched aged control subjects, and 26 healthy young volunteers. Compared to young subjects, aged controls showed volume reductions in amygdala (17%, p=0.02), hippocampus (15%, p=0.0001) and temporal lobe (22%, p=0.0001). Compared to aged controls, Alzheimer's subjects showed further volume reductions in amygdala (33%, p=0.0001) and hippocampus (20%, p=0.006) but not temporal lobe (7%, p=0.15). In Alzheimer's subjects, left temporal lobe volume correlated strongly with the Mini Mental State (MMSE) score (adjusted r² =0.46, p=0.0006) whereas right amygdala volume correlated inversely with the noncognitive ADAS score (adjusted r²=0.46, p=0.0006). The authors conclude that significant volume changes occur in the temporal lobe in aging and in Alzheimer's disease, with the greatest percentage reductions in the amygdala in Alzheimer's disease. Temporal neocortical atrophy and temporal limbic atrophy might be associated with different patterns of performance and behavior in Alzheimer's patients.     

How Do Scores on the ADAS-Cog,MMSE, and CDR-SOB Correspond?

Objective: Clinicians and researchers who measure cognitive dysfunction often use the Alzheimer’s Disease Assessment Scale—Cognitive Subscale (ADAS-Cog), the Mini-Mental State Examination (MMSE), or the Clinical Dementia Rating scale (CDR-SOB). But, the use of different measures can make it difficult to compare data across patients or studies. What is needed is a simple chart that shows how scores on these three important measures correspond to each other. Methods: Using data from 1709 participants from the Alzheimer’s Disease Neuroimaging Initiative and item response theory-based statistics, we analyzed how scores on each measure, the ADAS-Cog, the MMSE, and the CDR-SOB, correspond. Results: Results indicated multiple inflections in CDR-SOB and ADAS-Cog scores within a given MMSE score, suggesting that the CDR-SOB and ADAS-Cog are more precise in measuring the severity of cognitive dysfunction than the MMSE. Conclusions: This study shows how scores on these three popular measures of cognitive dysfunction correspond to each other, which is very useful information for both researchers and clinicians.     

Depressive symptoms of Alzheimer caregivers are mainly due to personal rather than patient factors

Objectives. To investigate the predictors of caregiver's depressive symptoms in a sample of community-dwelling Alzheimer's patients. Design. A cross-sectional study was conducted in an Alzheimer's unit specifically devoted to the care of demented patients in Brescia Province (Italy). One hundred and three dyads were consecutively recruited between July 1994 and July 1995. Caregivers were sons/daughters (65%) or husbands/wives; mean age was 54·6±13·2. Alzheimer's patients Mini Mental State Examination score was 11·3±8·3; patients were equally distributed among disease severity levels. The following variables have been collected: (a) background and context variables (caregiver's age, gender, marital status, education, relationship and cohabitation with the patient, employment status, satisfaction with household income); (b) caregiver's personal resources (health, social relationships and social interactions, formal supports use, and self-rated adequacy of performance as caregivers); (c) objective burden indicators (number of daily hours for assistance and vigilance); (d) primary stressors (patient's age and gender, cognitive status, functional status, frequency of behavioural disturbances). Caregiver's depressive symptoms represented the main outcome measure. Results. Being husband or wife, low self-rated health and caregiving competence, high numbers of hours for assistance and patient's behavioural disturbances and younger age were associated with caregiver's depressive symptoms. With multivariate analysis only relationship to the patient, caregiver's health and competence were independent predictors of caregiver's depressive symptoms. Conclusion. Factors related to the caregiver—relationship, health and competence—rather than to the patient constitute the main risk factors for caregiver's depressive symptomatology. © 1998 John Wiley & Sons, Ltd.     

Relationship between saliva level of 3-methoxy-4-hydroxyphenylglycol and mental health in the elderly general population

Aims: A large number of studies on the monoamine systems in Alzheimer's disease (AD) have found abnormalities of the noradrenergic system in the brain, but there has been no report concerning the relationship between noradrenergic activity and cognitive function in elderly living in a community. The aim of the present study was to explore the relationship between saliva level of 3‐methoxy‐4‐hydroxyphenylglycol (sMHPG) and mental health in this population. Methods: The study was to examine the relationship between sMHPG and performance on the Mini‐Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Beck Depression Inventory (BDI) in 213 elderly people living in the local community. Results: sMHPG in female subjects was positively correlated with age (r = 0.24, P = 0.003) and negatively correlated with scores on the MMSE (r = ?0.26, P = 0.0016) and FAB (r = ?0.19, P = 0.024), even after controlling for the effect of age (MMSE r = ?0.20, P = 0.013). Notably, sMHPG was correlated with the pentagon drawing score (P = 0.0008) of MMSE. sMHPG was significantly correlated with BDI score in male subjects, but negatively correlated in female subjects. A gender difference was found in the relationship between the sMHPG and BDI score. Conclusion: The measurement of sMHPG may be a useful marker of mental health in elderly community‐dwelling subjects.     

Nivel de conocimiento de la enfermedad de Alzheimer en cuidadores y población general

IntroductionUnderstanding of Alzheimer disease is fundamental for early diagnosis and to reduce caregiver burden. The objective of this study is to evaluate the degree of understanding of Alzheimer disease among informal caregivers and different segments of the general population through the Alzheimer's Disease Knowledge Scale.Patients and methodsWe assessed the knowledge of caregivers in different follow-up periods (less than one year, between 1 and 5 years, and over 5 years since diagnosis) and individuals from the general population. Alzheimer's Disease Knowledge Scale scores were grouped into different items: life impact, risk factors, symptoms, diagnosis, treatment, disease progression, and caregiving.ResultsA total of 419 people (215 caregivers and 204 individuals from the general population) were included in the study. No significant differences were found between groups for overall Alzheimer's Disease Knowledge Scale score (19.1 vs. 18.8, P = .9). There is a scarce knowledge of disease risk factors (49.3%) or the care needed (51.2%), while symptoms (78.6%) and course of the disease (77.2%) were the best understood aspects. Older caregiver age was correlated with worse Alzheimer's Disease Knowledge Scale scores overall and for life impact, symptoms, treatment, and disease progression (P < .05). Time since diagnosis improved caregivers’ knowledge of Alzheimer disease symptoms (P = .00) and diagnosis (P = .05).ConclusionAssessing the degree of understanding of Alzheimer disease is essential to the development of health education strategies both in the general population and among caregivers.     

Managing the burden of Alzheimer's disease: a partnership between caregiver and physician

Alzheimer's disease is a progressive, neurodegenerative disease that preferentially afflicts the elderly. Its clinical features include impairment of cognitive function and decline in activities of daily living, as well as emotional and personality changes. The effective management of Alzheimer's disease requires a partnership between physician and caregiver. Caregivers play a crucial role in the long-term care of demented patients. The demonstration that home-based care is a more economically viable solution than institutional care has led to the realization that community-based care must be supported and preserved if society is to cope with the burgeoning number of patients with Alzheimer's disease. Physicians depend upon caregivers to impart information concerning a patient's cognitive, functional and behavioural symptoms, whether for diagnosis, to assess the efficacy of a particular treatment, or to ascertain the staging of the disease. Caregivers suffer an enormous physical, emotional, financial and psychological burden as a consequence of the demands of caring. They are frequently at risk of ill-health and depression themselves, jeopardizing their ability to care. These problems can be alleviated through support, information, education, counselling, and various treatment programmes, which the physician can provide either directly to the caregivers, or can arrange for them. Where caregivers have a more realistic expectation of their caregiving role, and of the patient's capabilities, they are invariably better able to cope. They can be taught to manage effectively the troublesome behavioural symptoms of Alzheimer's disease, which are the most distressing features for the caregiver. The result of a strong and effective alliance between caregiver and physician is a carer who is more accepting and realistic about the caregiving role, and therefore better able to rise to the demands of caring. In turn, the physician is fully informed about the patient and in the best possible position to prescribe treatment, whether pharmacological or non-pharmacological, for the patient and/or caregiver. The patient whose behavioural symptoms are better managed, thereby reducing anxiety and aggression, receives an optimal level of care, both from the Caregiver and physician.     

Caring and coping: the dementia caregivers

Objectives: Caring for a family member with Alzheimer's disease is associated with increased burden and depression. Effective coping with the hardships and demands of caring may help to sustain the caregiver and lessen the effect of the stressors. The objective of this study was to examine caregivers’ coping styles and the relationship with reported levels of burden and depression.

Method: A cross-sectional correlation study was employed. One hundred and seventy-two caregivers of patients suffering from Alzheimer's type dementia participated in the study. All patients were recruited from neurology clinics. The Greek versions of four measuring instruments used were: the Memory and Behaviour Problem Checklist, the Burden Interview, the Centre for Epidemiological studies-Depression scale and the Ways of Coping Questionnaire.

Results: Positive coping is negatively correlated with burden (r?=??0.20) and wishful thinking strategies were related positively (r?=?0.16). The relation between depression and positive coping strategies is highly significant (p?p?

Conclusion: Positive coping approaches need to be developed by caregivers so as to continue their caring role.     

A CASE-CONTROL STUDY OF SMOKING AND ALZHEIMER'S DISEASE

Objectives. To study the association between Alzheimer's disease and smoking history. Design. An unmatched case-control study. Setting. Psychogeriatric unit serving an elderly population of Warrington. Period. 2 years 1991–1993. Subjects. 198 cases of Alzheimer's disease (ADRDA–NINCDS diagnostic criteria) were compared to two selected control groups (164 other dementias and 176 non-dementing group) with respect to their smoking history. Main outcome measure. Relative risk (odds ratio) of Alzheimer's disease. Results. The odds ratio for Alzheimer's disease in patients who smoked was 0.68 (95% CI 0.47–0.98). The negative association was statistically significant only in male patients, OR 0.45 95% CI (0.23–0.87), p<0.05. The inverse association was also only significant in patients with family history of dementia, OR 0.34 95% CI (0.12–0.92), p<0.05. Conclusion. The study supports previous findings of an inverse relationship between smoking and Alzheimer's disease. This, however, does not suggest that smoking is used as a preventive measure for Alzheimer's disease. © 1997 by John Wiley & Sons, Ltd.     

Uncinate fasciculus-correlated cognition in Alzheimer's disease: a diffusion tensor imaging study by tractography

Background: Neuroimaging studies show increased diffusivity and decreased anisotropy in Alzheimer's disease (AD) patients by diffusion tensor imaging (DTI). Previous reports have analyzed a correlation with cognitive function and DTI parameters, but their results are inconsistent. A reason for this might be a region of interest (ROI) method, used to calculate parameters for DTI, because this method has various usages of how to place a ROI and includes summations of values for various neuronal fiber tracts, resulting in contamination of unintended fibers. To improve the instability with ROI placement, a tractography‐based method might be useful. Our coworker reported decreased fractional anisotropy (FA) and increased apparent diffusion coefficient (ADC) of uncinate fasciculus (UF) in patients with AD by tractography. To confirm whether DTI parameter values are related to severity of cognitive function in patients with AD, we measured mean diffusion anisotropy and diffusivity of coregistered voxels along the tracking lines (i.e. tract of interest) of UF. Methods: The subjects were 30 patients with probable AD (NINCDS‐ADRDA criteria). Assessment of cognitive function was carried out according to the Mini‐Mental State Examination (MMSE) and the Alzheimer's Disease Assessment Scale‐cognitive component‐Japanese version (ADAS‐Jcog). A 1.5‐T clinical magnetic resonance unit was used to obtain diffusion tensor images. Diffusion tensors were computed and fiber‐tract maps were created using ‘dTV II’ DTI software developed by Masutani et al. We measured mean FA and ADC values along the bilateral UF. Results: FA values were positively correlated with MMSE score (r= 0.67) and were negatively correlated with ADAS‐Jcog score (r=?0.62), while ADC values were negatively correlated with MMSE score (r=?0.58) and were positively correlated with ADAS‐Jcog score (r= 0.59). Conclusion: FA and ADC values might reflect the severity of cognitive dysfunction. The tract‐of‐interest method might be a useful tool for objectively evaluating DTI parameters in AD.     

CLOX: an executive clock drawing task

OBJECTIVE—To describe a clock drawing task (CLOX) designed to elicit executive impairment and discriminate it from non-executive constructional failure.
SUBJECTS—90 elderly subjects were studied (45 elderly and well persons from the independent living apartments of a continuing care retirement community and 45 patients with probable Alzheimer''s disease). The clock drawing performance of elderly patients was compared with that of 62 young adult controls.
METHODS—Subjects received the CLOX, an executive test (EXIT25), and the mini mental state examination (MMSE). The CLOX is divided into an unprompted task that is sensitive to executive control (CLOX1) and a copied version that is not (CLOX2). Between rater reliability (27 subjects) was high for both subtests.
RESULTS—In elderly subjects, CLOX subscores correlated strongly with cognitive severity (CLOX1: r=−0.83 v the EXIT25; CLOX2: r=0.85 v the MMSE). EXIT25 and MMSE scores predicted CLOX1 scores independently of age or education (F(4,82)=50.7, p<0.001; R²=0.71). The EXIT25 accounted for 68% of CLOX1 variance. Only the MMSE significantly contributed to CLOX2 scores (F(4,72)= 57.2,p<0.001; R²=0.74). CLOX subscales discriminated between patients with Alzheimer''s disease and elderly controls (83.1% of cases correctly classified; Wilkes'' lambda=0.48, p<0.001), and between Alzheimer''s disease subgroups with and without constructional impairment (91.9% of cases correctly classified; Wilkes'' lambda=0.31, p<0.001).
CONCLUSIONS—The CLOX is an internally consistent measure that is easy to administer and displays good inter-rater reliability. It is strongly associated with cognitive test scores. The pattern of CLOX failures may discriminate clinical dementia subgroups.

     

Increased homocysteine and decreased adenosine formation in Alzheimer's disease

Abstract

Vascular risk factors increase the risk of Alzheimer's disease. Increased concentrations of circulating homocysteine are associated with vascular risk factors and Alzheimer's disease but the underlying mechanisms are unclear. Homocysteine inhibits the hydrolysis of S-adenosylhomocysteine leading to a decrease in the intracellular adenosine concentration. Adenosine is an endogenous protective molecule against atherosclerotic and vaso-occlusive disorders that contribute to the pathology of Alzheimer's disease. In this study the concentrations of homocysteine and adenosine were determined in the plasma of 25 patients with Alzheimer's disease and 25 control subjects. There was a significant increase in the plasma concentration of homocysteine (p < 0.0001) and a significant decrease in the plasma concentration of adenosine (p < 0.001). In the combined Alzheimer and control groups a significant negative correlation was found between the plasma concentrations of homocysteine and adenosine (r = -0.769, p < 0.0001). There was also a significant negative correlation between the plasma concentrations of homocysteine and adenosine in the Alzheimer group (r =-0.773, p < 0.0001). The decrease in adenosine formation may play a role in the vascular pathology of homocysteine in Alzheimer's disease.     

CARERS' KNOWLEDGE OF DEMENTIA AND THEIR EXPRESSED CONCERNS

Objective. The authors wished to determine how much carers from different settings caring for patients with dementia knew about the disorder and elicit their main concerns about the disease. Design. A survey questionnaire was administered to 136 carers. Setting. Two old age psychiatric services and an Alzheimer's support group in urban areas of the UK. Participants. The carers came from one of three categories: (1) carers with no prior contact with elderly mental health services (preassessment group); (2) carers who had been in contact with mental health care professionals (postassessment group); (3) carers in contact with an Alzheimer's Disease Society support group. Measures. A questionnaire on the subject of dementia. Carers' worries about the disorder were also recorded. Results. Carers in contact with an Alzheimer's support group were the most knowledgeable and carers in the preassessment group were the least knowledgeable on the subject of dementia. While carers in the postassessment group had a level of knowledge above that of the preassessment group, this difference failed to reach statistical significance. Conclusion. The study highlights the need for elderly mental health teams to evaluate their methods of dissemination of knowledge to carers, develop educational packages for carers and evaluate their effectiveness. © 1997 by John Wiley & Sons, Ltd.     

The relationship between self-efficacy and positive aspects of caregiving in Alzheimer's disease caregivers

Objectives: Positive aspects of the caregiving experience may buffer caregivers from the many negative psychological and physical consequences of caregiving. Understanding what factors relate to the recognition of positive aspects of caregiving is important for the enhancement of caregiver well-being. Self-efficacy is a potentially modifiable psychological construct that has been associated with positive thinking, improved control of negative affect, and enhanced motivation.

Methods: This study examined the relationship between positive aspects of caregiving and self-efficacy among 57 family members caring for a loved one with Alzheimer's disease. Participant data was gathered through individual interviews conducted as a part of a larger randomized controlled trial of a caregiver intervention.

Results: We found that self-efficacy accounted for a significant percentage of the variance in positive aspects of caregiving after controlling for other factors commonly associated with positive aspects of caregiving including caregiver demographics, care recipient neuropsychiatric symptoms, and caregiver depression.

Conclusions: Our results suggest that high self-efficacy relates to caregivers’ perception of positive aspects of the caregiving experience.     

Low plasma vitamin C in Alzheimer patients despite an adequate diet

Objective. To compare the vitamin C and E plasma levels in patients with Alzheimer's disease (AD) and to assess the vitamin C intake and nutritional status. Design. Case-control study. Four groups of sex- and age-matched subjects were compared: severe AD and moderate AD, in patients with moderate AD and controls. Setting. Community and hospitalized patients in the region of Toulouse, France. Participants. Patients with dementia who fulfilled criteria for Alzheimer's disease: severe Alzheimer group (N=20), Mini-Mental State Examination (MMSE) score range 0–9; moderate Alzheimer group (N=24), MMSE 10–23; hospitalized Alzheimer group (N=9), MMSE 10–23. Control group (N=19), MMSE 24–30. Measures. Plasma vitamin E and C were quantified by HPLC-fluorescence. Consumption of raw and cooked fruit and vegetables was evaluated in order to determine the mean vitamin C intakes. Mini Nutritional Assessment (MNA) and plasma albumin were used to measure nutritional status. Results. Institutionalized and community subjects were analysed separately. MNA scores were normal in home-living Alzheimer subjects with moderate dementia and significantly lower in those with severe disease, despite normal plasma albumin levels. In the home-living Alzheimer subjects, vitamin C plasma levels decreased in proportion to the severity of the cognitive impairment despite similar vitamin C intakes, whereas vitamin E remained stable. The hospitalized Alzheimer subjects had lower MNA scores and albumin levels but normal vitamin C intakes, but their plasma vitamin C was lower than that of community-living subjects. Institutionalized Alzheimer subjects had significantly lower MNA scores but normal vitamin C and albumin levels and vitamin C intakes compared with community-dwelling subjects of similar degree of cognitive impairment. Conclusion. Plasma vitamin C is lower in AD in proportion to the degree of cognitive impairment and is not explained by lower vitamin C intake. These results support the hypothesis that oxygen-free radicals may cause damage. Copyright © 1998 John Wiley & Sons, Ltd.     

Dementia caregivers’ coping with pre-death grief: effects of a CBT-based intervention

Objectives: Pre-death grief plays a significant role in dementia caregiving, and has adverse impacts on caregivers. It was the purpose of the present study to examine whether a cognitive-behavioral intervention including a grief intervention module could increase caregivers’ coping with pre-death grief and whether these effects could be maintained as of a six-month follow-up assessment.

Method: In a randomized-controlled trial examining the effectiveness of a cognitive-behavioral intervention, 273 caregivers were allocated to either an intervention or control group. Intervention group participants received 12 therapy sessions over six months; all participants completed a measure of pre-death grief. The analysis was conducted using latent change models. In the first model, study group was included as a predictor of change in pre-death grief; subsequent models also included care situation and sociodemographic variables.

Results: The burden due to pre-death grief was reduced for intervention but not control group participants at the time of the six-month follow-up assessment (Cohen's d = ?0.361). When controlling for changes in the care situation and sociodemographic variables, the treatment effect was also found in the assessment completed post intervention (Cohen's d = ?0.248).

Conclusion: Results indicate that a cognitive-behavioral intervention including grief-specific strategies can successfully foster caregivers’ coping with loss and reduce burden of pre-death grief.