Supporting Informal Caregivers of People With Dementia in Cost-Effective Ways: A Systematic Review and Meta-Analysis

ObjectivesCaring for persons with dementia is a heavy burden for informal caregivers. This study aimed to appraise the economic evidence of interventions supporting informal caregivers of people with dementia.MethodsLiterature was searched, and trial-based studies evaluating the costs and effects of interventions supporting informal caregivers of people with dementia were included. Cost data were analyzed from both healthcare and societal perspectives. Random-effects models were used to synthesize cost and effect data, based on mean differences (MDs) or standardized MDs.ResultsOf 33 eligible studies identified from 48 588 records, 14 (42.4%) showed net savings in total cost regardless of analytical perspectives. Among 22 studies included in meta-analyses, caregiver-focused psychosocial interventions showed improvements in caregivers’ psychological health (n = 4; standardized MD 0.240; 95% confidence interval 0.094-0.387); nevertheless, the increases in societal cost were significant (n = 5; MD 3144; 95% confidence interval 922-5366). Psychological intervention and behavioral management engaging patient-caregiver dyads showed positive effects on caregivers’ subjective burden, also with increases in total cost. Subgroup analyses indicated that the inclusion of different intervention components, the caregiver characteristics, and the follow-up periods could affect the costs and effects of interventions supporting informal caregivers.ConclusionsPsychosocial interventions directed at informal caregivers and dyad-based psychological and behavioral interventions are effective but also expensive. The use of these interventions depends on the society’s willingness to pay. More comprehensive economic evidence of interventions supporting informal caregivers is required, and the design of intervention should focus more on different intervention components, characteristics of patients and caregivers, and healthcare systems.     

Effects of a Humanoid Companion Robot on Dementia Symptoms and Caregiver Distress for Residents in Long-Term Care

ObjectivesTo test the effects of deploying a humanoid companion robot (Kabochan) in comparison with usual care for long-term care facilities’ residents with dementia.DesignA 2-arm, randomized controlled trial with ABAB withdrawal design, lasting 32 weeks. After an 8-week baseline period, Kabochan was introduced in a nonfacilitated, individual approach with experimental-group participants (n = 52) for 8 weeks, then removed for 8 weeks, and then reintroduced for another 8 weeks. The control group (n = 51) received the usual standardized care.Setting and ParticipantsSeven long-term care facilities in Hong Kong. 103 residents (76% women, 87.2 ± 7.4 years) with a clinical diagnosis of dementia.MeasuresOutcome assessments occurred at 5 time points: baseline (week 1) and the end of each phase (weeks 8, 16, 24, and 32). Primary outcomes were assessed with the Neuropsychiatric Inventory Questionnaire (symptom severity and caregiver distress subscales) and the Geriatric Depression Scale; secondary outcomes were measured by the Hong Kong Montreal Cognitive Assessment 5-minute Protocol, the Modified Barthel Index for Activities of Daily Living, and the Quality of Life–Alzheimer's disease scale.ResultsA multivariate analysis of variance indicated a statistically significant group × time interaction for neuropsychiatric-related caregiver distress at week 16 (F = 6.72, P = .011), with a moderate effect size (η_p² = 0.06). When Kabochan was removed in the withdrawal phase (weeks 17–24), the neuropsychiatric symptoms became more severe at week 24 for the intervention group (F = 4.68, P = .003), although the effect size was small to moderate (η_p² = 0.04). No statistical between-group differences were found in other health outcomes.Conclusions and ImplicationsThe Kabochan was potentially effective at reducing short-term neuropsychiatric symptoms and relevant caregiver distress for residents with dementia. An individualized care plan with continuous monitoring is required to integrate the humanoid robot into routine dementia care.     

Factors Associated With Family Caregiver Burden of Home-Dwelling Patients With Advanced Dementia

ObjectivesTo realize patients’ preferences for home death, this study aimed to identify factors associated with family caregiver burden of home-dwelling patients with advanced dementia and examine its relationship with end-of-life care treatment decisions.DesignA prospective cohort study.Setting and ParticipantsPatient-family caregiver dyads enrolled in a home-based palliative care program for patients with advanced dementia, with family caregiver burden assessed using the Zarit Burden Interview (ZBI) on enrolment, were included.MethodsIndependent variables included sociodemographic data, patients’ clinical phase, symptom severity, quality of life, informal paid help availability, and community resources utilized. Dependent variable was continuous ZBI scores and ZBI scores dichotomized into <24 and ≥24 for predicting depression risk. Place of death and interventions received 2 weeks before death were also collected. Data were analyzed using multivariate linear and logistic regression.ResultsFrom October 2014 to December 2020, a total of 377 family caregivers were assessed with ZBI. Median score was 25 (IQR 15-36), and 54.4% of them were at risk of depression. Younger family caregivers had higher ZBI scores (β = ?0.22, 95% CI –0.38, ?0.07), with the depression risk doubling for family caregivers aged <60 years (OR 2.13, 95% CI 1.33, 3.43). Absence of informal paid help also increased the ZBI scores (β = ?9.04, 95% CI –14.86, ?3.22) and depression risk (OR 2.50, 95% CI 1.03, 6.09). In addition, caregivers’ ZBI scores increased with patients’ neuropsychiatric symptom severity (β = 0.49, 95% CI 0.08, 0.89), and caregivers of clinically unstable patients had a higher depression risk (OR 1.80, 95% CI 1.03, 3.12). Baseline caregiver burden was not associated with treatment decisions made at the end of life.Conclusions and ImplicationsYounger family caregivers caring for clinically unstable patients with severe neuropsychiatric symptoms experienced greater burden without informal paid help. For end-of-life care at home in advanced dementia to be tenable, relevant national agencies and stakeholders are recommended to work collectively to support family caregivers holistically.     

Patient-Related Factors Associated With Depressive State in Caregivers of Patients With Dementia at Home

ObjectvesTo identify patient-related factors associated with depressive state in caregivers of patients with dementia, we investigated the caregivers' and patients' characteristics in relation to the depressive state in their caregivers.DesignProspective hospital-based cohort study.SettingTwo memory clinics in Japan.ParticipantsOutpatients with dementia (n = 135) and their caregivers at home.MeasurementsThe outpatients and their caregivers were divided into 2 groups according to the Center for Epidemiologic Studies Depression Scale for caregivers. To identify the patient-related factors that cause depressive state in caregivers, Mini-Mental State Examination (MMSE), the Physical Self-Maintenance Scale for fundamental activities of daily living (ADL), and the instrumental ADL scale (IADL) scores for instrumental ADL and the neuropsychiatric inventory (NPI) subscale score for behavioral and psychological symptoms of dementia were compared between the 2 groups. We used logistic regression to determine the independent predictors of caregiver depressive state.ResultsThere was no significant difference in MMSE score between the 2 groups. Logistic regression analysis revealed that the depressive state in caregivers was related with IADL score and delusion in NPI subscale of patients.ConclusionsDepressive state in caregivers was independent of the decline in cognitive function in patients with dementia but was associated with decline in instrumental ADL and severity of delusion.     

Social Networks Effects on Spouse and Adult-Child Dementia Caregivers’ Experiences: A Cross-Sectional Study

ObjectivesA large body of literature addresses experiences of spouse and adult-children caregiver of individuals with dementia (IWDs) but has not examined the role and strength of social networks in associations between spouses and adult-children caregivers’ experience. Based on the stress process model, we aimed to explore the strength levels of social networks and their association with spouses/adult-children caregivers for IWDs.DesignA cross-sectional study.Setting and ParticipantsA questionnaire-based survey was conducted with a total of 146 family caregivers of IWDs (78 adult-child, and 68 spouses) in China.MethodsData collection comprised 4 sections: (1) care-related stressors (dementia stage, neuropsychiatric symptoms); (2) caregiver context; (3) social network, using the Lubben Social Network Scale; and (4) caregiving experience, using the short-form Zarit Burden Interview and 9-item Positive Aspects of Caregiving Scale. Linear regression, mediation model analysis, and interactive analysis were performed to explore the mechanisms of associations between variables.ResultsSpouses had weaker social network strength (β = −0.294, P = .001) and reported greater positive aspects of caregiving (β = 0.234, P = .003) than adult-children caregivers; no significant difference was found between them for caregiver burden. Mediation analysis suggests that associations between caregiver type and caregiver burden are indirect-only mediation effects of social networks (β = 0.140, 95% CI = 0.066-0.228). The social network strength suppressed the association between caregiver type and positive aspects of caregiving. The caregiver type/social network interaction statistically significantly (P = .025) affected the “positive aspects”: a stronger social network was associated with more positive aspects of caregiving among the spouse subgroup (β = 0.341, P = .003).Conclusions and ImplicationsSocial networks mediate responses to caregiving experiences among different care provider types and are vital intervention targets, especially for spousal caregivers. Our results can serve as references for identifying caregivers for clinical intervention.     

Depression in People With Dementia and Caregiver Outcomes: Results From the European Right Time Place Care Study

ObjectiveTo investigate the cross-sectional associations between depression in people with dementia and both caregiver burden and quality of life in 8 European countries, and to test these associations compared with the presence of other neuropsychiatric symptoms.DesignCross-sectional study.Setting and ParticipantsIn total, 1223 dyads comprised of informal caregivers and people with dementia living in a community-dwelling setting, recruited from the Right Time Place Care study, a cohort survey from 8 European countries.MeasuresTo test the associations between depression (according to the Cornell Scale for Depression in Dementia) and informal caregiver burden (defined by the Zarit scale and hours of supervision in terms of Resource Utilization in Dementia), distress (defined by the Neuropsychiatric Inventory Questionnaire distress score), and quality of life (according to the visual analogue scale and 12-item General Health Questionnaire).ResultsLinear regressions showed an association between depression and main outcomes (Zarit scale: β 3.7; P = .001; hours of supervision: β 1.7; P = .004; Neuropsychiatric Inventory Questionnaire distress score: β 1.2; P = .002). A similar association was found concerning psychological and overall well-being (12-item General Health Questionnaire: β 1.8; P < .001; Euroqol Visual Analogue Scale: β −4.1; P = .003). Both associations remained significant despite the presence of other NPS and after adjusting for confounders.Conclusions and ImplicationsFurther studies are needed to assess whether providing tailored strategies for optimizing diagnosis and managing of depression in people with dementia might improve caregiver quality of life and reduce their burden in the community-dwelling setting.     

Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial

BackgroundInappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use.ObjectivesThe objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC.DesignA prospective, stepped-wedge study design was used to evaluate the effect of the intervention.Settings and participantsInterdisciplinary staff at 10 Canadian LTC facilities.MethodsThe intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator.ResultsThe weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was −4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms.Conclusions and implicationsThis multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.     

Discontinuation of Long-Term Antipsychotic Drug Use for Behavioral and Psychological Symptoms in Older Adults Aged 65 Years and Older With Dementia

BackgroundAntipsychotic drugs are often used to treat behavioral and psychological symptoms (BPSD) in adults aged 65 years and older with dementia, although there is uncertainty about the effectiveness of long-term use for this indication and there are concerns that they may cause harm.ObjectivesTo evaluate whether discontinuation of long-term antipsychotic drugs for BPSD is successful in adults aged 65 years and older with dementia. This article is based on a Cochrane review updated in 2018.DesignA Cochrane systematic review and meta-analysis.Setting and ParticipantsEight databases were searched in January 2018 to identify 10 randomized controlled trials with 632 older adults.MeasuresWe used standard methodological procedures according to the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the number of patients completing the study. We considered sustained withdrawal of antipsychotics until the end of the study period as successful outcome.ResultsBased on assessment of 7 studies (n = 446), discontinuation may make little or no difference to whether or not participants complete the study (low-quality evidence). In 2 trials, including participants with psychosis, agitation, or aggression who had responded to antipsychotic treatment, discontinuation of antipsychotics was associated with a higher risk of leaving the study prematurely because of symptomatic relapse or a shorter time to symptomatic relapse. We found low-quality evidence from 7 trials (n = 519) that discontinuation may make little or no difference to overall BPSD, measured using various scales. There was some evidence from subgroup analyses in 2 trials that discontinuation may be associated with a worsening of BPSD in participants with more severe BPSD at baseline.ConclusionsOur meta-analysis revealed that there is low-quality evidence that long-term antipsychotic drugs for BPSD may be successfully discontinued in most adults aged 65 and older.     

Spouse and Adult-Child Dementia Caregivers in Chinese American Families: Who Are More Stressed Out?

ObjectivesThough many studies have explored differences between spouses and adult children in dementia care, empirical evidence is lacking on racial- and ethnic-minority populations. To fill this research gap, this study examined care tasks, caregiver burden, and depressive symptoms of Chinese spouse and adult-child caregivers in dementia care. Guided by the stress process model, this study asked 3 questions: Do spouse and adult-child caregivers take up different care tasks and experience different levels of caregiver burden and depressive symptoms? Does gender moderate the differences between spouse and adult-child caregivers? Whether care tasks and burden mediate the association between being a spouse/adult-child caregiver and depressive symptoms?Setting and ParticipantsData were collected from a questionnaire-based survey of Chinese Americans who provided care for their family members with dementia in New York City. The analytical sample included 126 Chinese spouse or adult-child caregivers.MethodsCare tasks was indicated by intensity of 8 types of care tasks. Caregiver burden and depressive symptoms were measured by Zarit's Burden Interview and the 10-item Center for Epidemiologic Studies Depression Scale. Linear regression, interaction term (spouse/adult-child caregiver by gender), and path analysis were conducted to address the 3 questions.ResultsThe results of linear regression show no significant difference in care tasks between the 2 groups, but spouse caregivers had significantly higher levels of caregiver burden and depressive symptoms than adult children. Wives had higher levels of caregiver burden and depressive symptoms than husbands, daughters, and sons. Caregiver burden mediated the association between being a spouse caregiver and higher depressive symptoms, whereas care tasks did not shape such association.Conclusions and ImplicationsThis study highlighted the emotional stress of Chinese American older adults in providing care for their spouses. The findings indicate the necessity of developing culturally meaningful activities to support Chinese American spouse caregivers.     

The Effect of Using PARO for People Living With Dementia and Chronic Pain: A Pilot Randomized Controlled Trial

ObjectivesTo evaluate the effect of interaction with a robotic seal (PARO) on pain and behavioral and psychological symptoms of people with dementia and chronic pain.DesignA parallel pilot randomized controlled trial conducted between January 2018 and January 2019.SettingThree long-term care facilities in Australia.ParticipantsForty-three participants aged ≥65 years living with dementia and chronic pain.InterventionParticipants were randomized to the PARO group (individual, nonfacilitated, 30-minute sessions, 5 days per week for 6 weeks) or a usual care group using a computer-generated random number.MeasurementsThe primary outcome was researcher-rated observational pain behaviors before and after each session. Secondary outcomes were staff-rated pain level, agitation, depression, and anxiety measured at baseline and the end of week 6. Medications regularly prescribed and as needed were recorded weekly. Analyses followed intention-to-treat, using the generalized estimating equation model. Australian New Zealand Clinical Trials Registry (ACTRN12618000082202).ResultsParticipants in the PARO group had a significantly lowered level of observed pain [−0.514, 95% confidence interval (CI) −0.774 to −0.254, P < .001] and used fewer pro re nata medications (−1.175, 95% CI −2.205 to −0.145, P = .025) than those in usual care after controlling for age, sex, cognitive function and medications. There were no significant differences in staff-rated pain, agitation, anxiety, and depression, nor regularly scheduled medications between intervention and control group.Conclusions and ImplicationsPARO shows promise in reducing pain and medications for individuals with dementia and chronic pain in long-term care facilities. This intervention might be incorporated into daily practice as an alternative to manage pain in people with dementia. Larger randomized controlled trials with longer time frames are needed to identify further and test the use of PARO in long-term care settings.     

Use of Antipsychotic Drugs Among Residents With Dementia in European Long-Term Care Facilities: Results From the SHELTER Study

BackgroundBehavioral and psychological symptoms of dementia (BPSD) are common reasons for use of antipsychotic drugs among older individuals with dementia. These drugs are not approved for such use and both the Food and Drug Administration and European Medicines Agency have issued warnings to limit such use.ObjectivesThis study aimed to describe patterns of antipsychotic drug use in a sample of nursing home residents with dementia in 7 European countries and Israel.DesignThis cross-sectional, retrospective cohort study used data from the SHELTER study that collected comprehensive resident data using the interRAI Long-Term Care Facility instrument.MethodsFifty-seven long-term care facilities participated from 8 countries, and the sample included 4156 long-term care residents from these settings. Individuals with dementia, both Alzheimer and non-Alzheimer types, were identified. Potential correlates of any antipsychotic and atypical versus conventional antipsychotic drug use among residents with dementia were identified using generalized estimation equation modeling.ResultsA total of 2091 individuals with dementia were identified. Antipsychotic drug use among these individuals varied by country, with overall prevalence of use being 32.8% (n = 662). Among antipsychotic users, 7 in 10 were receiving atypical agents. Generalized estimation equation analysis revealed that the strongest correlate of any antipsychotic drug use was severe behavioral symptoms, which increased the likelihood by 2.84. Correlates of atypical versus conventional antipsychotic drug use included psychiatric services, more than 10 medications, moderate behavioral symptoms, and female gender.ConclusionDespite recommendations to avoid the use of antipsychotic drugs in patients with dementia, a large proportion of residents in European long-term care facilities continue to receive such agents. Future work should not only establish the appropriateness of such use through outcomes studies, but explore withdrawal strategies as well as alternative treatment modalities.     

Impacto sobre el cuidador principal de una intervención realizada a personas mayores dependientes

ObjectiveTo evaluate the impact of joining a home care program on primary caregivers of dependent elderly people.DesignNon-randomised “before-after” intervention study.SettingPrimary Care.ParticipantsPrimary carers of elderly dependent people included in a home care program (n = 156; 7.8% loss to follow up).InterventionsInclusion in a home care program for chronically dependent elderly and the assessment of the primary carer in the same year.Variables assessedperceived health, frequency of visits, questionnaires of quality of life (Nottingham questionnaire), psychological health (Goldberg questionnaire), social support (Duke-UNC scale) and overburden of caregivers (Zarit questionnaire) and satisfaction with care received.ResultsThere were no significant changes in perceived health. Improvement in the areas of energy, sleep, emotional and social relationship of the quality of life. Decreased attendance (8.4 vs. 7.5, p < 0.05) and the percentage of overusers (30.1 vs 6.9%, P < .01). A reduced percentage of caregivers expressed low social support (8.3 vs 2.8%, P < .05) and caregiver overburden (56.4 vs 44.4%, P < .05). 90.3% of caregivers believed that care had improved at the end of intervention, with a significant improvement of satisfaction of overall medical and nursing care received (7.6 vs 8, 4, 7.9 vs 8.5 and 7 vs 8.5; P < .05).ConclusionsJoining a home care program for dependents has a positive impact on their primary caregiver and improves their perception of care received, reducing their use of health services, reducing the level of overburden and their perceived lack of social support.     

Music Compared with Auditory Books: A Randomized Controlled Study Among Long-Term Care Residents with Alzheimer's Disease or Related Dementia

BackgroundOver 5 million Americans age 65 years and older were diagnosed with Alzheimer's disease and/or related dementia (ADRD), a majority of whom exhibit behavioral and psychological symptoms leading to placement in long-term care settings. These facilities need nonmedical interventions, and music-based programs have received supportive evidence.SettingThirteen long-term care facilities were among a wave of facilities that volunteered to be trained and to administer a music-based intervention. The residents within were randomized into intervention or control groups (intervention/music, n = 103; control/audiobook, n = 55).DesignThis team used a pragmatic trial to randomly embed music and control (audiobooks) into 13 long-term care facilities to compare the effects on agitation in people with ADRD.MethodsMeasures included a demographic survey; the Mini-Mental Status Examination, used to assess cognitive status; and the Cohen-Mansfield Agitation Inventory with 4 subscales, used to measure agitation. These measures were implemented at baseline and every 2 weeks for 8 weeks. Mixed-effects models were used to evaluate change in agitation measures while addressing dependencies of scores within participants and facility.ResultsDecreases in agitation were attributable to both music and audiobooks in 3 of 4 agitation subscales. In the fourth, physical agitation, which was not directed toward staff, initially, it decreased given music, and increased thereafter; and generally, it increased with the audiobooks.Conclusion and ImplicationsBoth music and control audiobooks delivered by headphones after personalized selection reduced some aspects of agitation in residents diagnosed with ADRD. The effects of music were greater initially then diminished.     

Rejection of Care and Aggression among Older Veterans with Dementia: The Influence of Background Factors and Interpersonal Triggers

ObjectivesTo test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model.DesignA mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system.Setting and ParticipantsIn total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes).MethodsText data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling.ResultsRejection of care was directly affected by interpersonal triggers (β = 0.32, P < .005) and background factors such as depression (β = 0.29, P < .018), anxiety (β = −0.18, P < .023), and cognitive status (β = 0.10, P < .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × β = 0.13 × 0.32 = 0.04, P < .012). Aggression was directly affected by both interpersonal triggers (β = 0.19, P < .009) and functional status (β = 0.17, P < .011). Both function (α × β = 0.12 × 0.19 = 0.02, P < .035) and depression (α × β = 0.13 × 0.19 = 0.03, P < .005) had indirect effects on aggression through interpersonal triggers.Conclusions and ImplicationsInterpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.     

Important components for Dutch in‐home care based on qualitative interviews with persons with dementia and informal caregivers

BackgroundDementia care in the Netherlands is increasingly dependent on informal care and has the aim to keep persons with dementia at home for as long as possible. However, little is known about the preferences and needs of people with dementia living at home. Including people with dementia and their informal caregivers in research and policy creation could help to identify necessary forms of support, and tailor care to their personal preferences and needs.ObjectiveTo identify important components of in‐home care for persons with dementia and their informal caregivers in the Netherlands.DesignSemi‐structured interviews across the Netherlands, between March and June 2019 using thematic analysis.Setting and participantsPersons with dementia (n = 5) and informal caregivers (n = 14) were primarily recruited through dementia care organizations. Additionally, a case manager was recruited to reflect upon the semi‐structured interviews findings.ResultsFive themes concerning important care components were identified including the need for: a social network, formal care, information, emotional support and easier access to care. The complexity of the dementia care system posed a common difficulty for persons with dementia and informal caregivers.ConclusionThis study suggests that a dementia care package should be developed that includes both informal and formal care, the provision of information and emotional support, and help with access to care. The creation of this care package could help to tailor dementia care to the preferences and needs of the persons with dementia and their informal caregivers.     

Online Education and Cognitive Behavior Therapy Improve Dementia Caregivers' Mental Health: A Randomized Trial

ObjectivesTo compare online cognitive-behavioral therapy (CBT) with and without telephone support respectively to online psychoeducation in a randomized controlled trial (RCT) in caregivers of people with dementia with mild anxiety or depression.DesignThree-arm parallel-group RCT comparing online CBT with and without telephone support respectively to online psychoeducation.Setting and ParticipantsOnline study with caregivers of people with dementia.MeasuresThe primary outcome measure was mental health measured by General Health Questionnaire–12 (GHQ-12) at 26 weeks. Secondary outcomes included the Hospital Anxiety and Depression Scale (HADS); the Relative Stress Scale (RSS) and the Short Sense of Competency Questionnaire. The primary analysis focused on people completing GHQ-12 at both baseline and 26 weeks, evaluated using analysis of covariance.Results638 people were randomized to the 3 treatment arms, of whom 208 were included in the analysis population. There were significant improvements in GHQ-12 in all treatment arms compared to baseline (P < .001 for all interventions), but neither CBT with nor without telephone support conferred any significant advantage compared to psychoeducation. For the secondary outcomes, there were no significant differences between CBT with telephone support and psychoeducation, but CBT without telephone support was less effective than psychoeducation with respect to HADS depression subscale [mean difference 1.86, 95% confidence interval (CI) 0.61, 3.11; P = .004] and caregiver stress (RSS mean difference 3.11, 95% CI 0.13, 6.09; P = .04). Good safety was achieved in all 3 treatment arms, with no deaths or serious adverse events.Conclusions and ImplicationsOnline CBT with telephone support and psychoeducation both achieved significant benefits over 26 weeks compared with baseline in mental health and mood, but there were no advantages for CBT compared with the psychoeducation intervention. CBT without telephone support was less effective with respect to mood outcomes than psychoeducation and should not be recommended based on current evidence.     

ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

ObjectivesTo design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers.DesignPilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes.SettingEleven long-term care sites in Massachusetts and Maine.ParticipantsAn interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites.InterventionLong-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing.MethodsBaseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites.ResultsForty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed.ConclusionsThe results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers.     

Exercise interventions ameliorate neuropsychiatric symptoms in dementia: A meta-analysis

ObjectivesThis meta-analysis was aimed at systematically synthesizing the effects of exercise interventions on neuropsychiatric symptoms in individuals with dementia. The possible moderators that may influence intervention effects were also examined.MethodsWe searched seven databases (PubMed, Web of Science, SCOPUS, SportDiscus, Ebsco, China National Knowledge Infrastructure, and Wanfang) for randomized clinical trials. The pooled effect sizes were computed by the standardized mean difference (SMD) from post-intervention scores using random-effects models. Potential moderators were also explored by performing subgroup analyses and meta-regression. The risk of bias for included studies was evaluated by the Cochrane Risk of Bias 2.0 Tool.ResultsA total of 22 effect sizes from 17 studies (n = 1344) fulfilled the inclusion criteria. The results indicated that exercise interventions had a small but significant effect on neuropsychiatric symptoms in dementia (SMD = −0.27, 95% CI [−0.40,−0.14], p < 0.001). Subgroup analyses showed that intervention frequency and disease severity moderated the effects. Specifically, interventions with medium-frequency (3 times/week) had a positive effect on neuropsychiatric symptoms (SMD = −0.5, 95% CI [−0.65, −0.34], p < 0.001), but not with low-frequency (1–2 times/week) (SMD = −0.07, 95% CI [−0.22, 0.08], p = 0.38) or high-frequency (4–7 times/week) (SMD = −0.11, 95% CI [−0.36, 0.14], p = 0.38). Interventions had a beneficial effect on neuropsychiatric symptoms in people with mild dementia (SMD = −0.48, 95% CI [−0.71, −0.26], p < 0.001), and moderate dementia (SMD = −0.21, 95%CI [−0.37, 0.05], p < 0.05), but not severe dementia (SMD = −0.01, 95% CI [−0.33, 0.3], p = 0.94).ConclusionsExercise interventions effectively improve neuropsychiatric symptoms in mild and moderate dementia patients. Interventions occurring three times per week were associated with significant effects. Our findings provide evidence that exercise interventions may be an accessible and effective means for improving dementia patients' neuropsychiatric symptoms.