Mohammed T. Abou-Saleh

768 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYHealth Care and Lost Employment CostsWe found that over the first 12 months of follow-up there wereno appreciable differences between the groups in the number ofvisits to all doctors, general practitioners or non-medical healthpractitioners; or in the use of medication or of hospitals. In thesecond 6 months of the first year, memory retraining patientsspent more nights in institutional care than the other twogroups.Prediction of Nursing Home Admission and DeathBy 5 years follow-up, 75.8% of patients had entered a nursinghome and 41.8% had died. Dementia severity and rate ofdeterioration and carer psychological morbidity significantlyinfluenced rates of nursing home admission and death. Theserates were comparable to previous reports 23,24 .Carer training had a significant protective effect against nursinghome admission and, surprisingly (and independently of nursinghome admission), against death. There was an associationbetween earlier nursing home admission and caregiver distress,as measured by the GHQ; index measures of dementia severityand problem behaviours; more rapid decline in cognitive function;more rapid decline in overall dementia severity; and increase inproblem behaviours.COMMENTSCarer intervention programs have considerable potential. Theycan improve the quality of life of the carers and probably that ofpatients 1 . We have recently reviewed 35 controlled studies of carerintervention and found that a minority of them demonstratedclinically significant beneficial effects 8 .Limitations to previous studies included: heterogeneity ofpatients and of carers in the sample; variety of recruitmentmethods; ceiling and floor effects as regards the outcomemeasures; low number of numbers and insufficient power; lackof blindness; insufficient duration of follow-up; and lack ofspecificity in matching interventions with carer needs 8 .The Sydney Carer Training Program study overcame many ofthese limitations and demonstrated psychological improvement incarers, delay in nursing home admissions and cost savings. Thedelay in institutionalization was not at the expense of increasedcarer distress.There were a number of unanswered questions from the study.It was not possible to know which components of the package ofinterventions were effective. We provided a broad-spectrumintervention—something for everybody. This was confirmed atexit interviews after 12 months’ follow-up, where each componentof the program was identified by at least one carer as being helpfulto him/her.The program was unnecessarily expensive in that it wasconducted within a hospital setting. While this provided manyadvantages, it was very costly, and the cost analyses allowed for20 hospital bed-days per patient–carer couple. We do not knowwhether the program needed to be residential, although this didprovide some advantages. The advantages of residential programsare that they promote more cohesive bonding and allow forobservation of behaviours not easily accessible within a dayprogram. Clearly, residential programs could be conducted in lessexpensive settings.The ideal number of couples per training cohort isunknown, but our impression was that numbers greaterthan 10 would impede the group process. Also, ourexperience suggested that the earlier the intervention, thebetter, and that matching carer cohorts, e.g. spouses, youngerpeople with dementia, socioeconomically and geographically,may have advantages.Future research might benefit from a more targeted, selectiveapproach—matching the needs of carers with appropriateinterventions. The questions of which carer interventions benefitwhich carers for which patients at what time in the course of thedementia are complex. Finally, the advent of specific drugtreatments for Alzheimer’s disease begs the question of whethercarer interventions plus drug treatments are superior to eitheralone.REFERENCES1. Brodaty H, Gresham M, Luscombe G. The Prince Henry Hospitaldementia caregivers’ training programme. Int J Geriat Psychiat 1997;12: 183–92.2. Brodaty H, Gresham M. Effect of a training programme to reducestress in carers of patients with dementia. Br Med J 1989; 299:1375–9.3. Morris RG, Morris LW, Britton PG. Factors affecting the emotionalwell-being of the caregivers of dementia sufferers. Br J Psychiat 1988;153: 147–56.4. Brodaty H. Dementia and the family. In Bloch S, Hafner J, Harari E,Szmukler GI, eds, The Family in Clinical Psychiatry. Oxford: OxfordUniversity Press, 1994: 224–46.5. Brodaty H, Green A. Family caregivers for people with dementia. InO’Brien J, Ames D, Burns A, eds, Dementia, 2nd edn. London:Chapman & Hall, 2000.6. Donaldson C, Tarrier N, Burns A. Determinants of carer stressin Alzheimer’s disease. Int J Geriatr Psychiat 1998; 13(4): 248–56.7. Brodaty H. Carers: training informal carers. In Arie T, ed., RecentAdvances in Psychogeriatrics 2. Singapore: Churchill Livingstone,1992.8. Green A, Brodaty H. Evidence-based dementia: caregiver interventions.In Qizilbash N, Schneider L, Chui H et al., eds, Evidence-basedDementia Practice: a Practical Guide To Diagnosis and Management.Oxford: Blackwell Science (in press).9. Ball J. Communicating with people with dementia. 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