Dementia

Dementia: A public health priority
> CHAPTER 5 > Dementia Caregiving and Caregivers
Interventions Brief description Key citations
Individual and family counselling
Psychoeducational programmes ¹, e.g.:
• Coping with Caregiving
• Savvy Caregiving
Specialized skill trainings, e.g.:
• Behaviour Management
• STAR-C (Staff Training in Assisted-living
Residences-Caregivers)
• In-Home Modifications
Multicomponent programmes (i.e. REACH
II (Resources for Enhancing Alzheimer’s
Caregiver Health II)) ²
Psychotherapy / cognitive behavioural
therapy
Individual and family counselling provided by trained providers for treatment of caregiver depression
and managing stress. Ad hoc telephone access also available.
Caregivers are taught a set of behavioural and cognitive skills for coping with caregiving
demands and stress, using a structural format.
Training focuses on a specific issue related to caregiving, such as home modifications, managing
difficult behaviours and dealing with the frustrations of the person with dementia, managing
sleep disruption, and promotion of exercises to alleviate stress.
A multicomponent programme that consists of home visits to create individualized plans for
caregivers to manage their stress, behavioural interventions, telephone support group calls, and
access to various local resources.
Use of cognitive behavioural therapy to treat caregivers who are clinically depressed or who have
other significant mental health problems.
References
308–312
References
307, 314–317
References
318–324
References
325, 326
References
327, 328
¹ Psychoeducational and / or behaviour management training programmes have been used in the Australia, India, Spain, United Kingdom and some other parts of
Europe. Work is ongoing in other regions of the world (e.g. China, Hong Kong Special Administrative Region).
² Adaptations of REACH II are currently in dissemination trials in many parts of the USA.
Table 5.5 Examples of effective interventions for family caregivers
The beneficial effects of caregiver interventions on institutionalization
of the care recipient have been clearly and directly demonstrated. In
their meta-analysis, Brodaty et al (304) concluded that caregiver
interventions could delay nursing home admission. Interventions
which involved the person with dementia and those which were
multicomponent were more likely to be successful. A systematic
review of 10 randomized controlled trials has indicated a 40% reduction
in the pooled odds of institutionalization (306). The effective
interventions were structured, intensive and multicomponent, offering
a choice of services and supports to caregivers (283, 306). The
Mittelman trial observed a greater benefit as regards institutionalization
when the interventions were started earlier in the disease course
(310). Interventions that help reduce nursing home utilization without
increasing caregiver strain are important for achieving the move
towards quality community focused care in high-income countries.
Financial benefit from interventions that delay institutionalization have
also been measured. A USA-based cost-benefit analysis of earlier
diagnosis of Alzheimer’s Disease, treatment with acetylcholinestrase
inhibitors and provision of caregiver interventions showed that early
intervention can delay institutionalization and potentially reduce health
care costs. The net benefits were highest in cases that were identified
in the earlier stage of dementia and where caregiver intervention
programmes were implemented.
An important issue is the effectiveness of interventions in caregivers
from diverse ethnic, racial, cultural and linguistic backgrounds. Most of
the above programmes have been used only in high-income countries,
and some have not been used outside the USA, although a culturally-tailored
version of the REACH programme has been conducted
in a controlled study in China, Hong Kong Special Administrative
Region (Hong Kong SAR) (332). Another study suggests that psychosocial
intervention of demonstrated effectiveness might be
made available cheaply in LMIC since they are typically of low cost
(the cost being chiefly related to the human effort involved) (307).
Some literature is available from LMIC on caregiver interventions.
Dias et al. (235) reported on the effectiveness of the Helping Carers
to Care home care programme for dementia caregivers in Goa,
India (Box 4.9). In this study, the community-based intervention was
provided by a team consisting of home care advisers who were
supervised by a counsellor and a psychiatrist. The intervention
focused on supporting the caregiver by providing information on
dementia, guidance on behaviour management, a single psychiatric
assessment and psychotropic medication if needed. The strain on
caregivers was much reduced and the mental health of the caregivers
improved. The study concluded that home-based support for
caregivers of persons with dementia, which emphasizes the use of
locally available, low-cost human resources, is feasible, acceptable
and leads to significant improvements in caregiver mental health
and burden of caring. Researchers from the 10 / 66 Dementia
Research Group have since tested the effectiveness of this intervention
in randomized controlled trials in Peru and Russia (201, 236,
238). The results again indicated much larger treatment effects on
caregiver psychological morbidity and strain than are typically seen
in trials of such interventions in high-income countries.
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