Caregiver- and patient-directed interventions for dementia: an evidence-based analysis.

In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry's newly released Aging at Home Strategy.After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person's transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.AGING IN THE COMMUNITY: Summary of Evidence-Based AnalysesPrevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based AnalysisBehavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based AnalysisCaregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based AnalysisSocial Isolation in Community-Dwelling Seniors: An Evidence-Based AnalysisThe Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections: IntroductionCaregiver-Directed Interventions for DementiaPatient-Directed Interventions for DementiaEconomic Analysis of Caregiver- and Patient-Directed Interventions for Dementia CAREGIVER-DIRECTED INTERVENTIONS FOR DEMENTIA:

objectiveTo identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community. CLINICAL NEED: TARGET POPULATION AND CONDITION Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior's transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization. Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC. Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia. It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions. Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside. DESCRIPTION OF

interventionsThe 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver's needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends. Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions. METHODS OF EVIDENCE-BASED ANALYSIS: A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients. QUESTIONS: Section 2.1 Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?Do respite care services impact on rates of institutionalization of these seniors?Section 2.2 Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?Which interventions reduce the risk for institutionalization of seniors with dementia? OUTCOMES OF INTEREST: any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one's situation), reactivity to behaviour problems, etc.;rate of institutionalization; andcost-effectiveness. ASSESSMENT OF QUALITY OF EVIDENCE: The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply: HighFurther research is very unlikely to change confidence in the estimate of effect.ModerateFurther research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.LowFurther research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.Very lowAny estimate of effect is very uncertain. SUMMARY OF

findingsConclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report. Executive Summary Table 1:Summary of Conclusions on Caregiver-Directed InterventionsSectionInterventionConclusion2.1Respite care for dementia caregiversAssessing the efficacy of respite care services using standard evidence-based approaches is difficult.There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.There is considerable qualitative evidence of the perceived benefits of respite care.Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)2.2aBehaviourai interventions (individual ≥ 6 sessions)There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.2.2bMulticomponent interventionsThere is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.RCT indicates randomized controlled trial. PATIENT-DIRECTED INTERVENTIONS FOR DEMENTIA:

objectiveThe section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions: 3. (ABSTRACT TRUNCATED)