Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study Maintenance cognitive stimulation therapy: an economic evaluation within a randomized controlled trial. Problem-solving counseling for caregivers of the cognitively impaired: effective for whom? START (STrAtegies for RelaTives) study: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manual-based coping strategy programme in promoting the mental health of carers of people with dementia. Maintenance cognitive stimulation therapy for dementia: single-blind, multicentre, pragmatic randomised controlled trial. Do nurse-led skill training interventions affect informal caregivers' out-of-pocket expenditures? An Economic Evaluation of Resistance Training and Aerobic Training versus Balance and Toning Exercises in Older Adults with Mild Cognitive Impairment Early psychosocial intervention in Alzheimer's disease: cost utility evaluation alongside the Danish Alzheimer's Intervention Study (DAISY) Cognitive stimulation therapy for people with dementia: cost-effectiveness analysis. Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial. Cost effectiveness of a manual based coping strategy programme in promoting the mental health of family carers of people with dementia (the START (STrAtegies for RelaTives) study): a pragmatic randomised controlled trial The cost-effectiveness of a family meetings intervention to prevent depression and anxiety in family caregivers of patients with dementia: a randomized trial The effect of telephone support groups on costs of care for veterans with dementia. Challenges with cost-utility analyses of behavioural interventions among older adults at risk for dementia Effects of the Finnish Alzheimer disease exercise trial (FINALEX): a randomized controlled trial. Individual cognitive stimulation therapy for dementia: a clinical effectiveness and cost-effectiveness pragmatic, multicentre, randomised controlled trial. Cognitive-behavioural therapy for anxiety in dementia: pilot randomised controlled trial. The effect of exercise on behavioural and psychological symptoms of dementia: the EVIDEM-E randomised controlled clinical trial. The Danish Alzheimer Intervention Study: Rationale, Study Design and Baseline Characteristics of the Cohort Long-term clinical and cost-effectiveness of psychological intervention for family carers of people with dementia: a single-blind, randomised, controlled trial. REMCARE: reminiscence groups for people with dementia and their family caregivers - effectiveness and cost-effectiveness pragmatic multicentre randomised trial. The cost-effectiveness of a nonpharmacologic intervention for individuals with dementia and family caregivers: the tailored activity program. Does befriending by trained lay workers improve psychological well-being and quality of life for carers of people with dementia, and at what cost? A randomised controlled trial. Psychosocial interventions for people with dementia: An overview and commentary on recent developments Non-Pharmacological Treatment in People With Cognitive Impairment.
Objective To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint . Design Cost effectiveness study alongside a single blind r and omised controlled trial . Setting Memory clinic , day clinic of a geriatrics department , and participants ’ homes . Patients 135 patients aged ≥65 with mild to moderate dementia living in the community and their primary care givers . Intervention 10 sessions of occupational therapy over five weeks , including cognitive and behavioural interventions , to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision . Main outcome measures Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment ( that is , a combined patient and care giver outcome measure of clinical ly relevant improvement on process , performance , and competence scales ) at three months after r and omisation . Bootstrap methods used to determine confidence intervals for these measures . Results The intervention cost € 1183 ( £ 848 , $ 1738 ) ( 95 % confidence interval € 1128 ( £ 808 , $ 1657 ) to € 1239 ( £ 888 , $ 1820 ) ) per patient and primary care giver unit at three months . Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were € 1748 ( £ 1279 , $ 2621 ) lower in the intervention group , with the main cost savings in informal care . There was a significant difference in proportions of successful treatments of 36 % at three months . The number needed to treat for successful treatment at three months was 2.8 ( 2.7 to 2.9 ) . Conclusions Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective , especially in terms of informal care giving BACKGROUND Cognitive Stimulation Therapy ( CST ) is effective and cost-effective for people with mild-to-moderate dementia when delivered biweekly over 7 weeks . AIMS To examine whether longer-term ( maintenance ) CST is cost-effective when added to usual care . METHODS Cost-effectiveness analysis within multicenter , single-blind , pragmatic r and omized controlled trial ; subgroup analysis for people taking acetylcholinesterase inhibitors ( ACHEIs ) . A total of 236 participants with mild-to-moderate dementia received CST for 7 weeks . They were r and omized to either weekly maintenance CST added to usual care or usual care alone for 24 weeks . RESULTS Although outcome gains were modest over 6 months , maintenance CST appeared cost-effective when looking at self-rated quality of life as primary outcome , and cognition ( MMSE ) and proxy-rated quality -adjusted life years as secondary outcomes . CST in combination with ACHEIs  offered cost-effectiveness gains when outcome was measured as cognition . CONCLUSIONS Continuation of CST is likely to be cost-effective for people with mild-to-moderate dementia BACKGROUND Individualized problem-solving counseling for caregivers of cognitively impaired relatives is thought to help caregivers cope with the stress and burden of caregiving . Few studies have shown the effectiveness of counseling for these caregivers . OBJECTIVES To determine the effectiveness of individualized problem-solving counseling by nurses for caregivers and the expenditures of health care utilization . METHOD Caregivers ( n = 77 ) of the cognitively impaired living at home were r and omized to receive nurse counseling or not .  Psychosocial adjustment to their relative 's illness , psychological distress , burden , coping skills , and expenditures were measured after 6 months and 1 year . RESULTS Although on average , all caregivers receiving nurse counseling indicated no improvement in psychosocial adjustment to their relative 's illness , psychological distress , or caregiver burden , they found counseling very helpful and it was effective for a subgroup of caregivers . Those with poor logical analysis coping skills at baseline had decreased psychological distress ( F(1,53 ) = 9.7 , p = .003 ) and improved psychosocial adjustment ( F(1,53 ) = 4.7 , p = .035 ) after 1 year . Caregivers in control and counseling groups whose relatives entered a nursing home improved their psychosocial adjustment 23 % on average whereas those continuing to live in the community decreased by 8 % . Almost half as many relatives entered nursing homes in the counseling group ( n = 9 vs. n = 5 ) but these compared to control group relatives had greater annualized per person expenditures for health and social services ( Cdn$23,437 vs. Cdn$15,151 ) . CONCLUSIONS Caregivers found nurse counseling most helpful . Those indicating infrequent use of logical analysis coping skills showed benefits BACKGROUND Two-thirds of people with dementia live at home , receiving most care from family carers , about 40 % of whom have clinical ly significant depression or anxiety . This impacts on the person with dementia , families and society , predicting care breakdown . There are currently no clinical ly effective and cost-effective NHS family carer interventions . OBJECTIVES To assess the STrAtegies for RelaTives ( START ) intervention in the short ( 4 and 8 months ) and long term ( 1 and 2 years ) compared with treatment as usual ( TAU ) . DESIGN R and omised , parallel-group , superiority trial with blinded assessment recruiting participants 2:1 ( intervention to TAU ) to allow for therapist clustering . SETTING Three UK mental health services and one neurological service . PARTICIPANTS Family carers of people with dementia . INTERVENTION Eight-session manual-based coping intervention delivered by supervised psychology graduates to individuals . MAIN OUTCOME MEASURES Affective symptoms [ Hospital Anxiety and Depression Scale-total ( HADS-T ) ] and cost-effectiveness . Secondary measures : anxiety and depression symptoms and caseness , quality of life ( QoL ) , abusive behaviour and long-term care home admission . RESULTS Two hundred and sixty participants were r and omised ( 173 intervention , 87 TAU ) . We used intention-to-treat analysis in the short term ( 152 intervention , 77 TAU ) and in the long term ( 140 intervention , 69 TAU ) . In the short term , the intervention group had lower HADS-T [ mean difference -1.80 , 95 % confidence interval ( CI ) -3.29 to -0.31 ; p=0.02 ] and higher quality -adjusted life-years ( QALYs ) ( mean difference 0.03 , 95 % CI -0.01 to 0.08 ) . Costs were no different between groups [ mean £ 252 ( 95 % CI -£ 28 to £ 565 ) for intervention group ] . The cost-effectiveness acceptability curve showed a greater than 99 % chance of being cost-effectiveness at a £ 30,000/QALY willingness-to-pay threshold and a high probability of cost-effectiveness based on the HADS-T score . Carers in the intervention group had less case-level depression [ odds ratio ( OR ) 0.24 , 95 % CI 0.07 to 0.76 ] , a trend towards reduced case-level anxiety ( OR 0.30 , 95 % CI 0.08 to 1.05 ) , lower Hospital Anxiety and Depression Scale-anxiety ( HADS-A ) ( -0.91 , 95 % CI -1.76 to -0.07 ; p = 0.03 ) and Hospital Anxiety and Depression Scale-depression ( HADS-D ) ( -0.91 , 95 % CI -1.71 to -0.10 ; p = 0.03 ) and higher Health Status Question naire ( HSQ ) QoL ( mean difference 4.09 , 95 % CI 0.34 to 7.83 ) . Group differences in abusive behaviour ( OR 0.48 , 95 % CI 0.18 to 1.27 ) and the person with dementia 's quality of life-Alzheimer 's disease ( QoL-AD ) ( mean increase 0.59 , 95 % CI -0.72 to 1.89 ) were not significant . In the long term , the intervention group had lower HADS-T ( mean difference -2.58 , 95 % CI -4.26 to -0.90 ; p = 0.03 ) and higher QALYs ( mean difference 0.03 , 95 % CI -0.01 to 0.06 ) . Carers in the intervention group had less case-level depression ( OR 0.14 , 95 % CI 0.04 to 0.53 ) , a trend towards reduced case-level anxiety ( OR 0.57 , 95 % CI 0.26 to 1.24 ) , lower HADS-A ( -1.16 , 95 % CI -2.15 to -0.18 ) and HADS-D ( 1.45 , 95 % CI -2.32 to -0.57 ) , and higher HSQ ( mean difference 7.47 , 95 % CI 2.87 to 12.08 ) . Thirty-two ( 18.7 % ) people with dementia in the intervention group and 17 ( 20.2 % ) in TAU were admitted to a care home ( hazard ratio 0.83 , 95 % CI 0.44 to 1.56 ; p = 0.56 ) . There were no significant differences between groups in abusive behaviour ( OR 0.83 , 95 % CI 0.36 to 1.94 ) , the person with dementia 's QoL-AD ( 0.17 , 95 % CI -1.37 to 1.70 ) or costs ( £ 336 , 95 % CI -£ 223 to £ 895 ) for intervention group . The probability that the intervention would be seen as cost-effective at £ 30,000/QALY threshold and cost-effectiveness on the HADS-T remained high . CONCLUSIONS The START intervention was clinical ly effective and cost-effective in the short and longer term . The results are robust to the sensitivity analyses performed . Future work is needed to consider mechanism of action ; the effects on people with dementia in clinical terms ( cognition , neuropsychiatric symptoms , longer-term care home admission ) ; and on health and social care costs . In addition , we will explore the effects of carer abusive behaviour on the care recipient 's care home admission and if this then reduces abusive behaviour . We would also like to implement START and evaluate this implementation in clinical practice . TRIAL REGISTRATION Current Controlled Trials ISCTRN70017938 BACKGROUND There is good evidence for the benefits of short-term cognitive stimulation therapy for dementia but little is known about possible long-term effects . AIMS To evaluate the effectiveness of maintenance cognitive stimulation therapy ( CST ) for people with dementia in a single-blind , pragmatic r and omised controlled trial including a sub study with participants taking acetylcholinesterase inhibitors ( AChEIs ) . METHOD The participants were 236 people with dementia from 9 care homes and 9 community services . Prior to r and omisation all participants received the 7-week , 14-session CST programme . The intervention group received the weekly maintenance CST group programme for 24 weeks . The control group received usual care . Primary outcomes were cognition and quality of life ( clinical trial registration : IS RCT N26286067 ) . RESULTS For the intervention group at the 6-month primary end-point there were significant benefits for self-rated quality of life ( Quality of Life in Alzheimer 's Disease ( QoL-AD ) P = 0.03 ) . At 3 months there were improvements for proxy-rated quality of life ( QoL-AD P = 0.01 , Dementia Quality of Life scale ( DEMQOL ) P = 0.03 ) and activities of daily living ( P = 0.04 ) . The intervention subgroup taking AChEIs showed cognitive benefits ( on the Mini-Mental State Examination ) at 3 ( P = 0.03 ) and 6 months ( P = 0.03 ) . CONCLUSIONS Continuing CST improves quality of life ; and improves cognition for those taking AChEIs PURPOSE OF THE STUDY This paper is a report of a study of the Assistance , Support , and Self-health Initiated through Skill Training ( ASSIST ) r and omized control trial . The aim of this paper is to underst and whether participating in ASSIST significantly changed the out-of-pocket ( OOP ) costs for family caregivers of Alzheimer 's disease ( AD ) or Parkinson 's disease ( PD ) patients . DESIGN AND METHODS Secondary analysis of r and omized control trial data , calculating average treatment effects of the intervention on OOP costs .  Enrollment in the ASSIST trial occurred between 2002 and 2007 at 2 sites : Durham , North Carolina , and Birmingham , Alabama . We profile OOP costs for caregivers who participated in the ASSIST study and use 2-part expenditure models to examine the average treatment effect of the intervention on caregiver OOP expenditures . RESULTS ASSIST-trained AD and PD caregivers reported monthly OOP expenditures that averaged $ 500-$600 . The intervention increased the likelihood of caregivers spending any money OOP by 26 percentage points over usual care , but the intervention did not significantly increase overall OOP costs . IMPLICATION S The ASSIST intervention was effective and inexpensive to the caregiver in direct monetary outlays ; thus , there are minimal unintended consequences of the trial on caregiver financial well-being Background Mild cognitive impairment ( MCI ) represents a critical window to intervene against dementia . Exercise training is a promising intervention strategy , but the efficiency ( i.e. , relationship of costs and consequences ) of such types of training remains unknown . Thus , we estimated the incremental cost-effectiveness of resistance training or aerobic training compared with balance and tone exercises in terms of changes in executive cognitive function among senior women with probable MCI . Methods Economic evaluation conducted concurrently with a six-month three arm r and omized controlled trial including eighty-six community dwelling women aged 70 to 80 years living in Vancouver , Canada . Participants received twice-weekly resistance training ( n = 28 ) , twice weekly aerobic training ( n = 30 ) or twice-weekly balance and tone ( control group ) classes ( n = 28 ) for 6 months . The primary outcome measure of the Exercise for Cognition and Everyday Living ( EXCEL ) study assessed executive cognitive function , a test of selective attention and conflict resolution ( i.e. , Stroop Test ) . We collected healthcare re source utilization costs over six months . Results Based on the bootstrapped estimates from our base case analysis , we found that both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes . Compared with the balance and tone group , the resistance-training group had significantly improved performance on the Stroop Test ( p = 0.04 ) . Conclusions Resistance training and aerobic training result in health care cost saving and are more effective than balance and tone classes after only 6 months of intervention . Resistance training is a promising strategy to alter the trajectory of cognitive decline in seniors with MCI . Trial Registration Clinical Trials.gov NCT00958867 Objective To assess the cost utility of early psychosocial intervention for patients with Alzheimer 's disease and their primary caregivers . Design Cost utility evaluation alongside a multicentre , r and omised controlled trial with 3 years of follow-up . Setting Primary care and memory clinics in five Danish districts . Participants 330 community-dwelling patients and their primary caregivers . Intervention Psychosocial counselling and support lasting 8–12 months after diagnosis and follow-up at 3 , 6 , 12 and 36 months in the intervention group or follow-up only in the control group . Main outcome measures The primary outcome measure was the cost of additional quality -adjusted life years ( QALYs ) . Costs were measured from a societal perspective , including the costs of healthcare , social care , informal care and production loss . QALYs were estimated separately for the patient and the caregiver before aggregation for the main analysis . Results None of the observed cost and QALY measures were significantly different between the intervention and control groups , although a tendency was noted for psychosocial care leading to cost increases with informal care that was not outweighed by the tendency for cost savings with formal care . The probability of psychosocial intervention being cost-effective did not exceed 36 % for any threshold value . The alternative scenario analysis showed that the probability of cost-effectiveness increased over the range of threshold values used if the cost perspective was restricted to formal healthcare . Conclusions A multifaceted , psychosocial intervention programme was found unlikely to be cost-effective from a societal perspective . The recommendation for practice in setting s that are similar to the Danish setting is to provide follow-up with referral to available local support programmes when needed , and to restrict large multifaceted intervention programmes to patients and caregivers with special needs until further evidence for cost-effectiveness emerges . Trial registration The study was registered in the Clinical Trial Data base as IS RCT N74848736 BACKGROUND Psychological therapy groups for people with dementia are widely used , but their cost-effectiveness has not been explored . AIMS To investigate the cost-effectiveness of an evidence -based cognitive stimulation therapy ( CST ) programme for people with dementia as part of a r and omised controlled trial . METHOD A total of 91 people with dementia , living in care homes or the community , received a  CST group intervention twice weekly for 8 weeks ; 70 participants with dementia received treatment as usual .  Service use was recorded 8 weeks before and during the 8-week intervention and costs were calculated . A cost-effectiveness analysis was conducted with cognition as the primary outcome , and quality of life as the secondary outcome . Cost-effectiveness acceptability curves were plotted . RESULTS Cognitive stimulation therapy has benefits for cognition and quality of life in dementia , and costs were not different between the groups . Under reasonable assumptions , there is a high probability that CST is more cost-effective than treatment as usual , with regard to both outcome measures . CONCLUSIONS Cognitive stimulation therapy for people with dementia has effectiveness advantages over , and may be more cost-effective than , treatment as usual OBJECTIVES To investigate the effect of self-management group rehabilitation for persons with dementia ( PwD ) and their spouses on their health-related quality of life ( HRQoL ) , the cognition of the PwD , and the costs of health and social services . DESIGN A r and omized controlled trial . SETTING Primary care and memory clinics in the Helsinki metropolitan area , Finl and . PARTICIPANTS PwD ( N = 136 ) and their spouses ( N = 136 ) . INTERVENTION Couples were r and omized to usual care or eight-session self-management groups for PwD and concurrently for their spouses . Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support . MEASUREMENTS The primary outcome measures were the HRQoL of PwD ( measured using a generic , comprehensive ( 15-dimensional ) , self-administered instrument ( 15D ) ) and spouses ( measured using the R AND -36 ) and the spousal Sense of Competence Question naire ( SCQ ) . Secondary outcome measures were PwD cognition ( Verbal Fluency ( VF ) , Clock Drawing Test ( CDT ) ) and costs of health and social services during 24 months . RESULTS At 3 months , the spouse physical component of the R AND -36 improved ( mean change 1.0 , 95 % confidence interval ( CI ) = -0.5 to 2.4 ) for those undergoing the intervention and worsened for controls ( mean change -2.0 , 95 % CI = -3.5 to -0.4 ) ( P = .006 adjusted for age , sex , baseline value of the physical component of the R AND -36 ) . There were no differences between the groups on the mental component of the R AND -36 , the SCQ , or the 15D . At 9 months , PwD change in VF was -0.38 ( 95 % CI = -1.03 to 0.27 ) in intervention group and -1.60 ( 95 % CI = -2.26 to -0.94 ) for controls ( P = .011 adjusted for age , sex , baseline MMSE score ) . CDT changes were similar to VF changes . Differences in incremental costs between the groups was -436 € per person per year ( 95 % CI = -4,986 to 4,115 ) for PwD ( P = .35 adjusted for age , CDR ) and -896 € per person per year ( 95 % CI = -3,657 to 1,864 ) for spouses ( P = .51 adjusted for PwD age , CDR ) . CONCLUSIONS The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12611001173987 Objective To assess whether the START ( STrAtegies for RelatTives ) intervention added to treatment as usual is cost effective compared with usual treatment alone . Design Cost effectiveness analysis nested within a pragmatic r and omised controlled trial . Setting Three mental health and one neurological outpatient dementia service in London and Essex , UK . Participants Family carers of people with dementia . Intervention Eight session , manual based , coping intervention delivered by supervised psychology graduates to  family carers of people with dementia added to usual treatment , compared with usual treatment alone . Primary outcome measures Costs measured from a health and social care perspective were analysed alongside the Hospital Anxiety and Depression Scale total score ( HADS-T ) of affective symptoms and quality adjusted life years ( QALYs ) in cost effectiveness analyses over eight months from baseline . Results Of the 260 participants recruited to the study , 173 were r and omised to the START intervention , and 87 to usual treatment alone .  Mean HADS-T scores were lower in the intervention group than the usual treatment group over the 8 month evaluation period ( mean difference −1.79 ( 95 % CI −3.32 to −0.33 ) ) , indicating better outcomes associated with the START intervention . There was a small improvement in health related quality of life as measured by QALYs ( 0.03 ( −0.01 to 0.08 ) ) . Costs were no different between the intervention and usual treatment groups ( £ 252 ( −28 to 565 ) higher for START group ) . The cost effectiveness calculations suggested that START had a greater than 99 % chance of being cost effective compared with usual treatment alone at a willingness to pay threshold of £ 30 000 per QALY gained , and a high probability of cost effectiveness on the HADS-T measure . Conclusions The manual based coping intervention START , when added to treatment as usual , was cost effective compared with treatment as usual alone by reference to both outcome measures ( affective symptoms for family carers , and carer based QALYs ) . Trial Registration ISCTRN Background Dementia imposes a heavy burden on health and social care systems as well as on family caregivers who provide a substantial portion of the care . Interventions that effectively support caregivers may prevent or delay patient institutionalization and hence be cost-effective . However , evidence about the cost-effectiveness of such interventions is scarce . The aim of this study was to evaluate the cost-effectiveness of a family meetings intervention for family caregivers of dementia patients in comparison with usual care over a period of 12 months . Methods The economic evaluation was conducted from a societal perspective alongside a r and omized trial of 192 primary caregivers with community-dwelling dementia patients . Outcome measures included the Quality Adjusted Life-Years ( QALY ) of caregivers and patients and the incidence of depression and anxiety disorders in caregivers . Missing cost and effect data were imputed using multiple imputations . Bootstrapping was used to estimate uncertainty around the cost-differences and the incremental cost-effectiveness ratio ( ICER ) . The bootstrapped cost-effect pairs were plotted on a cost-effectiveness plane and used to estimate cost-effectiveness curves . Results No significant differences in costs and effects between the groups were found . At 12 months , total costs per patient and primary caregiver dyad were substantial : € 77,832 for the intervention group and € 75,201 for the usual care group ( adjusted mean difference per dyad € 4,149 , 95 % CI -13,371 to 21,956 , ICER 157,534 ) . The main cost driver was informal care ( 66 % of total costs ) , followed by patients ’ day treatment and costs of hospital and long-term care facility admissions ( 23 % ) . Based on the cost-effectiveness acceptability curves , the maximum probability that the intervention was considered cost-effective in comparison with usual care reached 0.4 for the outcome QALY per patient-caregiver dyad and 0.6 for the caregivers ’ incidence of depression and /or anxiety disorders regardless of the willingness to pay . Conclusions The annual costs of caring for a person with dementia were substantial with informal care being by far the largest contributor to the total societal costs . Based on this study , family meetings can not be considered a cost-effective intervention strategy in comparison with usual care . Trial registration IS RCT N register , IS RCT PURPOSE Few studies have addressed the effects of  caregiver interventions  on the costs of care for the care recipient . This study evaluated the effects of a caregiver education and support group delivered via the telephone on care recipient health care utilization and cost . DESIGN AND METHODS The Telehealth Education Program ( TEP ) is a manualized program of education and support design ed for caregivers of veterans with moderate-to-severe dementia . One hundred fifty-eight spousal caregivers were r and omly assigned to either the ten 1-hr sessions of TEP or the usual care ( UC ) .  Health care utilization and cost data were extracted from veterans Information System Technology Architecture data bases and included outpatient , inpatient , and nursing home data within the VA . RESULTS Total health care cost data showed a significant ( p = .039 ) average cost savings of $ 2,768 per patient at 6 months for TEP as compared with UC , but these were not maintained at 1 year . All costs included in the total costs measure contributed to this difference . Inpatient , outpatient , and nursing home costs were all assessed separately , but only nursing home costs reached significance ( p = .009 ) , with a savings of $ 1,057 per patient at 6 months . IMPLICATION S The TEP caregiver intervention result ed in short-term cost savings for veteran care recipients . Future studies of caregiver interventions should examine their effects on costs of care for the care recipients in addition to their effects on caregiver outcomes Background Cognitive decline is one of the most prominent healthcare issues of the 21st century . Within the context of combating cognitive decline through behavioural interventions , physical activity is a promising approach . There is a dearth of health economic data in the area of behavioural interventions for dementia prevention . Yet , economic evaluations are essential for providing information to policy makers for re source allocation . It is essential we first address population and intervention-specific method ological challenges prior to building a larger evidence base . We use a cost-utility analysis conducted alongside the exercise for cognition and everyday living ( EXCEL ) study to illustrate method ological challenges specific to assessing the cost-effectiveness of behavioural interventions aim ed at older adults at risk of cognitive decline . Methods A cost-utility analysis conducted concurrently with a 6-month , three-arm r and omised controlled trial ( ie , the EXCEL study ) was used as an example to identify and discuss method ological challenges . Results Both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes . In critically evaluating the economic evaluation of the EXCEL study we identified four category-specific challenges : ( 1 ) analysing costs ; ( 2 ) assessing quality -adjusted life-years ; ( 3 ) Incomplete data ; and ( 4 ) ‘ Intervention ’ activities of the control group . Conclusions Resistance training and aerobic training result ed in healthcare cost saving and were equally effective to balance and tone classes after only 6 months of intervention . To ensure this population is treated fairly in terms of cl aims on re sources , we first need to identify areas for method ological improvement IMPORTANCE Few rigorous clinical trials have investigated the effectiveness of exercise on the physical functioning of patients with Alzheimer disease ( AD ) . OBJECTIVES To investigate the effects of intense and long-term exercise on the physical functioning and mobility of home-dwelling patients with AD and to explore its effects on the use and costs of health and social services . DESIGN A r and omized controlled trial . SETTING AND PARTICIPANTS A total of 210 home-dwelling patients with AD living with their spousal caregiver . INTERVENTIONS The 3 trial arms included ( 1 ) group-based exercise ( GE ; 4-hour sessions with approximately 1-hour training ) and ( 2 ) tailored home-based exercise ( HE ; 1-hour training ) , both twice a week for 1 year , and ( 3 ) a control group ( CG ) receiving the usual community care . MAIN OUTCOME MEASURES The Functional Independence Measure ( FIM ) , the Short Physical Performance Battery , and information on the use and costs of social and health care services . RESULTS All groups deteriorated in functioning during the year after r and omization , but deterioration was significantly faster in the CG than in the HE or GE group at 6 ( P = .003 ) and 12 ( P = .015 ) months . The FIM changes at 12 months were -7.1 ( 95 % CI , -3.7 to -10.5 ) , -10.3 ( 95 % CI , -6.7 to -13.9 ) , and -14.4 ( 95 % CI , -10.9 to -18.0 ) in the HE group , GE group , and CG , respectively . The HE and GE groups had significantly fewer falls than the CG during the follow-up year . The total costs of health and social services for the HE patient-caregiver dyads ( in US dollars per dyad per year ) were $ 25,112 ( 95 % CI , $ 17,642 to $ 32,581 ) ( P = .13 for comparison with the CG ) , $ 22,066 in the GE group ( $ 15,931 to $ 28,199 ; P = .03 vs CG ) , and $ 34,121 ( $ 24,559 to $ 43,681 ) in the CG . CONCLUSIONS AND RELEVANCE An intensive and long-term exercise program had beneficial effects on the physical functioning of patients with AD without increasing the total costs of health and social services or causing any significant adverse effects . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12608000037303 BACKGROUND Group cognitive stimulation therapy programmes can benefit cognition and quality of life for people with dementia . Evidence for home-based , carer-led cognitive stimulation interventions is limited . OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of carer-delivered individual cognitive stimulation therapy ( iCST ) for people with dementia and their family carers , compared with treatment as usual ( TAU ) . DESIGN A multicentre , single-blind , r and omised controlled trial assessing clinical effectiveness and cost-effectiveness . Assessment s were at baseline , 13 weeks and 26 weeks ( primary end point ) . SETTING Participants were recruited through Memory Clinics and Community Mental Health Teams for older people . PARTICIPANTS A total of 356 caregiving dyads were recruited and 273 completed the trial . INTERVENTION iCST consisted of structured cognitive stimulation sessions for people with dementia  , completed up to three times weekly over 25 weeks . Family carers were supported to deliver the sessions at home . MAIN OUTCOME MEASURES Primary outcomes for the person with dementia were cognition and quality of life . Secondary outcomes included behavioural and psychological symptoms , activities of daily living , depressive symptoms and relationship quality . The primary outcome for the family carers was mental/physical health ( Short Form question naire-12 items ) . Health-related quality of life ( European Quality of Life-5 Dimensions ) , mood symptoms , resilience and relationship quality comprised the secondary outcomes . Costs were estimated from health and social care and societal perspectives . RESULTS There were no differences in any of the primary outcomes for people with dementia between intervention and TAU [ cognition : mean difference -0.55 , 95 % confidence interval ( CI ) -2.00 to 0.90 ; p-value = 0.45 ; self-reported quality of life : mean difference -0.02 , 95 % CI -1.22 to 0.82 ; p-value = 0.97 at the 6-month follow-up ] . iCST did not improve mental/physical health for carers . People with dementia in the iCST group experienced better relationship quality with their carer , but there was no evidence that iCST improved their activities of daily living , depression or behavioural and psychological symptoms . iCST seemed to improve health-related quality of life for carers but did not benefit carers ' resilience or their relationship quality with their relative . Carers conducting more sessions had fewer depressive symptoms . Qualitative data suggested that people with dementia and their carers experienced better communication owing to iCST . Adjusted mean costs were not significantly different between the groups . From the societal perspective , both health gains and cost savings were observed . CONCLUSIONS iCST did not improve cognition or quality of life for people with dementia , or carers ' physical and mental health . Costs of the intervention were offset by some reductions in social care and other services . Although there was some evidence of improvement in terms of the caregiving relationship and carers ' health-related quality of life , iCST does not appear to deliver clinical benefits for cognition and quality of life for people with dementia . Most people received fewer than the recommended number of iCST sessions . Further research is needed to ascertain the clinical effectiveness of carer-led cognitive stimulation interventions for people with dementia . TRIAL REGISTRATION Current Controlled Trials IS RCT N65945963 . FUNDING This project was funded by the National Institute of Health Research ( NIHR ) Health Technology Assessment ( HTA ) programme and will be published in full in Health Technology Assessment ; Vol . 19 , No. 64 . See the NIHR Journals Library website for further information BACKGROUND Anxiety is common and problematic in dementia , yet there is a lack of effective treatments . AIMS To develop a cognitive-behavioural therapy ( CBT ) manual for anxiety in dementia and determine its feasibility through a r and omised controlled trial . METHOD A ten-session CBT manual was developed . Participants with dementia and anxiety ( and their carers ) were r and omly allocated to CBT plus treatment as usual ( TAU ) ( n = 25 ) or TAU ( n = 25 ) . Outcome and cost measures were administered at baseline , 15 weeks and 6 months . RESULTS At 15 weeks , there was an adjusted difference in anxiety ( using the Rating Anxiety in Dementia scale ) of ( -3.10 , 95 % CI -6.55 to 0.34 ) for CBT compared with TAU , which just fell short of statistical significance . There were significant improvements in depression at 15 weeks after adjustment ( -5.37 , 95 % CI -9.50 to -1.25 ) . Improvements remained significant at 6 months . CBT was cost neutral . CONCLUSIONS CBT was feasible ( in terms of recruitment , acceptability and attrition ) and effective . A fully powered RCT is now required OBJECTIVE The objective of this study is to evaluate the effectiveness of a simple  dyadic ( person with dementia and their main carer ) exercise regimen as a therapy for the behavioural and psychological symptoms of dementia . METHOD A two arm , pragmatic , r and omised , controlled , single-blind , parallel-group trial of a dyadic exercise regimen ( individually tailored walking regimen design ed to become progressively intensive and last between 20 - 30 min , at least five times per week).Community-dwelling individuals with ICD-10 confirmed dementia with the following : clinical ly significant behavioural and psychological symptoms , a carer willing and able to co-participate in the exercise regimen , and no physical conditions or symptoms that would preclude exercise participation were invited by mental health or primary care services into the study . RESULTS One hundred and thirty-one dyads were recruited to this study . There was no significant difference in Behavioural and Psychological Symptoms as measured by the Neuropsychiatric Inventory at week 12 between the group receiving the dyadic exercise regimen and those that did not ( adjusted difference in means ( intervention minus control ) = -1.53 , p = 0.6 , 95 % CI [ -7.37 , 4.32 ] ) . There was a significant between-group difference in caregiver 's burden as measured by the Zarit Caregiver Burden Inventory at week 12 ( OR = 0.18 , p = 0.01 , CI [ 0.05 , 0.69 ] ) favouring the exercise group . CONCLUSIONS This study found that regular simple exercise does not appear to improve the behavioural and psychological symptoms of dementia , but did seem to attenuate caregiver burden . Further study to improve exercise uptake are needed Background : There is a lack of appropriately design ed trials investigating the efficacy of psychosocial interventions for patients with mild dementia and their family caregivers . This paper reports the rationale and design of the Danish Alzheimer Disease Intervention Study and baseline characteristics of the cohort . Methods : The study was a 1-year multicentre r and omized controlled rater-blinded trial with r and omization to follow-up and a multifaceted semitailored intervention programme or to follow-up only ( with extension of follow-up to 3 years ) . The intervention included a counselling programme , teaching courses , written information and logbooks . The outcomes included clinical efficacy parameters , patient satisfaction and health economic consequences . Results : A total of 330 patients and their 330 caregivers were included during a period of 18 months . The majority ( 65.2 % ) of the caregivers were spouses . At inclusion the mean age of the patients and caregivers was 76.2 and 66.0 years , respectively . Conclusion : The study will explore the added value of a multifaceted intervention programme and contribute to the design of future interventions for patients with mild dementia and their caregivers BACKGROUND Two-thirds of people with dementia live at home supported mainly by family carers . These carers frequently develop clinical depression or anxiety , which predicts care breakdown . We aim ed to assess the clinical effectiveness ( long-term reduction of depression and anxiety symptoms in family carers ) and cost-effectiveness of a psychological intervention called START ( STrAtegies for RelaTives ) . METHODS We did a r and omised , parallel-group trial with masked outcome assessment s in three UK mental-health services and one neurological-outpatient dementia service . We included self-identified family carers of people with dementia who had been referred in the previous year and gave support at least once per week to the person with dementia . We r and omly assigned these carers , via an online computer-generated r and omisation system from an independent clinical trials unit , to either START , an 8-session , manual-based coping intervention delivered by supervised psychology graduates , or treatment as usual ( TAU ) . The primary long-term outcomes were affective symptoms ( Hospital Anxiety and Depression Scale total score [ HADS-T ] ) 2 years after r and omisation and cost-effectiveness ( health and social care perspectives ) over 24 months . Analysis was by intention to treat , excluding carers with data missing at both 12 and 24 months . This trial is registered ISCTRN70017938 . FINDINGS From November 4 , 2009 , to June 8 , 2011 , we recruited 260 carers . 173 carers were r and omly assigned to START and 87 to TAU .  Of these 260 participants , 209 ( 80 % ) were included in the clinical efficacy analysis ( 140 START , 69 TAU ) . At 24 months , compared with TAU the START group was significantly better for HADS-T ( mean difference -2·58 points , 95 % CI -4·26 to -0·90 ; p=0·003 ) . The intervention is cost effective for both carers and patients ( 67 % probability of cost-effectiveness at the £ 20 000 per QALY willingness-to-pay threshold , and 70 % at the £ 30 000 threshold ) . INTERPRETATION START is clinical ly effective , improving carer mood and anxiety levels for 2 years . Carers in the control TAU group were seven times more likely to have clinical ly significant depression than those receiving START . START is cost effective with respect to carer and patient outcomes , and National Institute for Health and Care Excellence ( NICE ) thresholds . The number of people with dementia is rapidly growing , and policy frameworks assume that their families will remain the frontline providers of ( unpaid ) support . This cost-neutral intervention , which substantially improves family-carers ' mental health and quality of life , should therefore be widely available . FUNDING National Institute for Health Research Health Technology Assessment programme 08/14/06 OBJECTIVES The aim of the REMiniscence groups for people with dementia and their family CAREgivers ( REMCARE ) study was to assess the effectiveness and cost-effectiveness of joint reminiscence groups for people with dementia and their family caregivers  as compared with usual care . DESIGN A multicentre , pragmatic r and omised controlled trial with two parallel arms - an intervention group and a usual-care control group - was carried out . A restricted dynamic method of r and omisation was used with an overall allocation ratio of 1 : 1 , restricted to ensure intervention groups of a viable size . Assessment s , blind to treatment allocation , were carried out at baseline , 3 months and 10 months ( primary end point ) . SETTING Most participants were recruited through NHS Memory Clinics and Community Mental Health Teams for older people . Assessment s were usually carried out in the person 's home , and treatment groups were held in a variety of community setting s. PARTICIPANTS A total of 488 individuals ( mean age 77.5 years ) with mild to moderate dementia ( meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria ) , who were initially living in the community , and who had a relative or other caregiver maintaining regular contact , who could act as an informant and was willing and able to participate in the intervention , were recruited to the study . Most carers were spouses ( 71 % ) . A total of 350 dyads completed the study . INTERVENTIONS The intervention consisted of joint reminiscence groups held weekly for 12 consecutive weeks , followed by monthly maintenance sessions for a further 7 months . The sessions followed a treatment manual , and were led by two trained facilitators in each centre , supported by a number of volunteers . Up to 12 dyads were invited to attend each group . MAIN OUTCOME MEASURES The primary outcome measures were self-reported quality of life for the person with dementia and psychological distress for the carer [ General Health Question naire-28 item version ( GHQ-28 ) ] . Secondary outcome measures included autobiographical memory and activities of daily living for the person with dementia , carer stress for the carer and mood , relationship quality and service use and costs for both parties . RESULTS The intention-to-treat analysis identified no differences in outcome between the intervention and control conditions on primary or secondary outcomes [ self-reported quality of life in Alzheimer 's disease : mean difference 0.07 , st and ard error ( SE ) 0.65 ; F = 0.48 ; p = 0.53 ] . Carers of people with dementia allocated to the reminiscence intervention reported a significant increase in anxiety on a subscale of the GHQ-28 at the 10-month end point ( mean difference 1.25 , SE 0.5 ; F = 8.28 ; p = 0.04 ) . Compliance analyses suggested some benefits for people with dementia who attended more reminiscence sessions ; however , carers attending more groups showed increased caregiving stress . Use of health- and social-care services was modest , with no significant difference in service use between conditions . Owing to negligible difference in quality -adjusted life-year gains ( derived from European Quality of Life-5 Dimensions ) between the conditions the planned full economic analysis was curtailed . CONCLUSIONS This trial does not provide support for the effectiveness or cost-effectiveness of joint reminiscence groups for people with dementia and their carers . Although there may be some beneficial effects for people with dementia who attend sessions as planned , this must be viewed in the context of raised anxiety and stress in their carers . The reasons for these discrepant outcomes need to be explored further , and may necessitate re appraisal of the movement towards joint interventions . TRIAL REGISTRATION Current Controlled Trials IS RCT N42430123 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 16 , No. 48 . See the HTA programme website for further project information OBJECTIVES To evaluate cost-effectiveness of the Tailored Activity Program ( TAP ) for individuals with dementia and family caregivers . DESIGN Cost-effectiveness study of a two-group r and omized controlled trial involving 60 patients -caregiver dyads r and omized to intervention or wait-list control . SETTING Participants ' homes in Philadelphia region . PARTICIPANTS Caregivers were aged ≥ 21 years , lived with patients , and provided ≥ 4 hours of daily care . Patients had moderate dementia and behavioral symptoms INTERVENTION Eight sessions of occupational therapy over 4 months to identify patients ' preserved capabilities , previous roles , habits and interests , develop customized activities , and train families in their use . MEASUREMENTS Incremental cost-effectiveness ratios ( ICER ) expressed as the cost to bring about one additional unit of benefit measured by caregiver hours per day " doing things " and hours per day " being on duty . " Decision tree and Monte Carlo analyses tested robustness of the economic models . RESULTS Total average intervention cost was $ 941.63 per day . Intervention caregivers saved one extra hour per day " doing things " at a cost of $ 2.37/day and one extra hour per day " being on duty " at a cost of $ 1.10/day . Monte Carlo showed that TAP was cost-effective 79.2 % of the time for " doing things " and 79.6 % of the time for " being on duty . " Varying the cost assumptions did not change cost-effectiveness . CONCLUSIONS Findings suggest that investment in TAP  is cost-effective and afforded families an important , limited and highly valued re source , needed time off from caregiving . This nonpharmacologic approach should be considered part of the clinical management of dementia OBJECTIVES To determine whether a social support intervention ( access to an employed befriending facilitator in addition to usual care ) is effective compared with usual care alone . Also to document direct and indirect costs , and establish incremental cost-effectiveness . DESIGN The Befriending and Costs of Caring ( BECCA ) trial was a cost-effectiveness r and omised controlled trial . Data on well-being and re source use were collected through interviews with participants at baseline and at 6 , 15 and 24 months . SETTING This research was carried out in the English counties of Norfolk and Suffolk , and the London Borough of Havering . It was a community-based study . PARTICIPANTS Participants were family carers who were cohabiting with , or providing at least 20 hours ' care per week for , a community-dwelling relative with a primary progressive dementia . INTERVENTIONS The intervention was ' access to a befriender facilitator ' ( BF ) . BFs , based with charitable/voluntary-sector organisations , were responsible for local befriending schemes , including recruitment , screening , training and ongoing support of befriending volunteers , and for matching carers with befrienders . The role of befrienders was to provide emotional support for carers . The target duration for befriending relationships was 6 months or more . MAIN OUTCOME MEASURES Depression was measured by the Hospital Anxiety and Depression Scale ( HADS ) at 15 months postr and omisation . The health-related quality of life scale EQ-5D ( EuroQol 5 Dimensions ) was used to derive utilities for the calculation of quality -adjusted life-years ( QALYs ) . RESULTS A total of 236 carers were r and omised into the trial ( 116 intervention ; 120 control ) . At final follow-up , 190 carers ( 93 intervention ; 97 control ) were still involved in the trial ( 19 % attrition ) . There was no evidence of effectiveness or cost-effectiveness from the primary analyses on the intention-to-treat population . The mean incremental cost per incremental QALY gained was in excess of 100,000 pounds , with only a 42.2 % probability of being below 30,000 pounds per QALY gained . Where care-recipient QALYs were included , mean incremental cost per incremental QALY gained was 26,848 pounds , with a 51.4 % probability of being below 30,000 pounds per QALY gained . Only 60 carers ( 52 % ) took up the offer of being matched with a trained lay befriender , and of these only 37 ( 32 % ) were befriended for 6 months or more . A subgroup analysis of controls versus those befriended for 6 months or more found a reduction in HADS-depression scores that approached statistical significance ( 95 % CI -0.09 to 2.84 ) . CONCLUSIONS ' Access to a befriender facilitator ' is neither an effective nor a cost-effective intervention in the support of carers of people with dementia , although there is a suggestion of cost-effectiveness for the care dyad ( carer and care recipient ) . In common with many services for carers of people with dementia , uptake of befriending services was not high . However , the small number of carers who engaged with befrienders for 6 months or more reported a reduction in scores on HADS depression that approached statistical significance compared with controls ( 95 % CI -0.09 to 2.84 ) . While providing only weak evidence of any beneficial effect , further research into befriending interventions for carers is warranted An influential review in 2010 concluded that non-pharmacological multi-component interventions have positive effects on cognitive functioning , activities of daily living , behaviour and mood of people with dementia . Our aim here is to provide an up-to- date overview of research into psychosocial interventions and their impact on psychosocial outcomes . We focused on r and omised controlled trials , controlled studies and review s published between October 2008 and August 2015 , since the earlier review . The search of PsychInfo , Medline and the Cochrane data base of systematic review s yielded 61 relevant articles , organised into four themes echoing key phases of the care pathway : Living at home with dementia ( five review s , eight studies ) , carer interventions ( three review s , four studies ) , interventions in residential care ( 16 review s , 12 studies ) and end-of-life care ( three review s , two studies ) , along with an additional group spanning community and institutional setting s ( six review s , two studies ) . Community findings suggested that appointment of dementia specialists and attention to case management can produce positive outcomes ;  physical therapies , cognitive training and modified cognitive behaviour therapy also had a range of benefits . There was more limited evidence of positive benefits for people with dementia through interventions with family carers . Thirty-two articles focused on the management of ‘ behavioural symptoms ’ through a range of interventions all of which had some evidence of benefit . Also a range of multi-component and specific interventions had benefits for cognitive , emotional and behavioural well-being of people with dementia in residential setting s , as well as for quality of life . Overall , interventions tended to be short term with impact only measured in the short term . We recommend further research on interventions to promote living well in the community post-diagnosis and to address end-of-life care . Development of psychosocial interventions would benefit from moving beyond the focus on control of behaviours to focus on wider aspects of life for people with dementia BACKGROUND A number of non-pharmacological methods are available to help elderly people with cognitive impairment .  Unstructured and non- evidence based interventions are commonly used . The multicomponent therapy MAKS ( a German acronym for Motor , Activities of daily living , Cognitive , Social ) has already been evaluated in nursing homes ; in this study , we investigated its use in day care centers ( DCCs ) . METHODS A cluster-r and omized , controlled , single-blinded trial involving a 6-month intervention phase was performed . 362 cognitively impaired persons in 32 DCCs took part in the trial . Multiple regression analyses were used to determine whether MAKS therapy led to any statistically significant and clinical ly relevant improvement over time ( compared to membership in the control group ) in these persons ' cognitive abilities and activities of daily living ( ADL ) abilities , as assessed , respectively , with the Mini-Mental State Examination ( MMSE ) and the Erlangen Test of Activities of Daily Living in Persons with Mild Dementia or Mild Cognitive Impairment ( ETAM ) . A primary per- protocol analysis was supplemented by an intention-to-treat analysis . Two secondary outcomes ( social behavior and neuropsychiatric symptoms ) were analyzed exploratively as well . Study registration : IS RCT N16412551 . RESULTS In the primary per- protocol analysis at 6 months , the intervention group had significantly better MMSE and ETAM scores than the control group ( Cohen 's d , 0.26 and 0.21 , respectively ; p = 0.012 for both ) . The same was found in the ITT analysis at 6 months ( Cohen 's d = 0.21 , p = 0.033 ; and Cohen 's d = 0.20 , p = 0.019 , respectively ) . Neuropsychiatric symptoms , one of the secondary outcomes , also evolved more favorably in the intervention group ( Cohen 's d = 0.23 , p = 0.055 ) . CONCLUSION MAKS therapy is effective for persons with cognitive impairment ranging from mild cognitive impairment ( MCI ) to moderate dementia who live at home and regularly visit a day care center . The fact that 32 day care facilities from all over Germany participated in this study gives its findings high external validity
Background This systematic review aims to review the literature on trial-based economic evaluations of non-pharmacological interventions directly targeted at persons with dementia as well as persons with mild cognitive impairment and their respective caregivers .