A randomized trial of family caregiver support in the home management of dementia. Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. An intervention that delays institutionalization of Alzheimer's disease patients: treatment of spouse-caregivers. Randomized controlled trial of a dementia care programme for families of home-resided older people with dementia. A biobehavioral home-based intervention and the well-being of patients with dementia and their caregivers: the COPE randomized trial. Evaluation of a Telephone-Based Support Group Intervention for Female Caregivers of Community-Dwelling Individuals With Dementia A nursing intervention to decrease depression in family caregivers of persons with dementia. Telephone-delivered psychoeducational intervention for Hong Kong Chinese dementia caregivers: a single-blinded randomized controlled trial Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study. Modifying repetitive verbalizations of community-dwelling patients with AD. Helping carers to care--the 10/66 dementia research group's randomized control trial of a caregiver intervention in Russia. Cognitive Intervention in Alzheimer Disease: A Randomized Placebo-Controlled Study Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union. 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A three-year follow-up on the efficacy of psychosocial interventions for patients with mild dementia and their caregivers: the multicentre, rater-blinded, randomised Danish Alzheimer Intervention Study (DAISY) Helping carers to care: the 10/66 dementia research group's randomized control trial of a caregiver intervention in Peru. Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. Effects of the Medicare Alzheimer's Disease Demonstration on caregiver burden and depression. A randomized controlled trial of a home hospital intervention for frail elderly demented patients: behavioral disturbances and caregiver's stress. Effects of supporting community-living demented patients and their caregivers: a randomized trial. Efficacy of Behavioral Interventions for Dementia Caregivers A pilot study on a home‐based caregiver training program for improving caregiver self‐efficacy and decreasing the behavioral problems of elders with dementia in Taiwan Prognostic Factors of Effectiveness of a Support Program for Caregivers of Dementia Patients Counselling carers of the elderly at home: a preliminary study. A controlled study of respite service for caregivers of Alzheimer's patients.
A r and omized trial of family caregiver support for the home management of older people suffering from moderate to severe progressive irreversible dementia was conducted in an urban center in southern Ontario . Thirty caregivers were allocated to receive the experimental intervention consisting of : caregiver-focused health care , education about dementia and caregiving , assistance with problem solving , regularly scheduled in-home respite , and a self-help family caregiver support group .  Thirty control subjects received conventional community nursing care . Before completion of the intervention , 18 ( 30 % ) were withdrawn , almost equally from each group . The most frequent reason was long-term institutionalization of the demented relative ( n = 10 ) . At baseline , caregivers in both groups were suffering from above-average levels of depression and anxiety . After the six-month intervention period , we found neither experimental nor control group improved in these areas . However , the experimental group showed a clinical ly important improvement in quality of life , experienced a slightly longer mean time to long-term institutionalization , found the caregiver role less problematic , and had greater satisfaction with nursing care than the control group OBJECTIVE To determine the effectiveness of community based occupational therapy on daily functioning of patients with dementia and the sense of competence of their care givers . DESIGN Single blind r and omised controlled trial . Assessors were blinded for treatment allocation . SETTING Memory clinic and day clinic of a geriatrics department and participants ' homes . PARTICIPANTS 135 patients aged > or = 65 with mild to moderate dementia living in the community and their primary care givers . INTERVENTIONS 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 Patients ' daily functioning assessed with the assessment of motor and process skills ( AMPS ) and the performance scale of the interview of deterioration in daily activities in dementia ( IDDD ) . Care giver burden assessed with the sense of competence question naire ( SCQ ) . Participants were evaluated at baseline , six weeks , and three months . RESULTS Scores improved significantly relative to baseline in patients and care givers in the intervention group compared with the controls ( differences were 1.5 ( 95 % confidence interval 1.3 to 1.7 ) for the process scale ; -11.7 ( -13.6 to -9.7 ) for the performance scale ; and ( 11.0 ; 9.2 to 12.8 ) for the competence scale ) . This improvement was still significant at three months . The number needed to treat to reach a clinical ly relevant improvement in motor and process skills score was 1.3 ( 1.2 to 1.4 ) at six weeks . Effect sizes were 2.5 , 2.3 , and 1.2 , respectively , at six weeks and 2.7 , 2.4 , and 0.8 , respectively , at 12 weeks . CONCLUSIONS Occupational therapy improved patients '  daily functioning and reduced the burden on the care giver , despite the patients ' limited learning ability . Effects were still present at 12 weeks , which justifies implementation of this intervention . TRIAL REGISTRATION Clinical Trials NCT00295152 [ Clinical Trials.gov ] Spouse-caregivers of Alzheimer 's disease patients were r and omly assigned to either a treatment group ( individual and family counseling , support group participation , and ad hoc consultation ) or a control group ( only routine support ) . In the first year after intake , the treatment group had less than half as many nursing home placements as the control group . This suggests that a comprehensive counseling program can reduce the socioeconomic impact of Alzheimer 's disease . Nursing home placement also was affected by the patient 's need for assistance with activities of daily living , patient income , and the age of the patients and caregivers AIM This paper reports a study to examine the effectiveness of a 6-month dementia care programme for Chinese families living with and caring for a relative with dementia , compared with routine family support services in Hong Kong . BACKGROUND Recognizing the adverse psychosocial health effects inherent in dementia care , different psychosocial interventions provided preliminary evidence of their effectiveness in improving family members ' knowledge and skills in caregiving and delaying dementia sufferers ' illness deterioration and institutionalization . Little is known about the effects of such interventions for family caregivers ' psychosocial health conditions , particularly in non-Western population s. METHODS A r and omized controlled trial was conducted with 92 Chinese families of a relative with dementia in two dementia care centres in Hong Kong . They were r and omly selected from a dementia client list and then r and omly assigned to receive either the dementia family care programme ( n=46 ) , or routine care only ( n=46 ) . Clients ' symptoms and institutionalization , and caregivers ' quality of life , burden and social support at recruitment , 1 week , and 12 and 18 months following intervention were measured and compared between the study groups using repeated measures MANOVAS followed by Helmert 's contrast tests . Data was collected over a period of 24 months , between September 2007 and August 2009 . RESULTS Results of the MANOVAS and contrast tests indicated that at 18-month follow-up , participants in the family programme reported significantly greater improvements in clients ' symptoms and institutionalization rates , and caregivers ' quality of life and burden , when compared with their counterparts in the routine care group . CONCLUSION These findings provide evidence that the dementia care family programme can improve the psychosocial functioning of both clients with dementia and their family caregivers in a Chinese population . Further research is recommended to investigate whether this intervention can also apply to families with different socio-economic background s and across cultures CONTEXT Optimal treatment to postpone functional decline in patients with dementia is not established . OBJECTIVE To test a nonpharmacologic intervention realigning environmental dem and s with patient capabilities . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve 2-group r and omized trial ( Care of Persons with Dementia in their Environments [ COPE ] ) involving patients with dementia and family caregivers ( community-living dyads ) recruited from March 2006 through June 2008 in Pennsylvania . INTERVENTIONS Up to 12 home or telephone contacts over 4 months by health professionals who assessed patient capabilities and deficits ; obtained blood and urine sample s ; and trained families in home safety , simplifying tasks , and stress reduction . Control group caregivers received 3 telephone calls and educational material s. MAIN OUTCOME MEASURES Functional dependence , quality of life , frequency of agitated behaviors , and engagement for patients and well-being , confidence using activities , and perceived benefits for caregivers at 4 months . RESULTS Of 284 dyads screened , 270 ( 95 % ) were eligible and 237 ( 88 % ) r and omized . Data were collected from 209 dyads ( 88 % ) at 4 months and 173 ( 73 % ) at 9 months . At 4 months , compared with controls , COPE patients had less functional dependence ( adjusted mean difference , 0.24 ; 95 % CI , 0.03 - 0.44 ; P = .02 ; Cohen d = 0.21 ) and less dependence in instrumental activities of daily living ( adjusted mean difference , 0.32 ; 95 % CI , 0.09 - 0.55 ; P = .007 ; Cohen d = 0.43 ) , measured by a 15-item scale modeled after the Functional Independence Measure ; COPE patients also had improved engagement ( adjusted mean difference , 0.12 ; 95 % CI , 0.07 - 0.22 ; P = .03 ; Cohen d = 0.26 ) , measured by a 5-item scale . COPE caregivers improved in their well-being ( adjusted mean difference in Perceived Change Index , 0.22 ; 95 % CI , 0.08 - 0.36 ; P = .002 ; Cohen d = 0.30 ) and confidence using activities ( adjusted mean difference , 0.81 ; 95 % CI , 0.30 - 1.32 ; P = .002 ; Cohen d = 0.54 ) , measured by a 5-item scale . By 4 months , 64 COPE dyads ( 62.7 % ) vs 48 control group dyads ( 44.9 % ) eliminated 1 or more caregiver-identified problems ( chi(2/1 ) = 6.72 , P = . 01 ) . CONCLUSION Among community-living dyads , a nonpharmacologic biobehavioral environmental intervention compared with control result ed in better outcomes for COPE dyads at 4 months . Although no group differences were observed at 9 months for patients , COPE caregivers perceived greater benefits . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00259454 Family caregivers , the “ second victims ” or hidden patients in dementia care , are at risk for social isolation , stress , depression , and mortality . Telephone-based support ( telesupport groups ) represents a practical , low-burden , low-cost source of emotional support . The present study evaluated the feasibility and effectiveness of professionally led telephone-based support groups for female family caregivers of community-dwelling dementia patients . Recruited through various community sources , 103 female caregivers were r and omized to the telesupport group treatment or a control condition . Effects on caregiver burden , depression , and personal gains were evaluated at 6 months , the main end point . Older care-givers ( ≥65 ) in telesupport  reported lower depression than control group caregivers did The goal of this study was to evaluate a community-based psychoeducational-nursing intervention design ed to teach home caregivers  to manage behavioral problems of persons with Alzheimer 's disease and related dementias ( ADRD ) using the Progressively Lowered Stress Threshold ( PLST ) model , and to compare this intervention with routine information and referrals for case management , community-based services , and support groups . Previous caregiver studies have overwhelmingly pointed to the adverse effects of caregiving on the caregivers ' physical and mental health , and high prevalence rates of depression among caregivers of persons with ADRD have consistently been reported . Therefore , a primary aim was to evaluate the impact of the intervention on caregivers ' affective responses , especially depression . Data from both the Profile of Moods States and the Geriatric Depression Rating Scale support the effectiveness of this intervention in decreasing depression among caregivers who received the experimental training . Additional analysis of factors associated with caregiver depression are also reported . The pivotal role of psychiatric nurses in the assessment and treatment of depression among caregivers of persons with ADRD is discussed Purpose Many family caregivers of persons with dementia ( PWD ) are unable to participate in community center-based caregiver support services because of logistical constraints . This study evaluated the effectiveness of a telephone-delivered psychoeducational intervention for family caregivers of PWD in alleviating caregiver burden and enhancing caregiving self-efficacy . Subjects and methods In a single-blinded r and omized controlled trial , 38 family caregivers of PWD were r and omly allocated into an intervention group or a control group . The intervention group received psychoeducation from a registered social worker over the phone for 12 sessions . Caregivers in the control group were given a DVD containing educational information about dementia caregiving . Outcomes of the intervention were measured by the Chinese versions of the Zarit Burden Interview and the Revised Scale for Caregiving Self-efficacy . Mann – Whitney U tests were used to compare the differences between the intervention and control groups . Results The level of burden of caregivers in the intervention group reduced significantly compared with caregivers in the control group . Caregivers in the intervention group also reported significantly more gain in self-efficacy in obtaining respite than the control group . Conclusion A structured telephone intervention can benefit dementia caregivers in terms of self-efficacy and caregiving burden . The limitations of the research and recommendations for intervention are discussed OBJECTIVE To test whether the Tailored Activity Program ( TAP ) reduces dementia-related neuropsychiatric behaviors , promotes activity engagement , and enhances caregiver well-being . DESIGN Prospect i ve , two-group ( treatment , wait-list control ) , r and omized , controlled pilot study with 4 months as main trial endpoint . At 4 months , controls received the TAP intervention and were reassessed 4 months later . SETTING Patients ' homes . PARTICIPANTS Sixty dementia patients and family caregivers . INTERVENTION The eight-session occupational therapy intervention involved neuropsychological and functional testing , selection , and customization of activities to match capabilities identified in testing , and instruction to caregivers in use of activities . MEASUREMENTS Behavioral occurrences , activity engagement , and quality of life in dementia patients ; objective and subjective burden and skill enhancement in caregivers . RESULTS At 4 months , compared with controls , intervention caregivers reported reduced frequency of problem behaviors , and specifically for shadowing and repetitive question ing , and greater activity engagement including the ability to keep busy . Fewer intervention caregivers reported agitation or argumentation . Caregiver benefits included fewer hours doing things and being on duty , greater mastery , self-efficacy , and skill enhancement . Wait-list control participants following intervention showed similar benefits for reductions in behavioral frequency and caregiver hours doing things for the patient and mastery .  Caregivers with depressed symptoms derived treatment benefits similar to nondepressed caregivers . CONCLUSIONS Tailoring activities to the capabilities of dementia patients and training families in activity use result ed in clinical ly relevant benefits for patients and caregivers . Treatment minimized trigger behaviors for nursing home placement and reduced objective caregiver burden . Noteworthy is that depressed caregivers effectively engaged in and benefited from the intervention Seven caregivers of a home-dwelling spouse with Alzheimer 's disease were trained during 12 weekly home visits to implement behavior management programs including written cuing procedures in response to repetitive verbalizations . Data from 7 trained caregivers and 7 matched control caregivers who only tracked repetitive behavior were compared . Results revealed that trained caregivers were successful at decreasing patient repetitions using written cues . Patients of control subjects showed no systematic changes in behavioral disturbances due to behavior tracking . In addition , intervention effects lasted for 16 weeks or longer and several caregivers reported applying the cuing intervention to other , nontargeted behaviors . Trained caregivers ' perceptions of their efficacy in managing difficult patient behavior improved significantly at the 3-month follow-up assessment when program staff were no longer visiting them weekly OBJECTIVES Dementia is a rapidly growing public health problem in low and middle income countries . There is an urgent need , in the absence of formal services , to develop interventions design ed to improve the lives of people with dementia , and their families . This study tests the effectiveness of the 10/66 caregiver intervention among people with dementia , and their carers . DESIGN A single blind parallel group r and omized controlled trial ( IS RCT N41039907 ) . SETTING Moscow . PARTICIPANTS Sixty family caregivers of people aged 65 and over with dementia were r and omized to receive the intervention and medical care as usual ( n = 30 ) or medical care as usual only ( n = 30 ) . Caregiver and person with dementia outcomes were assessed at baseline and after 6 months . INTERVENTION The caregiver education and training intervention was delivered over five , weekly , half-hour sessions and was made up of three modules : ( i ) assessment ( one session ) ; ( ii ) basic education about dementia ( two sessions ) ; and ( iii ) training regarding specific problem behaviors ( two sessions ) . MEASUREMENTS Dementia was diagnosed using DSM-IV criteria . Caregiver : Zarit Carer Burden Interview ; carer psychological distress ( SRQ 20 ) ; and carer Quality of Life ( WHOQOL-BREF ) . Person with dementia : Behavioural and Psychological symptoms ( NPI-Q ) ; quality of life ( DEMQOL ) . RESULTS Caregivers in the intervention group reported large and statistically significant net improvements at 6-month follow-up in burden compared to controls . No group differences were found on caregiver psychological distress and patient and caregiver quality of life . CONCLUSIONS The low-level intervention seems to be as , if not more , effective than similar interventions applied in high income countries The efficacy of a cognitive intervention consisting of training in face-name associations , spaced retrieval , and cognitive stimulation was tested in a sample of 37 patients ( 16 men , 21 women ) with probable Alzheimer disease ( AD ) . Patients with AD were r and omly assigned to receive either the cognitive intervention or a mock ( placebo ) intervention for 5 weeks . The placebo group then crossed over to receive the intervention . During the intervention , AD patients showed significant improvement in recall of personal information , face-name recall , and performance on the Verbal Series Attention Test . Improvement did not generalize to additional neuropsychologic measures of dementia severity , verbal memory , visual memory , word generation , or motor speed , or to caregiver-assessed patient quality of life . Results suggest that although face-name training , spaced retrieval , and cognitive stimulation may produce small gains in learning personal information and on a measure of attention , improvement does not generalize to overall neuropsychologic functioning or patient quality of life Objective : To determine the effectiveness of a counseling and support intervention for spouse caregivers in delaying time to nursing home placement of patients with Alzheimer disease ( AD ) , and identify the mechanisms through which the intervention accomplished this goal . Methods : We conducted a r and omized controlled trial of an enhanced counseling and support intervention compared to usual care . Participants were a referred volunteer sample of 406 spouse caregivers of community-dwelling patients who had enrolled in the study over a 9.5-year period . The intervention consisted of six sessions of individual and family counseling , support group participation , and continuous availability of ad hoc telephone counseling . Structured question naires were administered at baseline and at regular follow-up intervals , every 4 months for the first year and every 6 months thereafter . Cox proportional hazard models were used to test the effects of the intervention on the time to nursing home placement for the patients after controlling for multiple time-invariant and time-dependent predictors of placement . Results : Patients whose spouses received the intervention experienced a 28.3 % reduction in the rate of nursing home placement compared with usual care controls ( hazard ratio = 0.717 after covariate adjustment , p = 0.025 ) . The difference in model-predicted median time to placement was 557 days . Improvements in caregivers ’ satisfaction with social support , response to patient behavior problems , and symptoms of depression collectively accounted for 61.2 % of the intervention ’s beneficial impact on placement . Conclusion : Greater access to effective programs of counseling and support could yield considerable benefits for caregivers , patients with Alzheimer disease , and society BACKGROUND In 1998 , a research study was conducted to compare existing programs in the European Union providing both care to people with senile dementia of the Alzheimer type , and support to their informal caregiver . METHOD Five programs were selected in seven centres . Home social services ( Denmark ) , Day centres ( Germany ) , Expert Centres ( Belgium , Spain ) , Group Living/Cantou ( Sweden , France ) , Respite hospitalization ( France ) . In each centre , 50 patients were r and omly selected . The question naire addressed informal caregivers ( or referents ) . It included the Nottingham Health Profile ( NHP ) , the Zarit Scale , and it collected data on age , sex and position ( spouse or child ) of the informal caregiver , as well as age , level of mental deterioration and disabilities of the patient . RESULTS ( n=322 subjects ) Comparatively with caregivers of Respite hospitalization patients chosen as the reference , caregivers of patients cared by Group living/Cantou and Home social services experienced a significantly lower burden . The benefit from the Expert centre program concerned emotional reactions ( depression ) ( odds ratio=0.32 ; P=0.02 ) and work burden ( Zarit ) ( OR=0.32 ; P=0.04 ) . The main benefit for caregivers who received Day centre help was the important reduction of feelings of social isolation ( OR=0.13 ; P=0.0003 ) . CONCLUSIONS The Group Living/Cantou program appeared as the most efficient way to reduce informal caregiver burden , independently from the country considered Objectives To develop and evaluate the effectiveness of a home based intervention in reducing caregiver burden , promoting caregiver mental health and reducing behavioural problems in elderly persons with dementia . Methodology and Principal Findings This was a r and omised controlled trial in which the person with dementia-caregiver dyad was r and omly allocated either to receive the intervention immediately or to a waiting list group which received the intervention after 6 months . It was carried out in communities based in two talukas ( administrative blocks ) in Goa , India . Mild to moderate cases with dementia ( diagnosed using the DSM IV criteria and grade d using the Clinical Dementia Rating scale ) and their caregivers were included in the trial . Community based intervention provided by a team consisting of Home Care Advisors who were supervised by a counselor and a psychiatrist , focusing on supporting the caregiver through information on dementia , guidance on behaviour management , a single psychiatric assessment and psychotropic medication if needed . We measured caregiver mental health ( General Health Question naire ) , caregiver burden ( Zarit Burden Score ) , distress due to behavioural disturbances ( NPI-D ) , behavioural problems in the subject ( NPI-S ) and activities of daily living in the elder with dementia ( EASI ) . Outcome evaluations were masked to the allocation status . We analysed each outcome with a mixed effects model . 81 families enrolled in the trial ; 41 were r and omly allocated to the intervention . 59 completed the trial and 18 died during the trial . The intervention led to a significant reduction of GHQ ( −1.12 , 95 % CI −2.07 to −0.17 ) and NPI-D scores ( −1.96 , 95%CI −3.51 to −0.41 ) and non-significant reductions in the ZBS , EASI and NPI-S scores . We also observed a non-significant reduction in the total number of deaths in people with dementia in the intervention arm ( OR 0.34 , 95 % CI 0.01 to 1.03 ) . Conclusion Home based support for caregivers of persons with dementia , which emphasizes the use of locally available , low-cost human re sources , is feasible , acceptable and leads to significant improvements in caregiver mental health and burden of caring . Clinical Trials.gov OBJECTIVES To determine whether community care of people with dementia can be prolonged with a 2-year multicomponent intervention program and to analyze effects of the intervention on total usage and expenses of social and healthcare services . DESIGN R and omized controlled trial . SETTING Community-dwelling couples with one spouse caring for the other spouse with dementia . PARTICIPANTS Couples with dementia ( N=125 ) were allocated at r and om to the intervention ( n=63 ) or control group ( n=62 ) . INTERVENTION Intervention couples were provided with a multicomponent intervention program with a family care coordinator , a geriatrician , support groups for caregivers , and individualized services . MEASUREMENTS Time from enrollment to institutionalization of spouses with dementia and use of services and service expenditure of couples . RESULTS At 1.6 years , a larger proportion in the control group than in the intervention group was in long-term institutional care ( 25.8 % vs 11.1 % , P=.03 ) . At 2 years , the difference was no longer statistically significant . The 2-year adjusted hazard ratio for the intervention group was 0.53 ( 95 % confidence interval (CI)=0.23 - 1.19 , P=.12 ) . Intervention led to reduction in use of community services and expenditures . The difference for the benefit of intervention group was -7,985 Euro ( 95 % CI=-16,081 to -1,499 , P=.03 ) . When the intervention costs were included , the differences between the groups were not significant . CONCLUSION Although the intervention did not result in a significant difference in the need for institutional care after 2 years , individualizing services in collaboration with families may lead to reduction in use of and expenditures on municipal services OBJECTIVES To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders . DESIGN 18-month r and omized controlled trial of 303 community-living elders . SETTING 28 postal code areas of Baltimore , MD . PARTICIPANTS Age 70 + years , with a cognitive disorder , community-living , English-speaking , and having a study partner available . INTERVENTION 18-month care coordination intervention to systematic ally identify and address dementia-related care needs through individualized care planning ; referral and linkage to services ; provision of dementia education and skill-building strategies ; and care monitoring by an interdisciplinary team . MEASUREMENTS Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months . RESULTS Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37 % ( Hazard ratio : 0.63 , 95 % Confidence Interval : 0.42 - 0.94 ) compared with control participants . Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months , the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls . Intervention participants had a significant improvement in self-reported quality of life ( QOL ) relative to control participants . No group differences were found in proxy-rated QOL , neuropsychiatric symptoms , or depression . CONCLUSIONS A home-based dementia care coordination intervention delivered by non- clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home , reduced unmet needs , and improved self-reported QOL In recent years research ers have carried out an increasing number of clinical trials with family caregivers of the elderly . The results of these interventions have suggested that caregiver skill-building interventions may be more effective than information/support interventions . Although research ers have given considerable attention to the information and support needed by family caregivers , less is known about how this information and support translates into caregiver skills or into changes in behavior . This is the second in a series of three articles on a study in which research ers used qualitative methods to analyze summaries from the group component of a larger caregiver clinical trial . In this article we describe caregiver issues and concerns in five major areas : ( a ) . dealing with change , ( b ) . managing competing responsibilities and stressors , ( c ) . providing a broad spectrum of care , ( d ) . finding and using re sources , and ( e ) . experiencing emotional and physical responses to care . We identify specific skills needed by caregivers in addressing these caregiving issues and concerns , and we compare and contrast skilled with less skilled caregivers . Further work is needed concerning the focus and methods of future caregiver skill-based interventions This r and omized clinical trial tested a new self-directed educational intervention to improve caregiver competence to create a safer home environment for persons with dementia living in the community . The sample included 108 patient/caregiver dyads : the intervention group ( n = 60 ) received the Home Safety Toolkit ( HST ) , including a new booklet based on health literacy principles , and sample safety items to enhance self-efficacy to make home safety modifications . The control group ( n = 48 )  received customary care . Participants completed measures at baseline and at twelve-week follow-up . Multivariate Analysis of Covariance ( MANCOVA ) was used to test for significant group differences . All caregiver outcome variables improved in the intervention group more than in the control . Home safety was significant at P ≤ 0.001 , caregiver strain at P ≤ 0.001 , and caregiver self-efficacy at P = 0.002 . Similarly , the care receiver outcome of risky behaviors and accidents was lower in the intervention group ( P ≤ 0.001 ) . The self-directed use of this Home Safety Toolkit activated the primary family caregiver to make the home safer for the person with dementia of Alzheimer 's type ( DAT ) or related disorder . Improving the competence of informal caregivers is especially important for patients with DAT in light of all stakeholders reliance on their unpaid care Context Providing care for patients with dementia can pose enormous burdens that may be eased with assistance and support . Needs may differ by race or ethnicity . Contributions The investigators r and omly assigned Hispanic , black , and white dementia caregivers to receive written educational material s or an intensive intervention to improve caregiver quality of life .  The specific interventions were determined by caregivers , were delivered via trained personnel and telephone support groups , and targeted several dimensions of need . The study found that quality of life improved for Hispanic and white caregivers and for black spousal caregivers in the intervention group but not in the control group . The intervention had no detectable effect on the number of care recipients who were institutionalized . Caution s The study used only a single 6-month follow-up assessment , combined heterogeneous cultures and ethnicities into 3 groups , and excluded some ethnicities . Implication s An intensive intervention targeting several dimensions of caregiver need improved caregiver quality of life without an apparent effect on care recipient institutionalization . The effect did not differ by caregiver race or ethnicity . The Editors Caring for a family member with dementia is extremely stressful , contributes to psychiatric and physical illness , and increases the risk for death ( 1 , 2 ) . The accumulating evidence on the personal , social , and health effects of dementia caregiving has generated a broad range of intervention studies , including r and omized trials aim ed at decreasing the burden and stress of caregiving . Several studies have demonstrated statistically significant effects in reducing caregiver burden , lowering caregiver depression , and delaying institutionalization of care recipients ( 1 , 3 , 4 ) through either targeted interventions that treat a specific caregiver problem , such as depression , or broad-based multicomponent interventions that include counseling , case management , and telephone support . Persistent limitations of caregiver intervention research are the paucity of well-controlled r and omized trials , the limited range of outcomes examined , small sample sizes and insufficient power , geographic limitations , inadequate racial or ethnic variation , and a scarcity of comprehensive multicomponent interventions ( 4 ) . Indeed , none of the 41 r and omized clinical trials published in the last 5 years met Consoli date d St and ards of Reporting Trials ( CONSORT ) recommendations for reporting r and omized trials ( 5 ) , and many have serious method ologic problems that call into question the reported findings ( 4 ) . To address these limitations , the National Institute on Aging and the National Institute of Nursing Research funded a multisite research program design ed to develop and test an effective caregiver intervention : the Re sources for Enhancing Alzheimer 's Caregiver Health ( REACH ) study . We performed the study in 2 phases . In the first phase ( REACH I ) , we tested several different interventions at 6 U.S. sites to identify the most promising approaches to decreasing  caregiver burden and depression ( 6 ) . Results from the study showed that active treatments were superior to control conditions in reducing caregiver burden and that active engagement in skills training statistically significantly reduced  caregiver depression ( 7 , 8) . The existing literature and findings from REACH I helped guide the design of the REACH II intervention ( 7 , 8) . We based the REACH II study on the premise that caregivers can have problems in several areas at varying levels of intensity , and thus , interventions must be responsive to variations in needs among caregivers . The findings from REACH I also suggest that interventions that use active techniques , such as role-playing and interactive practice , are more effective at improving outcomes , such as depression symptoms , compared with more passive methods , such as providing information ( 7 ) . We based the REACH II intervention on these assumptions and design ed the intervention to maximize outcomes by systematic ally targeting several problem areas , tailored the intervention to respond to the needs of each individual , and actively engaged the caregiver in the intervention process . We hypothesized that participants assigned to the intervention would do better than those in the control group on several indicators of caregiver quality of life , including depression , burden , self-care , and social support and care recipient problem behaviors , and that these differences would be largest among Hispanic or Latino persons because they have lower access to support services ( 8) . In additional analyses , we assessed the effects of treatment on rates of caregiver clinical depression and care recipient institutional placement , as well as the benefits derived from study participation . Methods Caregivers Eligibility criteria for caregivers included the following : Hispanic or Latino , white or Caucasian , or black or African-American race or ethnicity ; age 21 years or older ; living with or sharing cooking facilities with the care recipient ; providing care for a relative with diagnosed Alzheimer disease or related disorders for at least 4 hours per day for at least the past 6 months ; and reported distress associated with caregiving ( reported at least 2 of the following 6 items at baseline assessment : felt overwhelmed , felt like they often needed to cry , were angry or frustrated , felt they were cut off from family or friends , reported  moderate to high levels of general stress , or felt their health had declined ) . We excluded caregivers who were involved in another caregiver intervention study , who had participated in REACH I , or who had an illness that would prevent 6 months of study participation . Other requirements were logistic , including having a telephone , planning to remain in the geographic area for at least 6 months , and competency in either English or Spanish ( see Appendix Table 1 for a detailed list of exclusions ) . Appendix Table 1 . Reasons for In eligibility Care Recipients To be eligible for the study , caregivers had to confirm that their relative had diagnosed Alzheimer disease or related disorders . In addition , we screened care recipients for a history of severe mental illness , head injury , Parkinson disease , or stroke , and we administered the  MiniMental State Examination ( MMSE )  ( 9 ) . We excluded patients who were bedbound with MMSE scores of 0 because we felt that our intervention had little to offer caregivers who were caring for such patients . Moreover , being bedbound is a risk factor for institutional placement or death , and we sought to exclude caregivers who were likely to transition out of the caregiving role within the 6-month study . For patients who scored more than 23 on the MMSE or had other conditions , such as head injury , we required a physician 's diagnosis of Alzheimer disease or related disorders . Procedures We recruited caregiver and care recipient dyads at 5 sites : Birmingham , Alabama ; Memphis , Tennessee ; Miami , Florida ; Palo Alto , California ; and Philadelphia , Pennsylvania . Enrollment began in June 2002 , and follow-up ended in August 2004 . Recruitment occurred in memory disorder clinics , primary care clinics , social service agencies , physician offices , churches , and community centers and by using professionally design ed brochures , public service announcements on radio stations , newspaper articles , television , targeted newsletters , and community presentations . We translated all intervention material s and assessment instruments into Spanish for the Hispanic or Latino participants by using established techniques for forward- and -back translation and allowing for regional variation in language expression . We used bilingual and bicultural staff at the 3 sites that recruited Hispanic or Latino participants : Palo Alto , Philadelphia , and Miami . At all sites , assessors and interventionists received cultural sensitivity training and were certified before entering the field . Certified assessors were blinded to group assignment of study participants . The institutional review boards of all 5 site institutions and the coordinating center in Pittsburgh , Pennsylvania , approved the study . We obtained written informed consent from all caregivers and from care recipients whenever possible . Caregivers provided consent on behalf of care recipients who could not do so on their own . After telephone screening ( n= 995 ) and baseline assessment ( n= 670 ) , we r and omly assigned participants ( n= 642 ) to the intervention or control group ( Figure ) . We stratified r and omization by using a block size of 2 or 4 within strata defined by the 5 intervention sites , 3 racial or ethnic groups ( Hispanic or Latino , white or Caucasian , and black or African American ) , and 2 caregivercare recipient relationships ( spouse or nonspouse ) . We performed r and omization at the coordinating center by using a computer-generated algorithm and a st and ard protocol for transmitting r and omization information between the coordinating center and the study sites . We administered 1 of 3 follow-up batteries , on the basis of care recipient status at follow-up ( full follow-up , bereavement battery , or placement battery ) , to study participants 6 months after r and omization when the intervention was completed . To maximize the number of individuals who could be included in the outcome analyses , we ensured that the 3 batteries were as similar as possible . We did not ask caregivers about caregiver burden and care recipient functional status if their care recipients had died ; thus , we could not include these caregivers in the primary outcome analysis ( 10 ) . Figure . Study flow diagram . * See Appendix Table 1 for reasons for in eligibility . See Appendix Table 2 ( for reasons for unavailable end points and types of 6-month follow-up . Appendix Table 2 . Reasons for Unavailable End Points and Types of 6-Month Follow-up Trial Groups Intervention The intervention involved a range of strategies : provision of OBJECTIVE This study evaluated the effectiveness of a  technology-based psychoeducational intervention for family caregivers of dementia patients . An additional objective was to determine if the intervention could be implemented by a community-based social service agency . METHODS Forty-six caregivers were r and omly assigned to either a technology-based intervention or an information-only control condition . RESULTS Caregivers assigned to the intervention condition reported a significant decrease in burden postintervention and those who evidence d high depression at baseline experienced a significant decline in depression . CONCLUSION This study provides evidence that technology offers a cost-effective and practical method for delivering interventions to caregivers Behavioral problems are among the most challenging aspects of caring for a person with Alzheimer 's disease . A sample of 406 spouses-caregivers of patients with Alzheimer 's disease was r and omized to an active multicomponent counseling and support intervention condition or to a usual care condition . Caregivers reported on the frequency of troublesome patient behaviors and their reactions to them at baseline and at regular follow-up interviews . R and om-effects regression models over the first 4 years after r and omization revealed that , although the intervention did not affect the frequency of patient behavioral problems , it did significantly reduce caregivers ' reaction ratings . Because caregiver appraisal s have been found to mediate the impact of caregiving stress on depression and to predict nursing home placement rates , they deserve greater attention as an important target of intervention services PURPOSE We determine the main outcome effects of a 12-month computer-mediated automated interactive voice response ( IVR ) intervention design ed to assist family caregivers managing persons with disruptive behaviors related to Alzheimer 's disease ( AD ) . DESIGN AND METHODS We conducted a r and omized controlled study of 100 caregivers , 51 in the usual care control group and 49 in the technology intervention group , who received yearlong access to an IVR-mediated system .  The system provided caregiver stress monitoring and counseling information , personal voice-mail linkage to AD experts , a voice-mail telephone support group , and a distraction call for care recipients . We conducted analyses by using a repeated measures approach for longitudinal data and an intention-to-treat analytic approach . Outcomes included the caregiver 's appraisal of the bothersome nature of caregiving , anxiety , depression , and mastery at baseline , 6 , 12 , and 18 months . RESULTS There was a significant intervention effect as hypothesized for participants with lower mastery at baseline on all three outcomes : bother ( p = .04 ) , anxiety ( p = .01 ) , and depression ( p = .007 ) . Additionally , wives exhibited a significant intervention effect in the reduction of the bothersome nature of caregiving ( p = .02 ) . IMPLICATION S Wives who exhibited low mastery and high anxiety benefited the most from the automated telecare intervention . Findings suggest that , to optimize outcome effects , similar interventions should be tailored to match the users ' characteristics and preferences OBJECTIVE Recent work has shown that Chinese Americans caring for a family member with dementia experience considerable psychological distress . However , few studies evaluate treatments for them . This study evaluated the efficacy of in-home intervention , based on cognitive behavior therapy principles , to relieve stress and depression in female Chinese American caregivers ( CGs ) . METHODS Fifty-five CGs who met inclusion criteria were r and omly assigned to a telephone support condition ( TSC ) or to an in-home behavioral management program ( IHBMP ) for 4 months . In the TSC , biweekly calls were made and relevant material was mailed . In the IHBMP , specific psychological skills were taught to deal with caregiving stress . CGs were assessed before and after treatment . Outcome measures evaluated overall perceived stress , caregiving-specific stress , and depressive symptoms . RESULTS CGs in IHBMP were less bothered by caregiving-specific stressors and had lower depression levels than CGs in TSC . There was no difference in overall stress . CGs with low baseline level of self-efficacy for obtaining respite benefited from IHBMP , but showed little improvement in the TSC . CGs with higher self-efficacy benefited from both treatments . CONCLUSION This intervention is promising and warrants replication in future studies . Additional research is needed to evaluate longer-term effects and to identify individual differences associated with improvement OBJECTIVES To test the effects of an intervention that helps families manage  distressing behaviors in family members with dementia . DESIGN Two-group r and omized trial . SETTING In home . PARTICIPANTS Two hundred seventy-two caregivers and people with dementia . INTERVENTION Up to 11 home and telephone contacts over 16 weeks by health professionals who identified potential triggers of patient behaviors , including communication and environmental factors and patient undiagnosed medical conditions ( by obtaining blood and urine sample s ) and trained caregivers in strategies to modify triggers and reduce their upset . Between 16 and 24 weeks , three telephone contacts reinforced strategy use . MEASUREMENTS Primary outcomes were frequency of targeted problem behavior and caregiver upset with and confidence managing it at 16 weeks . Secondary outcomes were caregiver well-being and management skills at 16 and 24 weeks and caregiver perceived benefits . Prevalence of medical conditions for intervention patients were also examined . RESULTS At 16 weeks , 67.5 % of intervention caregivers reported improvement in targeted problem behavior , compared with 45.8 % of caregivers in a no-treatment control group ( P=.002 ) , and reduced upset with ( P=.03 ) and enhanced confidence managing ( P=.01 ) the behavior . Additionally , intervention caregivers reported less upset with all problem behaviors ( P=.001 ) , less negative communication ( P=.02 ) , less burden ( P=.05 ) , and better well-being ( P=.001 ) than controls . Fewer intervention caregivers had depressive symptoms ( 53.0 % ) than control group caregivers ( 67.8 % , P=.02 ) . Similar caregiver outcomes occurred at 24 weeks . Intervention caregivers perceived more study benefits ( P<.05 ) , including ability to keep family members home , than controls . Blood and urine sample s of intervention patients with dementia showed that 40 ( 34.1 % ) had undiagnosed illnesses requiring physician follow-up . CONCLUSION Targeting behaviors up setting to caregivers and modifying potential triggers improves symptomatology in people with dementia and caregiver well-being and skills PURPOSE We developed manual-guided , replicable interventions based on common needs and cultural preferences of White and African American family caregivers ( CGs ) of individuals with dementia , and we evaluated these interventions after a 6-month follow-up . DESIGN AND METHODS We r and omly assigned White ( n = 70 ) and African American ( n = 48 ) CGs of individuals with dementia to either a skills training condition or a minimal support control condition . RESULTS The degree of treatment implementation was method ically assessed , and findings demonstrated that both interventions were delivered according to protocol and were well received by CGs . CGs in both groups reported decreasing levels of problem behaviors and appraisal s of behavioral bother , and increased satisfaction with leisure activities over time . On a measure of appraisal of distress related to behavior problems , White CGs showed more improvement in the minimal support control condition , and African American CGs showed the greatest improvements in the skills training condition . Spouse and nonspouse CGs also showed differential responses to intervention . IMPLICATION S Brief manual-guided interventions can be effective with White and African American CGs , and greater attention should be paid to possible differential responses to interventions by race and relationship to care recipient To address the need for nonpharmacologic approaches to managing difficult behaviors in patients with dementia , a repeated measures design was used to test the effectiveness of educational and behavioral intervention on behavioral and functional outcomes in home-dwelling patients with dementia and their caregivers ' knowledge of dementia . Baseline and 6-month postintervention data were collected for 108 subjects ( 54 caregiver/patient pairs ) following r and om assignment to an intervention or comparison group . Findings included increases in caregiver knowledge in two treatment groups and patient self-care ability in one treatment group and ratings of the most effective behavioral interventions by caregivers To evaluate nonpharmacologic interventions , caregivers ( 65 women , 38 men ) and their dementia-diagnosed spouses ( patients ) were r and omized to one of four treatment programs ( cognitive stimulation , dyadic counseling , dual supportive seminar , and early-stage day care ) or to a wait-list control group . Assessment s occurred initially and at postintervention ( 3 months ) . Patients were evaluated on memory , verbal fluency , and problem-solving ability , and caregivers were assessed on marital interaction , emotional status , and physical health , along with stress , coping , and social support .  Caregivers also completed a program evaluation . Repeated measures procedures showed that patients in the cognitive stimulation group demonstrated more improvement over time in cognitive outcomes , and caregivers decreased in depressive symptoms . Early-stage day-care and dual supportive seminar group caregivers reported a decrease in hostility and a decrease in use of negative coping strategies , respectively . Although qualitatively derived benefits differed across groups , similarities in program content reduced the potential for quantitative differentiation among the groups OBJECTIVE The long-term effect of counseling and support on symptoms of depression was examined in spouse-caregivers of patients with Alzheimer 's disease . METHOD The participants were 406 spouse-caregivers of Alzheimer 's disease patients who lived at home at baseline . The caregivers were r and omly assigned to either a group receiving enhanced counseling and support treatment or a group receiving usual care ( control group ) . Caregivers in the enhanced treatment group were provided with six sessions of individual and family counseling , agreed to join support groups 4 months after enrollment , and received ongoing ad hoc counseling . The Geriatric Depression Scale was administered at baseline and at regular follow-up intervals for as long as the caregiver participated in the study . RESULTS After baseline differences were controlled for , caregivers in the enhanced treatment group had significantly fewer depressive symptoms after the intervention than did the control subjects . These effects were sustained for 3.1 years after baseline , similar across gender and patient severity level , and sustained after nursing home placement or death of the patient . CONCLUSIONS Counseling and support lead to sustained benefits in reducing depressive symptoms in spouse-caregivers of Alzheimer 's disease patients and should be widely available to provide effective , evidence -based intervention for family caregivers BACKGROUND Cure of dementia is not possible , but quality of life of patients and caregivers can be improved . Our aim is to investigate effects of community occupational therapy on dementia patients ' and caregivers '  quality of life , mood , and health status and caregivers ' sense of control over life . METHODS Community-dwelling patients aged 65 years or older , with mild-to-moderate dementia , and their informal caregivers ( n = 135 couples of patients with their caregivers ) were r and omly assigned to 10 sessions of occupational therapy over 5 weeks or no intervention . Cognitive and behavioral interventions were used to train patients in the use of aids to compensate for cognitive decline and caregivers in coping behaviors and supervision . Outcomes , measured at baseline , 6 weeks , and 12 weeks , were patients ' and caregivers ' quality of life ( Dementia Quality of Life Instrument , Dqol ) , patients ' mood ( Cornell Scale for Depression , CSD ) , caregivers ' mood ( Center for Epidemiologic Studies Depression Scale , CES-D ) , patients ' and caregivers ' health status ( General Health Question naire , GHQ-12 ) , and caregivers ' sense of control over life ( Mastery Scale ) . RESULTS Improvement on patients ' Dqol overall ( 0.8 ; 95 % confidence interval [ CI ] , 0.6-.1 , effect size 1.3 ) and caregivers ' Dqol overall ( 0.7 ; 95 % CI , 0.5-.9 , effect size 1.2 ) was significantly better in the intervention group as compared to controls . Scores on other outcome measures also improved significantly . This improvement was still significant at 12 weeks . CONCLUSION Community occupational therapy should be advocated both for dementia patients and their caregivers , because it improves their mood , quality of life , and health status and caregivers ' sense of control over life . Effects were still present at follow-up Those who provide care at home for a spouse with Alzheimer 's disease ( AD ) endure considerable challenges , including social isolation and increasing caregiving responsibilities . We examine the extent to which an intervention that helps spouse-caregivers mobilize their social support network , helps them better adapt to the caregiving role . We used detailed social support information collected from 200 spouse-caregivers participating in a r and omized , controlled trial of enhanced social support services in the USA . Using r and om effects regression models , we found that individuals in the intervention group reported higher levels of satisfaction with their social support network over the first 5 years of the intervention than those in the support group . Higher levels of emotional support , more visits , and having more network members to whom they felt close were all individually predictive of longitudinal changes in social support network satisfaction . We conclude with a discussion of the importance of having psychological respite when caregivers spend their days in the home and are isolated Context Dementia is an incurable chronic disease , but assistance to caregivers can reduce the severity of patients ' symptoms and delay institutionalization . Because this assistance requires provision of multiple health care and social services , patients and caregivers might benefit from a coordinated system of care . Contribution The investigators r and omly assigned patients with dementia and their caregivers to usual care or to a coordinated system of care . In the coordinated system , care managers regularly assessed patient and caregiver pairs and coordinated guideline -recommended provision of services by health care providers and community agencies using computerized information systems . The study found that pairs cared for in the coordinated system received higher- quality health care and more needed assistance than those who received usual care . Caution s The study focused on a relatively homogeneous population of white , well-educated , otherwise healthy , noninstitutionalized patients with health insurance . The findings might not apply to other population s. Implication s The quality of care for patients with dementia and their caregivers can be improved with a model of care in which services provided by the health system and community agencies are coordinated by a care manager . The Editors Dementia has enormous health and financial consequences for affected individuals , their family caregivers , and society ( 15 ) . Although most dementia is currently neither preventable nor reversible , existing practice guidelines reflect evidence from r and omized , controlled trials that caregiver assistance and support can delay institutionalization ( 68 ) , and nonpharmacologic management of problem behaviors and depression can reduce symptom severity and improve patient health ( 9 , 10 ) . Yet , adherence to published dementia care guidelines ( 1114 ) is poor ( 15 ) , including inappropriate use of psychoactive medications for initial management of agitation ( 16 ) ; low referral rates to community agencies ( 17 , 18 ) ; and underdetection of elder abuse , for which cognitive impairment is a risk factor ( 19 ) , and of depression ( 20 ) , a common comorbid condition ( 21 ) . There are few controlled trials of improvement interventions for dementia care . An opinion leader intervention improved neurologists ' reported adherence to dementia care guidelines ( 18 ) , and a recent trial using advanced practice nurses within primary care improved care quality ( 22 ) ; other trials reported limited impacts ( 23 , 24 ) . All studies were conducted primarily within or outside of health care delivery systems ; to date , trials of comprehensive , guideline -based dementia care interventions that incorporate all chronic care model components , including substantive collaboration between health systems and community agencies ( 25 , 26 ) , have not been reported . Yet , this would seem to be a well-suited approach because of the multifaceted nature of dementia care management and the need for coordinated efforts across health care delivery systems and community agencies to provide recommended medical , behavioral , and social services and support . To address gaps in care quality for persons with dementia , we design ed and tested a guideline -based , comprehensive dementia care management intervention in a clinic-level , cluster r and omized , controlled trial ( 27 ) . Intervention components were based on the chronic care model and emphasized linkages with community re sources and multiagency coordination ( 25 , 26 , 28 ) . Key components included dementia care managers , formal procedures for communication within and between organizations and agencies , Internet-based care management , collaborative care planning with caregivers , caregiver self-management support , ongoing follow-up , and provider education . We hypothesized that patient and caregiver dyads in intervention clinics would receive care in higher accordance with guidelines ; receive more community re sources and services ; have fewer unmet caregiving assistance needs ; and have better patient and caregiver health and caregiving quality , social support , and perceived care quality than dyads receiving usual care . Methods The institutional review boards of the University of California , Los Angeles , and all participating health care organizations approved the study procedures . All enrolled patient and caregiver dyads provided written informed consent . Three health care organizations ( Kaiser Permanente San Diego , Scripps Clinic , University of California , San Diego , Healthcare ) and 3 community agencies ( Alzheimer 's AssociationSan Diego Chapter , Southern Caregiver Re source Center , Meals on WheelsGreater San Diego ) providing services for persons with dementia and their informal caregivers in the San Diego metropolitan area participated . Private group practice , academic group practice , and health maintenance organization practice types were represented by the 3 health care organizations . Study Participants The study included 18 clinics from the participating health care organizations ( 4 to 8 per organization ) ( Table 1 ) . The inclusion criterion was that these be primary care clinics . Table 1 . Characteristics of Participating Health Care Organizations * Patients with dementia who were age 65 years or older and receiving Medicare were identified by querying health care organization administrative data bases for occurrence during the previous year of a dementia diagnosis code ( 29 ) at an outpatient visit or hospitalization or a cholinesterase inhibitor prescription . Patient lists were grouped by primary provider and were circulated to those providers for confirmation of dementia diagnosis and identification of additional potential participants from his or her practice ( generating < 5 % of the sample ) . Patients had to have an informal caregiver ( age 18 years ) . Patients were recruited by mail with English- and Spanish- language letters from their physician and an opt-out postcard , followed by up to 3 mailings of a patient consent or assent form ( depending on the physician 's design ation of the patient 's ability to provide consent ) , a caregiver consent form ( containing a proxy consent for the patient if he or she was judged unable to provide consent ) , and a baseline caregiver survey . R and omization was conducted at the clinic level , based on the clinic-focused design of the care management intervention . Within each health care organization , we paired clinics by patient volume ; within each pair , we r and omly assigned 1 clinic to the intervention and the other clinic to usual care using a computerized r and om-number generator operated by a study statistician . Participants were unaware of clinic r and omization status at enrollment and at completion of the baseline survey and were not reminded of r and omization status at follow-up . Intervention A steering committee that included a physician from each health care organization , a leader from each community agency , a community caregiver , and investigators used a formal method ( 30 ) to identify 23 existing dementia guideline recommendations as care goals ( 11 , 12 , 14 ) . They also design ed a structured assessment , algorithms linking specific care management actions to assessment results , and interorganization care coordination and referral protocol s. A key intervention element was health care organization and community agencybased dementia care managers ( primarily social workers ) who received formal training and used an Internet-based care management software system for care planning and coordination ( 25 , 26 , 28 ) . Every enrolled patient and caregiver dyad in the intervention group was assigned 1 health care organization care manager , who contacted them to schedule a structured home assessment . Assessment responses were entered into the software system , generating a preliminary problem list and guides to care-plan actions . The care manager collaborated with the caregiver to prioritize problem areas ; teach problem-solving skills ; initiate care plan actions ; and send an assessment summary , a problem list , and selected recommendations to the patient 's primary care physician and other design ated providers . A menu of potential care plan actions ( for example , referral for respite care services ) was documented in a comprehensive care management manual . The care management protocol included ongoing follow-up , usually by telephone , with frequency based on need and a formal in-home re assessment every 6 months to assess the need for major care-plan revisions . The software system had a feature to enable efficient tracking of multiple cases and tasks . Referrals to a particular community agency were guided by flagged problem areas . With patient and caregiver consent , referrals were communicated through the software system to that agency , whose design ated care manager subsequently received system access to the assessment , problem list , and care plan . Each dyad could have 1 or more community agency care managers . Care managers from the health care organizations and community agencies received the same formal education and training program , which was conducted jointly , and met monthly to refine care coordination procedures . Care management began within a month after enrollment of the first dyads and was active throughout the study follow-up unless a case was closed , for example , because a patient moved out of the study area and no longer was enrolled in the health care organization . At each intervention clinic , more than 90 minutes of st and ardized , interactive seminars ( in up to 5 sessions ) on relevant care issues , including  evaluation of acute behavioral changes , depression management  , and determination of decision-making capacity  ( 31 ) , were offered to primary care providers . Selected intervention tools and documents with more detailed descriptions can be accessed at www.adc.ucla.edu/access/access.swf . Patients , caregivers , and providers in the usual care group were not offered study interventions . Outcome Measures Primary Outcome The study 's primary outcome was OBJECTIVE To determine the feasibility and efficacy of a home-based exercise intervention program to improve the functional performance of patients with Alzheimer 's Disease ( AD ) . METHODS Twenty-seven home-dwelling patients with AD were r and omized to either an exercise intervention program delivered by their caregivers or a home safety assessment control .  Measures of functional performance ( primary ) , cognition , neuropsychiatric symptoms , quality of life and caregiver burden ( secondary ) were obtained at baseline and at 6 and 12 weeks following r and omization . For each outcome measure , intent-to-treat analyses using linear r and om effects models were performed . Feasibility and adverse events were also assessed . RESULTS Adherence to the exercise program was good . On the primary outcomes ( functional performance ) patients in the exercise group demonstrated a trend for improved performance on measures of h and function and lower extremity strength . On secondary outcome measures , trends toward worse depression and lower quality of life ratings were noted . CONCLUSIONS The physical exercise intervention developed for the study , delivered by caregivers to home-dwelling patients with AD , was feasible and was associated with a trend for improved functional performance in this group of frail patients . Given the limited efficacy to date of pharmacotherapies for AD , further study of exercise intervention , in a variety of care setting , is warranted PURPOSE We investigated whether community consultants could be trained to teach family caregivers a systematic behavioral approach for reducing mood and behavior problems in persons with Alzheimer 's disease . DESIGN AND METHODS This study consisted of a r and omized controlled trial ; we r and omly assigned 95 family caregivers and care recipients with Alzheimer 's disease to STAR-caregivers ( STAR-C ) or control groups . Masked interviewers conducted assessment s at baseline , after treatment , and after 6 months . Consultants were master's-level health care professionals who were currently practicing in community setting s serving older adults . We assessed the extent to which consultants were able to learn and adhere to the treatment protocol , and the relationship between adherence and measures of caregiver mood , burden , and care recipient mood and behavior . RESULTS Community consultants were able to learn and adhere to the behavioral treatment protocol . Caregivers receiving STAR-C training showed significant improvements in depression , burden , and reactivity to behavior problems in the care recipient . There were also significant reductions in the frequency and severity of care recipient behavior problems , and improved quality of life . Results were maintained at 6-month follow-up . IMPLICATION S Community-based consultants successfully implemented a behavioral intervention with family caregivers of persons with Alzheimer 's disease . Consequently , STAR-C seems to be a practicable and reasonable evidence d-based approach to caregiver training in actual clinical setting PURPOSE The majority of persons with Alzheimer 's disease ( AD ) are cared for at home by a family member such as a spouse or daughter . Caregiving places enormous dem and s on these caregivers , and the negative consequences associated with caregiving are well documented . This paper reports results from the Miami site of the REACH ( Re sources for Enhancing Alzheimer 's Caregiver Health ) program that examined the efficacy of a family therapy and technology-based intervention in reducing depressive symptoms ( according to the Center for Epidemiological Studies Depression scale ) among family caregivers of AD patients at 6 months and 18 months follow-up . DESIGN AND METHODS There were 225 White American and Cuban American caregivers that were r and omized into a structural ecosystems therapy , structural ecosystems therapy + computer-telephone integrated system , or minimal support control condition .  RESULTS Caregivers in the combined family therapy and technology intervention experienced a significant reduction in depressive symptoms at 6 months . The 18-month follow-up data indicated that the intervention was particularly beneficial for Cuban American husb and and daughter caregivers . IMPLICATION S The results indicate that information technology has a promising role in alleviating distress and depression among groups of AD caregivers . The data also demonstrate that interventions have differential impacts according to ethnic group and the caregiver-patient relationship BACKGROUND Few studies evaluate whether short-term intervention effects are maintained over time for families caring for persons with dementia . This article examines whether treatment effects found at 6 months following active treatment were sustained at 12 months for 127 family caregivers who participated in an occupational therapy intervention tested as part of the National Institutes of Health Re sources for Enhancing Alzheimer 's Caregiver Health ( REACH ) initiative . METHODS A r and omized two-group design was implemented with three assessment points : baseline , 6 months , and 12 months . Caregivers were r and omly assigned to a usual care control group or intervention that consisted of six occupational therapy sessions to help families modify the environment to support daily function of the person with dementia and reduce caregiver burden . Following 6-month active treatment , a maintenance phase consisted of one home and three brief telephone sessions to reinforce strategy use and obtain closure . Non-inferiority statistical analysis was used to evaluate whether intervention caregivers maintained treatment benefits from 6 to 12 months in comparison to controls . RESULTS For the sample of 127 at 6 months , caregivers in intervention reported improved skills ( p = .028 ) , less need for help providing assistance ( p = .043 ) , and fewer behavioral occurrences ( p = .019 ) compared to caregivers in control . At 12 months , caregiver affect improved ( p = .033 ) , and there was a trend for maintenance of skills and reduced behavioral occurrences , but not for other outcome measures . CONCLUSION An in-home skills training program helps sustain caregiver affect for those enrolled for more than 1 year . More frequent professional contact and ongoing skills training may be necessary to maintain other clinical ly important outcomes such as reduced upset with behaviors PURPOSE We examine 6-month effects of the Environmental Skill-Building Program on  caregiver well-being and care recipient functioning  and whether effects vary by caregiver gender , race ( White or non-White ) , and relationship ( spouse or nonspouse ) . DESIGN AND METHODS We enrolled 255 family caregivers of community-residing persons with Alzheimer 's disease or related disorders , of whom 190 participated in a follow-up interview . Caregivers were r and omized to a usual care control group or intervention group that received five home contacts and one telephone contact by occupational therapists , who provided education , problem-solving training , and adaptive equipment . Baseline and 6-month follow-up included self-report measures of caregiver objective and subjective burden , caregiver well-being , and care recipient problem behaviors and physical function . RESULTS Compared with controls ( n = 101 ) , intervention caregivers ( n = 89 ) reported less upset with memory-related behaviors , less need for assistance from others , and better affect . Intervention spouses reported less upset with disruptive behaviors ; men reported spending less time in daily oversight ; and women reported less need for help from others , better affect , and enhanced management ability , overall well-being , and mastery relative to control group counterparts . Statistically significant treatment differences were not found for hours helping with instrumental activities of daily living , upset with providing assistance with instrumental activities of daily living and activities of daily living , perceived change in somatic symptoms , White versus non-White caregivers , or care recipient outcomes . IMPLICATION S The Environmental Skill-Building Program reduces burden and enhances caregiver well-being in select domains and has added benefit for women and spouses OBJECTIVES This study tested the effectiveness of a dementia care management program for Chinese families of relatives with dementia on  caregivers ' and  patients  ' health outcomes over a 12-month follow-up period . METHODS The dementia care management program is an educational and supportive group for caregivers that lasts six months . A controlled trial was conducted with 88 primary caregivers of persons with dementia in two dementia care centers in Hong Kong . Family members were assigned r and omly to either the dementia care program or st and ard care . The two groups were compared for patients ' symptoms and institutionalization rates and caregivers ' quality of life , burden , and social support upon recruitment and six and 12 months after group assignment . RESULTS Over the 12-month follow-up period , patients with family members in the dementia care program showed significantly greater improvements in symptoms and institutionalization rates and their caregivers reported significantly greater improvements in quality of life and burden compared with the control group . CONCLUSIONS The findings provide evidence that the dementia care management program can improve the psychosocial functioning of Chinese persons with dementia and their caregivers Objectives To examine the long-term efficacy at the 36-month follow-up of an early psychosocial counselling and support programme lasting 8–12 months for community-dwelling patients with mild Alzheimer 's disease and their caregivers . Design Multicentre , r and omised , controlled , rater-blinded trial . Setting Primary care and memory clinics in five Danish districts . Participants 330 home-dwelling patients with mild Alzheimer 's disease and their primary caregivers ( dyads ) . Interventions Dyads were r and omised to receive intervention during the first year after diagnosis . Both intervention and control groups had follow-up visits at 3 , 6 , 12 and 36 months . Main outcome measures Primary outcomes for the patients assessed at 36-month follow-up were changes from baseline in global cognitive function ( Mini-Mental State Examination ) , depressive symptoms ( Cornell Depression Scale ) and proxy-rated EuroQoL quality of life on visual analogue scale . The primary outcomes for the caregivers were changes from baseline in depressive symptoms ( Geriatric Depression Scale ) and self-rated EuroQoL quality of life on a visual analogue scale . The secondary outcome measures for the patient were proxy-rated Quality of Life Scale for Alzheimer 's disease ( QoL-AD ) , Neuropsychiatric Inventory- Question naire , Alzheimer 's disease Cooperative Study Activities of Daily Living Scale , all-cause mortality and nursing home placement . Results At a 36-month follow-up , 2 years after the completion of the Danish Alzheimer Intervention Study ( DAISY ) , the unadjusted positive effects previously detected at the 12-month follow-up in one patient primary outcome ( Cornell depression score ) and one patient secondary outcome ( proxy-rated QoL-AD ) disappeared ( Cornell depression score , p=0.93 ; proxy-rated QoL-AD , p=0.81 ) . No long-term effect of DAISY intervention on any other primary and secondary outcomes was found at the 36-month follow-up . Conclusions For patients with very mild Alzheimer 's disease and their caregivers , an intensive , multi-component , semitailored psychosocial intervention programme with counselling , education and support during the first year after diagnosis did not show any positive long-term effect on primary and secondary outcomes . Trial registration The study was registered in the Clinical Trial Data base ( http://www.controlled-trials.com/IS RCT N74848736 ) OBJECTIVE There is a need , in the absence of formal services , to design interventions aim ed at improving the lives of people with dementia and their families . This study tested the effectiveness of the 10/66 caregiver intervention among people with dementia and their caregivers in Lima , Peru . METHOD DESIGN / PARTICIPANTS a r and omized controlled trial was performed involving 58 caregivers of people with dementia that received the intervention in the beginning of the trial ( n = 29 ) or six months later ( n = 29 ) . The intervention consisted of three modules : 1 ) assessment ( one session ) ; 2 ) basic education about dementia ( two sessions ) ; and 3 ) training regarding specific problem behaviors ( two sessions ) . MAIN OUTCOME MEASURES Caregivers and patients with dementia were assessed at baseline and after six months . For caregivers , the measures included strain ( Zarit Burden Interview ) , psychological distress ( SRQ-20 ) , and quality of life ( WHOQOL-BREF ) . Dementia patients completed scales assessing behavioral and psychological symptoms ( NPI-Q ) and quality of life ( DEMQOL ) . RESULTS Caregivers in the intervention group reported significantly decreased strain measures six months after the intervention compared to controls . No group differences were found in respect to the caregivers ' psychological distress and to quality of life in both caregivers and patients . CONCLUSION The 10/66 intervention seems to be as effective as similar interventions used in more developed countries CONTEXT Exercise training for patients with Alzheimer disease combined with teaching caregivers how to manage behavioral problems may help decrease the frailty and behavioral impairment that are often prevalent in patients with Alzheimer disease . OBJECTIVE To determine whether a home-based exercise program combined with caregiver training in behavioral management techniques would reduce functional dependence and delay institutionalization among patients with Alzheimer disease . DESIGN , SETTING , AND PATIENTS R and omized controlled trial of 153 community-dwelling patients meeting National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer Disease and Related Disorders Association criteria for Alzheimer disease , conducted between June 1994 and April 1999 . INTERVENTIONS Patient-caregiver dyads were r and omly assigned to the combined exercise and caregiver training program , Reducing Disability in Alzheimer Disease ( RDAD ) , or to routine medical care ( RMC ) . The RDAD program was conducted in the patients ' home over 3 months . MAIN OUTCOME MEASURES Physical health and function ( 36-item Short-Form Health Survey 's [ SF-36 ] physical functioning and physical role functioning subscales and Sickness Impact Profile 's Mobility subscale ) , and affective status ( Hamilton Depression Rating Scale and Cornell Depression Scale for Depression in Dementia ) . RESULTS At 3 months , in comparison with the routine care patients , more patients in the RDAD group exercised at least 60 min/wk ( odds ratio [ OR ] , 2.82 ; 95 % confidence interval [ CI ] , 1.25 - 6.39 ; P = .01 ) and had fewer days of restricted activity ( OR , 3.10 ; 95 % CI , 1.08 - 8.95 ; P<.001 ) . Patients in the RDAD group also had improved scores for physical role functioning compared with worse scores for patients in the RMC group ( mean difference , 19.29 ; 95 % CI , 8.75 - 29.83 ; P<.001 ) . Patients in the RDAD group had improved Cornell Depression Scale for Depression in Dementia scores while the patients in the RMC group had worse scores ( mean difference , -1.03 ; 95 % CI , -0.17 to -1.91 ; P = .02 ) . At 2 years , the RDAD patients continued to have better physical role functioning scores than the RMC patients ( mean difference , 10.89 ; 95 % CI , 3.62 - 18.16 ; P = .003 ) and showed a trend ( 19 % vs 50 % ) for less institutionalization due to behavioral disturbance . For patients with higher depression scores at baseline , those in the RDAD group improved significantly more at 3 months on the Hamilton Depression Rating Scale ( mean difference , 2.21 ; 95 % CI , 0.22 - 4.20 ; P = .04 ) and maintained that improvement at 24 months ( mean difference , 2.14 ; 95 % CI , 0.14 - 4.17 ; P = .04 ) . CONCLUSION Exercise training combined with teaching caregivers behavioral management techniques  improved physical health and depression in patients with Alzheimer disease STUDY QUESTION Does improved access to community-based care reduce perceived burden and reported levels of depression among primary caregivers of people with dementia ? DATA SOURCES Baseline and periodic caregiver interviews with participants in the Medicare Alzheimer 's Disease Demonstration . Client and caregiver attributes and caregiver outcomes such as depression and burden scores were among the measures . STUDY DESIGN Applicants to the demonstration ( all voluntary ) were r and omly assigned into treatment and control groups . Treatment group cases were eligible for case management and for up to $ 699 per month in community care benefits . ( The actual monthly entitlement varied among the eight demonstration communities due to regional cost differences and inflation adjustments over the four-year demonstration period . ) DATA COLLECTION A total of 5,307 eligible individuals received a baseline assessment at the time of application to the demonstration and at least one semi-annual re assessment . Clients and their caregivers were periodically reassessed producing a total of 20,707 observations . PRINCIPAL FINDINGS Persons in the treatment group had a high exposure to case management and a greater likelihood of community service use relative to those in the control group . Treatment group membership was associated with statistically significant , but very small reductions in caregiver burden ( in four of eight sites ) and depression ( three of eight sites ) over a 36-month tracking period . These findings are not sustained with all cases combined , or among a higher-re source demonstration model considered separately . CONCLUSIONS Both the fact that these programmatic differences did not translate into substantial treatment group reductions in caregiver burden or depression , and the consistency of these findings with those of prior case management evaluations suggest the need to reformulate this programmatic intervention into areas not previously tested : 24-hour care , crisis intervention , coordination with primary care , or chronic disease management A Geriatric Home Hospitalization Service ( GHHS ) has been operating in Torino at S. Giovanni Battista Hospital since 1985 . GHHS allows us to perform diagnostic and therapeutic interventions , which are usually made in hospital , also at home . GHHS team includes geriatricians , nurses , physiotherapists , social workers and counselors . Between February 1999 and April 2002 , the GHH Service conducted a r and omized controlled trial on 109 elderly , demented patients requiring admission to the Hospital Emergency Department (ED)for acute illnesses . Objective of the study was to identify the benefits of the care in a GHHScompared to a general medical ward ( GMW ) in reducing behavioral disturbances in elderly patients with advanced dementia and in lowering caregiver 's stress .  Patients were r and omly assigned to GHHS ( 56 patients ) or to GMW ( 53 patients ) . Both groups were examined using the same protocol and were evaluated on admission and on discharge . All patients had a severe form of dementia as shown by the clinical dementia rating ( CDR ) scale mean value ( 3.7 + /- 0.9 ) with an important functional impairment and a relevant degree of comorbidity . The main reasons for hospitalization were infections , cerebrovascular accidents and malnutrition . Mortality of total sample was 19.3 % , without significant differences in the two setting s of care . On discharge , in GHHS patients there was a significant reduction of behavioral disturbances . The use of anti-psychotic drugs was significantly lower in GHHS patients compared to the GMW group ( p < 0.001 ) . The stress of caregivers on discharge was reduced only in GHHS group and not in the control ones . In conclusion , we can say that a GHHS continuous support allows us to reduce the family caregiver 's stress . When treated at home , demented patients do not have to change their environment or routine and it is possible to have a better control on behavioral disturbances OBJECTIVES To determine whether community care of demented patients can be prolonged by means of a 2-year support program based on nurse case management . DESIGN R and omized controlled intervention study with 2-year follow-up . SETTING Demented patients entitled to payments from the Social Insurance Institution for community care , in five municipalities in eastern Finl and . PARTICIPANTS One hundred demented patients , age 65 and older , living at home with the primary support of informal caregivers , allocated at r and om to the intervention ( n = 53 ) or control group ( n = 47 ) . INTERVENTION Intervention patients and their caregivers were provided with a 2-year intervention program of systematic , comprehensive support by a dementia family care coordinator . MEASUREMENTS Time to institutionalization ( period in community care ) from enrollment of patients in the study to their placement in long-term institutional care . RESULTS During the first months , the rate of institutionalization was significantly lower in the intervention group than in the control group ( P = .042 ) , but the benefit of the intervention decreased with time ( P = .028 ) . Estimated probability of staying in community care up to 6 , 12 , and 24 months was 0.98 , 0.92 , and 0.63 in the intervention group and 0.91 , 0.81 , and 0.68 in the control group , respectively . Results also suggest that the intervention used in the study might be especially beneficial to patients with severe dementia and those with problems threatening the continuity of community care . CONCLUSIONS The placement of demented patients in long-term institutional care can be deferred with the support of a dementia family care coordinator . However , by the end of the 2-year intervention , the number of patients institutionalized was similar in the intervention and control group . It seems to be beneficial to direct this type of intensive support at severely demented patients and their caregivers . On the basis of our experiences , we suggest that intervention by a dementia family care coordinator should be targeted especially at patients with problems threatening the continuity of community care Behavioral symptoms of Alzheimer 's disease , particularly agitation , appear to be a major contributing factor to the emotional distress exhibited by family caregivers .  Psychosocial interventions have been shown to reduce caregiver emotional distress , but few studies have examined the efficacy of these interventions with caregivers exposed to high levels of dementia-related behavioral symptoms . The purpose of this study is to test the efficacy of a caregiver skill building intervention in reducing emotional distress to agitated behaviors of care recipients . This study analyzed data from a subgroup of caregivers who participated in a larger r and omized clinical trial ( N = 295 ) . Data from 143 caregivers of family members with baseline agitated behaviors indicate that the skill building intervention was more effective than an information and support oriented comparison condition in reducing emotional distress over an 18-month period . These findings indicate that dementia caregivers exposed to agitated behaviors can benefit from psychosocial interventions , particularly those aim ed at building behavioral management skills To investigate the effectiveness of a  home‐based caregiver training program for caregivers of elders with dementia and behavioral problems In a r and omized controlled study , positive effects were found of a support program for caregivers of dementia patients . The aim of this study is to identify in a secondary analysis the prognostic factors of success of the support program by comparing characteristics of patients and primary caregivers for whom the support program was effective with those for whom the program was not effective ( n = 49 pairs of patients and caregivers ) . The theoretically based individualized support program which is presented in this article , was most effective with regard to primary caregivers ' sense of competence for females sharing a household with the dementia patient . The program was most effective in reducing the number of patient admissions when patients did not receive support from a district nurse and the primary caregivers experienced less emotional support from the informal network . A proactive approach by offering this flexible support before caregivers ask for support may prolong the stage in which they feel able to care for patients at home . Offering this support to females , who usually are supposed to care for the patient without assistance , may be both effective and efficient A comparative study of two different methods of counselling for informal carers of elderly people with dementia was carried out in their own homes over an 18-week period . Carers were r and omly allocated to short-term emotional support , information-provision or no-treatment control groups . Carers were assessed for mood , stress ( Beck Depression Inventory and General Health Question naire ) , degree of burden and knowledge of problems of dementia . Carers receiving emotional support experienced the greatest reduction in stress , whereas those receiving information only showed an increase in knowledge , but no reduction in stress After a baseline interview of 642 caregivers of aged Alzheimer 's disease victims , half were offered formal respite care . Over 12 months , families with respite care  maintained their impaired relative significantly longer in the community ( 22 days ) . Although respite was ineffective for caregiver burden and mental health , satisfaction was very high . Although not a strong intervention , respite care can increase caregivers ' quality of life
AIM The aim of this study was to explicate the outcomes of  home support interventions for older people with dementia and /or their carers to inform clinical practice , policy and research .
BACKGROUND Most people with dementia receive support at home .
However , components and effectiveness of home support interventions have been little explored .