Research report
Systematic review of the effect of psychological interventions on family caregivers of people with dementia

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Abstract

Background

Caregivers of people with dementia are at high risk of psychological morbidity and associated breakdown in care. Many psychologically based interventions have been designed to help caregivers of people with dementia. More work is needed to identify which, if any, are helpful for such caregivers.

Method

We conducted a systematic review of the immediate and long term efficacy of different types of psychological interventions for the psychological health of caregivers of people with dementia, using standardized criteria, to assist clinicians in implementing rational, evidence-based management recommendations. We reviewed studies examining the effects of any therapy derived from a psychological approach that satisfied pre-specified criteria. Using the Oxford Centre for Evidence-Based Medicine criteria we rated the quality of each study, extracted data and gave overall ratings to different types of intervention.

Results

We identified 244 references in our search of which 62 met our inclusion criteria.

Limitations

Our findings are limited by lack of good quality evidence, with only ten level 1 studies identified.

Conclusions

We found excellent evidence for the efficacy of six or more sessions of individual behavioral management therapy centered on the care recipient's behavior in alleviating caregiver symptoms both immediately and for up to 32 months. Teaching caregivers coping strategies either individually or in a group also appeared effective in improving caregiver psychological health both immediately and for some months afterwards. Group interventions were less effective than individual interventions. Education about dementia by itself, group behavioral therapy and supportive therapy were not effective caregiver interventions.

Introduction

The number of people with dementia is increasing with significant public health implications including the linked psychological morbidity of caregivers (CG) in terms of burden, general psychological distress and depressive symptomatology (Pinquart and Sorensen, 2003). In one study, for example, 47% of those caring for someone with dementia were depressed compared to only 3% caring for someone with physical health problems (Livingston et al., 1996). This morbidity is associated with care breakdown and institutionalisation of the care recipient (CR) (Brodaty et al., 1993). A meta-analysis of psychological interventions to help CGs of older people with physical ailments or dementia suggested that interventions are less efficacious when targeted at those looking after people with dementia, and if delivered to groups rather than individuals (Sorensen et al., 2002). Thus dementia CGs may be a particularly difficult group to help, although there is evidence from meta-analysis that interventions can decrease CG psychological morbidity (Brodaty et al., 2003, Schulz et al., 2002) and that only multicomponent interventions reduce CG burden (Acton and Kang, 2001). Further good quality studies of the individual components of these interventions is needed to identify which psychologically based interventions, if any, are helpful for CGs of people with dementia (Cooke et al., 2001, Pusey and Richards, 2001, Brodaty et al., 2003). This is the first systematic review to categorise interventions, rate the study quality, evaluate all studies of such approaches on the psychological health of CGs for dementia and assess the level of confidence in the results, in order to compare the efficacy of different types of interventions using standardised criteria. This is in order to assist clinicians in the implementation of rational, evidence-based management and mirrors the approach we followed in a systematic review examining the benefits of psychological treatments for the neuropsychiatric symptoms of patients with dementia (Livingston et al., 2005).

Section snippets

Search strategy

We searched electronic databases until July 2003, reference lists from articles, the Cochrane Library and hand-searched four journals. We asked experts about additional studies (even if post-July 2003). We used search terms encompassing caregivers/carers, individual dementias and interventions. We included primary research studies with quantitative outcome measures of CG psychological health but did not include outcomes regarding the person with dementia. If a scale measured a mixture of

Results

We identified 244 references in our search, of which 62 met the inclusion criteria. References were excluded as: 74 were not primary research; 36 had qualitative outcomes; 35 reported no psychological intervention; 32 had no family CG outcome fitting the inclusion criteria and in 5 some CRs did not have dementia.

Discussion

The most important result from our study is that there is consistent, excellent evidence that iBMT for six or more sessions is efficacious both immediately and in the longer term in alleviating CG depression. There is also good evidence that iCS and gCS are effective in alleviating depression and distress immediately and for some months. These findings fit well with the results of our group's previous systematic review which found that BMT centred on changing the behavior of individual patients

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    On behalf of the Old Age Taskforce of the World Federation of Biological Psychiatry. We would like to acknowledge the particular help of Henry Brodaty and Carlos Lima. The authors are all clinicians. There is no other conflict of interest.

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