Background
Methods
Search strategy
Study selection
Inclusion criteria | Exclusion criteria |
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▪ Solely trial-based, non-modelling economic studies were included. ▪ The study design had to compare cost outcomes of non-pharmacological interventions directly targeted at persons with dementia, persons with mild cognitive impairment or the respective informal caregiver. ▪ The presence of an independent control group. ▪ No restriction was made regarding the type or stage of dementia. ▪ The studies had to be written in English or German, and published between 01.01.2010 and 31.12.2016. | ▪ Model-based economic studies were excluded. ▪ Studies evaluating organizational changes and changes in the delivery of care and support were not considered. ▪ Qualitative research, cost-of-illness studies, case studies, studies without a control group, systematic reviews or meta-analyses were excluded. ▪ Conference abstracts were not considered. |
Data extraction
Results
Study selection
Basic characteristics of the included studies
Synthesis
Physical exercise interventions
Study, country | Type of study and economic evaluation | Time horizon C: Cost H: Health outcome | Study population, Number of participants | IG: Intervention group CG: Control group | Outcome measures (measures of benefit) | Cost data; source | Perspective | Results |
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D’Amico [28] UK, 2016 | RCT CEA CUA | C: 12 weeks H: 12 weeks | Community-dwelling persons with a clinical diagnosis of dementia according to ICD-10 and one or more significant BPSD symptoms defined by the NPI as well as a caregiver willing to participate in the exercise training ▪ 131 randomized dyads ▪ 113 completed (89%) ▪ economic analysis subsample 52 dyads | IG: Dyadic exercise regimen (individually tailored walking program, for 20–30 min at least five times per week for 12 weeks, in the first 6 weeks the intervention was facilitated by a registered exercise professional) CG: CAU | Primary ▪ NPI Secondary ▪ ZBI ▪ GHQ ▪ DEMQOL-Proxy ▪ QALY | CSRI completed by the caregiver; intervention cost | (I) Health & social care perspective (II) Societal perspective | Potentially cost-effective considering behavioral and psychological symptoms, not cost-effective considering QALY gains. Mean cost difference between the groups were not significantly different over 12 weeks. This holds for both perspectives. From the societal perspective, the ICER was £421 per incremental difference in NPI score. |
Davis [33] Canada, 2013 | RCT CEA | C: 6 months H: 6 months | Community dwelling women aged 70 to 80 years; MMSE score ≥ 24; Subjective memory complaints, scored ≥6/8 on the Lawton and Brody Instrumental Activities of Daily Living scale ▪ 86 randomized participants | Three-trial arms: IG: Resistance training IG: Aerobic training CG: Balance and toning | ▪ Executive cognitive function of selective attention and conflict resolution - Stroop test | Questionnaire to assess total healthcare resource utilization completed by the PwMCI | Health care system perspective | At 6 months resistance training and aerobic training yielded in health care cost savings when compared to controls doing balance and toning exercises. |
Pitkälä [20] Finland, 2013 | RCT CEA | C: 24 months H: 12 months | Community-dwelling persons with a clinical AD diagnosis and their spousal caregivers; 96% were receiving AD medication ▪ 210 randomized dyads ▪ Cost data 24 months: n = 210 ▪ Outcome assessed at 12 months: n = 161 | Three-trial arms: IG: 1-year group-based exercise provided during visits to day care centers twice a week (1 h training) IG: 1-year tailored home-based exercise for 1 h twice a week administered by physiotherapists CG: CAU and subjects received oral and written advice on nutrition and exercise methods | ▪ Patients physical functioning: FIM ▪ Mobility: SPPB | Data on use and cost of health and social services were retrieved from central registries and medical records of both patients and caregivers. Cost of patients and caregivers were summed. | Health and social care perspective (not explicitly stated) | Deterioration in patient’s physical functioning was delayed with the tailored home-based exercise program. Both intervention groups showed a significant reduction in the number of falls. The home-based exercise was found to be administered without increasing the total health and social service costs. The group exercise may even decrease the use and costs of health and social services. |
Interventions to support and enhance cognitive function
Study, country | Type of study and economic evaluation | Time horizon C: Cost H: Health outcome | Study population, Number of participants | IG: Intervention group CG: Control group | Outcome measures (measures of benefit) | Cost data; source | Perspective | Results |
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Orgeta [27] UK, 2015 | RCT CEA CUA | C: 26 weeks H: 26 weeks | Community-dwelling PwDs of any type (MMSE ≥10) and family caregivers ▪ 356 randomized dyads ▪ 273 dyads completed the second-follow-up (76.7%) ▪ 264 dyads with complete case information for the cost analyses | IG: Home-based individual cognitive stimulation therapy administered by the caregiver up to three times a week over 25 weeks CG: CAU | Primary* ▪ Cognition: ADAS-Cog (PwD) ▪ Self-reported QoL: QoL-AD (PwD) ▪ QALY (carer) derived from the EQ-5D-3 L Secondary PwD* ▪ Quality of caregiver-patient relationship: QCPR | CSRI | (I) Health & social care perspective (II) Societal perspective | CST did neither improve cognition or QoL of PwDs, nor carers’ physical and mental health. Costs of the intervention were offset by some reductions in social care and other services. Considering the primary outcomes for PwDs, it seems that the intervention is not more cost-effective compared to CAU (from both perspectives). |
Woods [26] UK, 2012 | RCT CEA CUA | C: 10 months H: 10 months | Community-dwelling PwDs with mild or moderate dementia and a respective caregiver willing to participate ▪ 488 randomized dyads ▪ 350 dyads completed the study | IG: Weekly reminiscence groups attended by both caregiver and patient over a period of 12 weeks followed by monthly maintenance sessions for a further 7 months CG: CAU | Primary (CEA) ▪ QoL-AD (PwD) ▪ GHQ of caregivers Secondary (CUA) ▪ EQ-5D of both caregiver and PwD ▪ EQ-5D proxy rated by the caregivers | CSRI | Public sector, multiagency perspective (NHS and local governments) | Joint reminiscence groups for PwDs and their caregivers are unlikely to be cost-effective. Potential beneficial effects for PwDs are offset by raised anxiety and stress in their caregivers. |
D’Amico [21] UK, 2015 | RCT CEA CUA | C: 6 months H: 6 months | Persons with mild-to-moderate dementia according to the DSM-IV criteria and a score between 0.5 and 2.0 on the Clinical Dementia Rating ▪ 236 randomized participants ▪ 199 completed the second follow up at 6 months | IG: After all participants completed 7 weeks of standard cognitive stimulation therapy (CST), the intervention group received MCST for 24 weeks in addition to usual care CG: 7 weeks of standard cognitive stimulation therapy (CST) and afterwards CAU | Primary ▪ ADAS-Cog ▪ QoL-AD Secondary ▪ MMSE ▪ ADCS-ADL ▪ NPI ▪ EQ-5D-3 L (PwD self-report or proxy) ▪ QoL-AD (proxy) ▪ DEMQOL | CSRI completed by caregivers or center workers | (I) Health & social care perspective (II) Societal perspective | Maintenance CST appeared cost-effective when looking at self-rated QoL and cognition (MMSE) and proxy-rated QoL as secondary outcomes. CST in combination with AChEIs offered cost-effectiveness gains when outcome was measured as cognition. |
Psychological and behavioral interventions
Study, country | Type of study and economic evaluation | Time horizon C: Cost H: Health outcome | Study population, Number of participants | IG: Intervention group CG: Control group | Outcome measures (measures of benefit) | Cost data; source | Perspective | Results |
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Spector [25] UK, 2015 | RCT cost analysis | C: 6 months H: 6 months | Community-dwelling patients with mild-to-moderate dementia and anxiety (N = 50) ▪ 50 randomized participants ▪ 38 participants completed second follow-up assessment | IG: Ten-session cognitive-behavioral therapy for anxiety in dementia CG: CAU | Primary ▪ RAID Secondary ▪ CSDD ▪ QoL-AD (self-reported) ▪ NPI ▪ HADS ▪ MMSE ▪ QCPR | CSRI | Health and social care perspective | Significant improvements in depression. CBT found to be cost neutral. |
Laakkonen [24] Finland, 2016 | RCT CEA | C: 24 months H: 9 months | Community-dwelling PwDs (shortly after the diagnosis) and their spouses ▪ 136 randomized dyads ▪ 134 completed the follow-up assessment after 9 months | IG: Self-management group rehabilitation for PwDs and their spouses; enhancement of self-efficacy and problem solving skills CG: CAU and the study nurses gave participants in the control group oral and written advice on nutrition and exercise | Primary ▪ HRQoL: 15D (PwD) ▪ RAND-36 (caregiver) ▪ SCQ | Resource utilization of health and social services was retrieved from central registers and medical records | Health and social care perspective | Improvement of caregivers’ HRQoL and the cognitive function of the PwD without increasing total costs. |
Søgaard [22] Denmark, 2014 | RCT CUA | C: 3 years H: 3 years | Community-dwelling persons with a diagnosis of AD, mixed AD diagnosis and vascular disease or dementia with Lewy bodies within the past 12 months, MMSE ≥20 and a primary caregiver willing to participate ▪ 330 randomized dyads ▪ 195 dyads in the complete case analysis | IG: Intensive, multicomponent, semi-tailored psychosocial intervention program with counselling, education and support CG: The control group was informed about available support programs in their respective community | ▪ Patient: EQ-5D proxy-rated by the caregiver ▪ Caregiver: self-rated EQ-5D | RUD and register data from national registries | Societal perspective | The psychosocial intervention is unlikely to be cost-effective since it did not generate additional QALY and it led to higher average usage of informal care. The provision of the intervention was estimated to incur an additional average cost of €3,401. Non-statistically significant cost savings were observed for the healthcare sector and for nursing home placements, whereas higher costs were observed for informal care. |
Occupational therapy
Study, country | Type of study and economic evaluation | Time horizon C: Cost H: Health outcome | Study population, Number of participants | IG: Intervention group CG: Control group | Outcome measures (measures of benefit) | Cost data; source | Perspective | Results |
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Gitlin [23] US, 2010 | RCT CEA | C: 4 months; H: 4 months | Caregivers of PwDs with a MMSE score < 24, mild to moderate dementia and showed at least one behavioral symptom; Caregivers living with the PwD, providing at least 4 h of daily care ▪ 60 randomized dyads | IG: Tailored home-based activity program delivered by occupational therapists with 8 sessions of occupational therapy over 4-month consisting of the assessment of patient’s abilities, caregiver communication & home environment. Development of three activities tailored to patient capabilities. CG: Wait-list control group that did not receive any study-related contact. | Two items from the Caregiver Vigilance Scale: (1) number of hours per day the caregiver is actually doing things for the PwD (2) number of hours per day the caregiver feels the need to be there or on duty to care for the PwD | Total average intervention cost | Perspective of the individual caregiver | Intervention caregivers saved: (1) one extra hour per day doing things for the PwD at a cost of $2.37/day (2) one extra hour per day feeling the need to be there or on duty to care for the PwD at a cost of $1.10/day. |
Psychosocial interventions mainly targeted at the caregiver
Study, country | Type of study and economic evaluation | Time horizon C: Cost H: Health outcome | Study population, Number of participants | IG: Intervention group CG: Control group | Outcome measures (measures of benefit) | Cost data; source | Perspective | Results |
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Joling [29] Netherlands, 2013 | RCT CEA CUA | C: 12 months H: 12 months | Caregivers of community-dwelling PwD and at least one other family member or friend available to take part in the family meetings ▪ 192 randomized caregivers ▪ 87 participants with complete cost and primary outcome data at the follow-up assessment at 12 months | IG: Family meetings intervention with six in-person counselling sessions led by trained counselors with a background in a health care related profession. The family meetings aimed to provide psycho-education, problem solving techniques and to mobilize the existing family networks. CG: CAU | ▪ MINI caregiver ▪ PwD: proxy-rated SF-12 ▪ Caregiver: SF-12 ▪ PwD QALY ▪ Caregiver QALY ▪ PwD-caregiver dyad QALY | ▪ Cost diaries and interview assessments to measure informal care time ▪ Direct and indirect costs of both the caregiver and patient were gathered. | Societal perspective | Family meetings cannot be considered as cost-effective compared to CAU. No significant differences in total costs between both groups were observed. Ambulatory care costs among caregivers in the intervention group were higher compared to the CAU group. No between groups differences in QALY for both patients and caregivers or on clinical mental parameters for caregivers were found. |
Dahlrup [30], Sweden, 2013 | Quasi-experimental cohort study, CUA | C: up to 60 months H: up to 60 months | Family caregivers of recently diagnosed community-dwelling PwDs ▪ 308 randomized participants | IG: Psychosocial intervention composed of education and provision of a support group for family caregivers of PwDs (5 weekly counselling sessions, followed by a group discussion). Caregivers who were unable to join group sessions received individual meetings. CG: CAU | ▪ Caregivers HRQoL: EQ-5D (two subsets were considered: PwDs still residing in the community and PwDs who had moved to a nursing home) | Municipality registers provided data on resource use in terms of home help service and cost of formal care for PwDs and caregivers | Not explicitly stated. | No group difference in cost was found. Significant higher HRQoL for caregiving children and grandchildren receiving the intervention. |
Wray [31] US, 2010 | RCT cost analysis | C: 12 months | Caregivers of community-dwelling veterans with at least a moderate level of dementia who are dependent on their respective caregiver in performing ADL and IADL. Caregivers were spousals, experiencing at least a moderate level of caregiver strain ▪ 158 randomized caregiver-veteran dyads | IG: 10-week telephone support group for caregivers of veterans with dementia. The Telehealth Education Program is composed of caregiver education and support CG: CAU | Not stated. | Health care utilization and cost data derived from the veterans Information System Technology Architecture databases. Data included inpatient, nursing home, outpatient and outpatient pharmacy files. | Not explicitly stated. | The telephone support groups yielded in significant short term average cost savings of $2,768 per patient at 6 months as compared with CAU, however these were not maintained at 12-month. |
Van Houtven [32] US, 2012 | RCT cost analysis | C: 12 months O: 12 months | Caregivers of person’s with AD or Parkinson’s disease ▪ 187 randomized dyads | IG: Caregiver skill training over a 24-week period. In-home or telephone-based sessions delivered by a trained nurse CG: Over the same 24-week period the wait-list comparison got social phone contacts administered by persons trained for the provision of socially supportive conversations by phone | Not reported. | Out-of-pocket costs of caregivers assessed by the caregiving assistance measure (including service use of the care recipient & the caregiver himself) | Individual caregiver perspective | Caregiver skill training yielded in clinically and statistically significant reduction in caregivers’ depression and improved caregiving mastery. It increased the likelihood of caregivers to experience any out-of-pocket expenditure (OOP) by 26% over usual care; overall OOP costs were not significantly altered. |
Livingston [19] UK, 2014 | RCT CEA CUA | Short-term C: 8 months H: 8 months Long-term C: 24 months H: 24 months | Family caregivers providing support at least once a week to community-dwelling PwD ▪ 260 randomized dyads | IG: Manual-based individual coping intervention for caregivers delivered in 8 sessions by supervised psychology graduates CG: CAU | Primary ▪ Carer: HADS-T Secondary ▪ Carer: QALY derived from the EQ-5D and societal weights | CSRI | Health and social care perspective | The intervention was clinically effective in terms of carers’ anxiety and depression as well as their quality of life. Moreover it was found to be cost-effective in the short and long term when considering caregiver-related cost. |
Livingston [18] UK, 2014 | RCT CEA CUA | Short-term C: 8 months H: 8 months Long-term C: 24 months H: 24 months | Family caregivers providing support at least once a week to community-dwelling PwD ▪ 260 randomized dyads ▪ 227 dyads completed 8 months follow-up session ▪ 196 randomized dyads completed 24 months follow-up session | IG: Manual-based individual coping intervention for caregivers delivered in 8 sessions by supervised psychology graduates CG: CAU | Carer: HADS-T Carer: QALY derived from the EQ-5D and societal weights Patient: QoL-AD (proxy-rated) | CSRI | Health and social care perspective | The intervention was clinically effective and cost-effective in the short and long term when considering carer plus PwD costs. |