Running head: PSYCHOEDUCATIONAL INTERVENTIONS

Effects of Psychoeducational Programs On Burden of Dementia Caregivers Name NURS 209 Professor Name School of Nursing University

PSYCHOSOCIAL INTERVENTIONS Effects of Psycho-educational Programs On Burden of Dementia Caregivers

Dementia is a progressive and debilitating neurological disorder that is manifested by decline in cognitive functioning, impaired memory, changes in personality, depression, and confusion. The causes of dementia include various diseases and infections, strokes, head injuries, drugs, and nutritional deficiencies. In 1991, dementia affected approximately 8% of the Canadian elderly population and was predicted to affect three-fold more individuals by 2031 (Canadian Study of Health and Aging Working Group, 1994). Additionally, the probability of suffering from dementia increases with age as the highest rates are among those over 85 years. The implications of these statistics demand great concern for the impact of dementia on those suffering from it, their families, and the health care system. While the poor prognosis for those diagnosed with dementia is likely to result in progressive deterioration of cognitive function and health, nurses still have the ability to improve quality of life for patients and their family. Dementia is complex in that it also involves psychiatric and behavioural disturbances that are devastating to both patients and their family caregivers. The best practice guideline provided by the Registered Nurses Association of Ontario (RNAO) states that providing therapeutic care to patients involves recognition of the patients existing abilities, interest, previous occupation, and values to enhance the effectiveness of interventions that strive to maintain functional capacity (RNAO, 2004). Another recommendation emphasizes need for

partnership between family caregivers and health care professionals (RNAO, 2004). Undoubtedly, the role of family caregivers cannot be underestimated as they have a great impact on the effectiveness of interventions with patients suffering from dementia. Given the phenomenal amount of time and energy put into to providing care to relatives, there is a growing recognition of

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the social, financial, health, and psychological consequences of caregiving (Lorensini & Gates, 1997). In view of the significant role of family caregivers, the health care system has responded to the need for caregiver support by integrating psychosocial and community-based programs for caregivers into the care for dementia patients. Generally, psychoeducational interventions include information about the disease, organization of care, practical advice, skills training for the handling of behavioural problems of the patient, decision-making, emotional repercussions on the caregiver, and advice about the self-care (Brodaty et al., 1997; Burns et al., 2003; Teri et al., 2003; Mittelman et al., 2004). Research is providing evidence for positive outcomes for both caregivers and dementia patients such as improved caregiver health, decreased caregiver burden, and delay in institutionalization of elderly suffering from dementia (Mittelman et al., 2004). Moreover, research suggests that psychoeducational intervention may be superior to other psychosocial programs due to the development of skills for coping rather than just educating (Sorensen, Pinquart, & Duberstein, 2002). Nurses need to be knowledgeable on providing caregivers with adequate resources to aid in achieving the caregiver role. It is also imperative to examine the research with regards to the effectiveness of psychosocial interventions. This paper will discuss whether family caregivers of elderly (65 years and older) persons with dementia receiving psychoeducational intervention later experience decreased caregiver burden when compared to those who receive standard care. Search strategy The approach to search for evidence on the research question focused on three aspects of the question: dementia, caregiver burden, and psychoeducational interventions. The CINAHL and

PSYCHOSOCIAL INTERVENTIONS MEDLINE databases were searched using the following categories in the search strategy (see Appendix): #1 dementia (nursing, prevention &control, therapy) #2 psychoeducational or psycho-educational #3 caregivers and psychological stress #1 and #2 and #3

The results were then filtered for Level II evidence such as randomized control trials that looked at the effects of psychoeducational interventions on caregiver burden in families dealing with dementia. Synthesis of evidence Interventions are best put to the test with randomized controlled trials that compare individuals undergoing an intervention to those that receive standard care. The four articles presented here provide findings of such research designs that involved caregivers of dementia patients randomly allocated to a group that was subjected to a psycho-educational intervention or not. In all cases, intervention and control groups included randomly assigned caregivers of patients that had a diagnosis of dementia and were cared for at home. The effects of the psychosocial support was assessed at a certain time point after the period of intervention, with tools that looked at variables that could indicate caregiver burden such as coping strategies, quality of life, level of distress, and perceived health. Differences between groups were then attributed to the effects of the psycho-educational intervention. While effectiveness of interventions for caregivers has been examined with regard to outcomes for both the caregiver and the cared, the studies retrieved in this analysis have focused on specific outcomes relevant to caregiver well-being. Interventions can make a difference to

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caregivers, with some of the reported benefits of interventions including reduced caregiver stress and burden (Ostwald, Hepburn, Caron, Burns, & Mantell, 1999; Martin-Carrasco et al., 2009), improved quality of life and rate of psychiatric morbidity (Martin-Carrasco et al., 2009), improved mastery of coping strategies and decreased distress (Hepburn, Lewis, Tornatore, Sherman, & Bremer, 2007) and improved self-efficacy leading to depression or anger management (Coon, Thompson, Steffen, Sorocco, & Gallagher-Thompson, 2003). Some studies also looked at the outcomes related to the care receivers well-being and found no improvement in disruptive behaviour (Ostwald et al., 1999), decline in cognitive status of care recipients (Ostwald et al., 1999), and decreased visits for a specialist or primary care provider (Martin-Carrasco et al., 2009). Results from some of these studies have led to discussion of concepts that may be at play in the beneficial effects of psychoeducational interventions. Coon et al. (2003) explained that caregivers' improved self-efficacy in controlling upsetting thoughts accounted for the reduced distress and improved coping measured among participants post-intervention. This study also discussed the role of moderators that represent characteristics of participants that can have an effect on the extent to which an intervention will benefit them. For example, caregivers experiencing high levels of distress are likely to benefit more from the psychoeducational intervention compared to those that are experiencing lower levels of distress. Another interesting aspect of psychoeducational intervention is the idea of using it as a preventative measure for all caregivers regardless of the levels of distress they experience. Prevention of increased caregiver distress has been evidenced in a three year old randomized control trial in which a multifaceted psychoeducational intervention involving educating, training of stress management skills, and building of family support showed lower caregiver burden and

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lower levels of depression in treatment group as opposed to an increase in the control group (Ostwald et al., 1999). Limitations such as high drop-out rates (Martin-Carrasco et al., 2009; Hepburn et al., 2007) in the studies indicate a need to investigate reasons for low compliance to determine if accessibility of psycho-educational programs can be improved. It is important to realize that samples represented by these randomized control trials are not as representative since participants are voluntary. This implies exclusion of caregivers that may have language barriers or cannot make time to come to the sessions due to other commitments. Wide variations exist in research design methods and the various factors that can be measured to determine decrease in caregiver burden. Many studies, even as they are well designed and implemented, cannot be compared due to difference in tools used to measure outcomes, differences in characteristics of caregiver and dementia patient samples, and difference in psychoeducational interventions being studied. Nonetheless, thus far many studies have found that such multi-dimensional psychosocial interventions are helpful to caregivers as they adapt to the caregiving role. Conclusion There is currently a great interest in the effects of psychotherapy and psychoeducational programs for family caregivers of dementia patients. The studies presented here have shown beneficial effects in multiple aspects of caregiver burden including caregiver knowledge and skills, as well as, psychological well-being. Nonetheless, the existing research must be built upon with more rigid methods and representative samples to ensure that potential confounding factors are accounted for and results are not biased. Meanwhile, health care providers can work towards ensuring caregivers of dementia patients have access to the appropriate resources and cognitive-

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behavioural interventions that can help alleviate the burden of looking after the needs of their family and themselves.

PSYCHOSOCIAL INTERVENTIONS References Brodaty, H., Green, A., & Koschera, A. (2003). Meta-analysis of psycho-social interventions for caregivers of people with dementia. Journal of the American Geriatrics Society, 51, 657-664. Burns, R., Nichols, L.O., Martindale-Adams, J., Graney, M.J. & Lummus, A. (2003). Primary care interventions for dementia caregivers: 2-year outcomes from the REACH study. Gerontologist, 43, 547-555. Canadian Study of Health and Aging Working Group. (1994). Canadian Study of Health and Aging: study methods and prevalence of dementia. Canadian Medical Association Journal, 150, 899-913. Coon, D., Thompson, L., Steffen, A., Sorocco, K., & Gallagher-Thompson, D. (2003). Anger

and depression management: psychoeducational skill training interventions for women caregivers of a relative with dementia. Gerontologist, 43(5), 678-689. Hepburn, K., Lewis, M., Tornatore, J., Sherman, C.W., Bremer, K.L. (2007). The Savvy Caregiver program: the demonstrated effectiveness of a transport-able dementia caregiver psychoeducation program. Journal of Gerontological Nursing, 33,30-36. Lorensini, S., Bates, G.W. (1997). The health, psychological and social consequences of caring for a person with dementia. Australian Journal on Ageing, 16(4), 198-202. Martin-Carrasco M., Martin, M.F., Valero, C.P., Millan, P.R., Garcia, C.I., Montalban, S.R., ... Vilanova, M.B. (2008). Effectiveness of a psychoeducational intervention program in the reduction of caregiver burden in Alzheimers disease patients caregivers. International Journal of Geriatric Psychiatry, 24, 489-499.

PSYCHOSOCIAL INTERVENTIONS Mittelman, M.S., Roth, D.L., Coon, D.W., & Haley, W.E. (2004). Sustained benefit of supportive intervention for depressive symptoms in caregivers of patients with Alzheimers disease. American Journal of Psychiatry, 161, 850-856. Ostwald, S., Hepburn, K., Caron, W., Burns, T., & Mantell, R. (1999). Reducing caregiver burden: a randomized psychoeducational intervention for caregivers of persons with dementia. Gerontologist, 39(3), 299-309. Registered Nurses Association of Ontario. (2004). Caring Strategies for Delirium, Dementia and Depression in Older Adults. Registered Nurses Association of Ontario. Retrieved from www.rnao.org/bestpractices Sorensen S, Pinquart, M. & Duberstein, P.(2002). How effective are interventions with caregivers? An updated meta-analysis. Gerontologist 2002;42(3):356-72 Teri, L., Gibbons, L.E., McCurry, Logsdon, R.G., Buchner, D.M., Barlow, W.E., ... Larson, E.B. (2003). Exercise Plus Behavioral Management in Patients With Alzheimer Disease: a Randomized Controlled Trial. Journal of American Medical Association, 290, 2015-2022.

PSYCHOSOCIAL INTERVENTIONS Appendix Search Strategy in MEDLINE and CINAHL