DEMENTIA ALZHEIMERS CAREGIVERS: A

COMPREHENSIVE REVIEW OF
INTERVENTIONS AND THERAPY
Sean Sandag
Wake Forest University
November 12, 2012
DEFINITION
The Diagnostic and Statistical Manual-IV-TR characterizes Dementia as the
development of multiple cognitive deficits (including memory impairment) that are due
to the direct physiological effects of a general medical condition, to the persisting
effects of a substance, or to multiple etiologies (American Psychiatric Association
(APA), 2002, p. 147).
More specifically to Alzheimers, the onset of Dementia of the Alzheimers Type is
gradual and involves continuing cognitive decline (APA, 2002, p. 148).
Diagnosis of Alzheimers can only be made after other etiologies are ruled out
including:
Central nervous system conditions (i.e. Parkinsons Disease)
Systematic conditions (i.e. hypothyroidism, HIV infection)
Substance abuse or head trauma
Warning signs and symptoms of Dementia Alzheimers:
Memory loss that disrupts daily life
Challenges in planning or solving problems
Difficulty completing familiar tasks at home, at work, or at leisure
Confusion with time or place
Trouble understanding visual images or spatial relationships
Changes in mood and personality
No treatment is available to stop or slow the Dementia of the Alzheimers type (Theis
& Bleiler, 2012).











SIGNIFICANCE/ROLE OF FAMILY CAREGIVERS

5.4 million people have AD.
AD is the sixth leading cause of death
in the United States and the fifth
leading cause of death in Americans
age 65 years and older.
(Theis & Bleiler, 2012)
In 2011, the average annual cost of a private nursing home room was $87,235.
This amounts to $239 a day.
In 2011, more than 15 million family members and other unpaid caregivers
provided an estimated 17.4 billion hours of care to people with AD.
The physical and emotional impact of caregivers was shown to cause $8.7
billion in additional health care costs (Theis & Beiler, 2012).
Caregiver Risks:
chronic disease and adverse health related physiological change which could result in
death
hypertension, reduced immune function, coronary heart disease, cardiovascular
disease
high amount of stress induced on caregivers can elicit sleep deprivation, personality
change, and loss of judgment




METHODOLOGY
Search conducted over two weeks using the access to databases
provided by the Wake Forest Z. Smith Reynolds Library.
DSM-IV-TR
Databases searched: PubMed, PsycInfo, ERIC
Key words searched separately and together: Dementia Alzheimers,
caregivers, interventions, counseling, mindfulness, Teasley, Segal,
therapy, caregiver needs, self-efficacy
Criteria of search:
Dementia of the Alzheimers type
Articles published from year 2000 to present
Studies in which caregivers were limited to unpaid family members, as opposed to paid caregivers
working privately or within institutions
Calling Dr. Clarke








RESULTS- CAREGIVER NEEDS
Wackerbarth and Johnson (2002) identified essential need for
caregivers is information including:
respite and nursing home care
services to help with caregiving
assistance from health professionals
support groups
legal protection
assistance with constant supervision
educational and social support
health plan coverage and best available care
Support needs that were most important to caregivers included
support for the one diagnosed with AD rather than support for
the caregivers themselves
Need for information greater than caregiver support needs

RESULTS- INTERVENTIONS AND THERAPY
Counseling/Group Therapy study by Gaugler, Roth, Haley, &
Mittelman (2008)
Experimental study conducted on 406 spouse caregivers over 9.5 years.
Six individual and family counseling sessions and ad hoc counseling given
based on caregiver needs of information.
Experimental and control experienced immediate relief of burden symptoms
upon institutionalization, but the experimental group had lower symptoms
before and lasted long after.
Counseling Combined with Pharmacotherapy study by Mittelman,
Brodaty, Wallen, & Burns (2008)
158 spouse caregivers from three countries given anti-depressant donepezil.
Experimental group given 5 individual/group counseling and unlimited ad hoc
counseling by telephone.
Beck Depression scores disparity small at first but gap continued to widen
between experimental and control group throughout five years of follow-up.
Study demonstrated effective multinational psychosocial interventions for
caregivers are achievable and practical and can provide significant benefits
when the patient is taking drugs such as donepezil.




RESULTS- INTERVENTIONS AND THERAPY
Internet-Based Therapy study by Glueckauf, Ketterson,
Loomis, and Dages (2004)
Alzheimers Caregiver Support Online also known as AlzOnline
21 participants completed six 45-minute live, interactive classes
Results showed significant improvements in caregiver self-efficacy, but little or no
change in the caregiver experience including time burden, stress and positive
caregiver appraisal
Video-Based Coping Skills study by Williams et al. (2010)
116 family caregivers given five weeks of training through two video modules per
week plus weekly coaching phone call
The video modules consisted of coping techniques and ways to handle stressful
situations
Improved psychological and first known physiological improvement
Exercise study by Castro, Wilcox, OSullivan, Baumann, &
King (2002)
12-month at home exercise program/four sessions per week /30 min. per session
Both the experimental and control group received nutrition wellness education
Social engagement and active participation in bettering their health may have
produced enough benefits to reduce stress.



RESULTS-SELF-EFFICACY AND MINDFULNESS
Interventions used measurements of self-efficacy to determine
the mental health of caregivers.
Self-efficacy- the belief of being able to produce desired results through
ones own actions
Positive correlation between caregiver health benefits and controlling
upsetting thoughts. (Robinowitz, 2010)
Mindfulness-teaching people to pay attention in a particular way has
benefits across a wide range of disorders (Baer, 2003).
Mindfulness study by Oken et al. (2010)
Three groups were studied for seven weeks: a.) 90-minute Mindfulness-
Based Cognitive Therapy sessions group b.) dementia education classes
group, and c.) respite only care group
RMBPC tests showed that the MBTC group and education group had
improved self-efficacy and lower stress than the respite only group.
Results did not show improvement of secondary outcomes including
mood, fatigue, salivary cortisols, and cytokines.
Enhancements of mindfulness were not observed despite MBTC
intervention.


DISCUSSION
Interventions and therapy efficacious in:
Relieving stress
Self-efficacy
Physiological benefits
Caregiver burden
Common thread of success in relieving caregiver
burden appeared to be human interaction.
All of the literature researched showed subjects
achieving benefits when having social interaction
and actively working on health, behavior solutions
or betterment of knowledge.
Example of Castro et al. exercise study





LIMITATIONS
How significant are the results?
Threshold of caregiver burden subjective/hard to define
Can they be generalized?
Needs of caregivers diverse/multifaceted
Similar study by Schultz et al.
More researchers, more time.
Narrowed clinical significance to specific criteria
Symptomology
Quality of Life
Social Significance
Social Validity
Broad range of interventions
Could have benefited from narrowing specific therapy (i.e.
person-centered)




FUTURE RESEARCH
Now that we know human interaction is crucial
What are the best interventions for specific needs?
i.e. needs of information vs. social support self-efficacy
Narrow scope of interventions
Technological interventions (i.e. internet or video-based)
Group counseling
Individual counseling types
Counseling combined with pharmacotherapy
Further narrowing of select therapy
Behavioral
Person-centered
Emotion-focused
Background-focused
Mindfulness
Formulate system to generalize results in categories
Large scale collaboration needed/use of similar stress scales



REFERENCES
American Psychiatric Association (2002). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington,
DC: Author
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and
Practice, 10(2), 125143.
Castro, C. M, Wilcox, S., OSullivan, P., Baumann, K., and King, A. C. (2002). An exercise program for women who are caring for
relatives with dementia. Psychosomatic Medicine 64(3), 458468.
Gaugler, J. E., Roth, D. L., Haley, W. E., and Mittelman, M. S. (2008). Can counseling and support reduce burden and depressive
symptoms in caregivers of people with alzheimers disease during the transition to institutionalization? Results from the New York
University caregiver intervention study. Journal of the American Geriatrics Society 56(3), 421428.
Glueckauf, R. L., Ketterson, T. U., Loomis, J. S., and Dages, P. (2004). Online support and education for dementia caregivers:
Overview, utilization, and initial program evaluation. Telemedicine Journal and e-Health 10(2), 223232.
Mittelman, M. S., Brodaty, H., Wallen, A. S., and Burns, A. (2008). A three-country randomized controlled trial of a psychosocial
intervention for caregivers combined with pharmacological treatment for patients with alzheimer disease: Effects on caregiver
depression. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry 16(11),
893904.
Oken, B. S., Fonareva, I., Haas, M., Wahbeh, H., Lane, J. B., Zajdel, D., and Amen, A. (2010). Pilot controlled trial of mindfulness
meditation and education for dementia caregivers. The Journal of Alternative and Complementary Medicine 16(10), 10311038.
Theis, W., and Bleiler, L. (2012). 2012 Alzheimers disease facts and figures. Alzheimers & Dementia 8(2), 131168.
Rabinowitz, Y. G., Mausbach, B. T., Thompson, L. W., and Gallagher-Thompson, D. (2007). The relationship between self-efficacy and
cumulative health risk associated with health behavior patterns in female caregivers of elderly relatives with alzheimers dementia.
Journal of Aging and Health 19(6), 946964.
Schulz, R., OBrien, A., Czaja, S., Ory, M., Norris, R., Martire, L. M., . . . Belle, S. H. (2002). Dementia caregiver intervention research:
In search of clinical significance. The Gerontologist 42(5), 589602.
Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (2003). Mindfulness training and problem formulation. Clinical Psychology: Science
and Practice, 10(2), 157-160.
Wackerbarth, S. B., and Johnson, M. S. (2002). Essential information and support needs of family caregivers. Patient Education and
Counseling 47(2), 95100.
Williams, V. P., Bishop-Fitzpatrick, L., Lane, J. D., Gwyther, L. P., Ballard, E. L., Vendittelli, A. P., . . . Williams, R. B. (2010). Video-
based coping skills to reduce health risk and improve psychological and physical well-being in alzheimers disease family caregivers.
Psychosomatic Medicine 72(9), 897904.