Author
CASSIE Kimberly M.; SANDERS Sara;
Familial caregivers of older adults.
Journal citation/publication details
Journal of Gerontological Social Work, 50(supplement 1), 2008, pp.293-320.
Summary
This review of three meta-analyses and primary research studies on individual, group, multi-modal and technology-based interventions demonstrates some evidence of effective methods for reducing the stress and burden associated with caring for older members of the family. However, future research needs to cover more diverse populations of both carers and care recipients, employ longitudinal designs and involve a greater range of disciplines.
Context
Family carers of older people with dementia or other conditions are at heightened risk of burden, stress, depression and a range of other mental and physical health problems. Many may receive medication for one or more of these problems, but psychosocial interventions may also be needed to relieve the difficulties they face.
Methods
What sources were used?
The following databases were searched: Academic Search Premier; CINAHL (Cumulative Index to Nursing and Allied Health Literature); the Cochrane Library; PsycINFO; and PubMed.
What search terms/strategies were used?
‘Several search terms were used including’: caregivers; older adults; dementia; interventions; evidence-based treatments; meta-analysis. It is clear, however, that these were not all combined in one search strategy because the review is not limited to meta-analyses and the searches delivered over 5,000 studies.
What criteria were used to decide on which studies to include?
Eligible studies were published in the past 20 years. Clinical drug trials were excluded, and the review was limited to meta-analyses of randomised controlled trials, and well designed controlled trials with or without randomisation.
Who decided on their relevance and quality?
No details of the yield from the searches, or subsequent relevance assessment are given. All reviews in this issue of the Journal of Gerontological Social Work judged the quality of evidence on the basis of a common framework: meta-analysis or systematic review of all relevant randomised controlled trials (RCTs) (Level I); at least one properly designed RCT (Level II); well designed controlled but non-randomised studies (Level III); non-controlled studies (Level 4a); and consensus reviews of expert opinion based on clinical experience or reports of expert committees (Level 4b).
How many studies were included and where were they from?
Sixteen studies were reviewed and are summarised in Tables 1-5. Geographical settings are not reported.
How were the study findings combined?
The review is narrative, with the findings grouped according to treatment mode.
Findings of the review
Individual interventions
Four studies of individual interventions for carers of dementia patients were identified. Two explored the Progressively Lowered Stress Threshold (PLST) model, a psychoeducational approach that involves the creation of an individualised care plan, education in environmental modifications, and referral to community support services. The other two studies in this group explored the effect of education in behavioural management techniques, and of an environmental skill-building programme designed to help carers modify the home to minimise memory-related behaviour problems. Overall, the individual interventions were associated with reduced carer depression, fatigue and tension, and improved management of the behaviour of family members with dementia.
Group interventions
The four group intervention studies focused on support groups for frail elderly people. These reported reduced rates of institutionalisation for care recipients, improved psychological functioning among carers (in respect of anxiety and depression), increased carer knowledge of community resources, and increased social support.
Multi-modal interventions
Two of the three multi-modal interventions assessed the impact of combinations of counselling, support groups and consultations on carer outcomes and care recipient placement; skills training in problem solving, cognitive restructuring and behaviour management. The third compared the effects of individual and group interventions on carer well-being. Overall, these proved effective in reducing carer stress and burden, increasing carer knowledge, improving carer attitudes and reducing the likelihood of care recipients being institutionalised.
In addition to these primary research studies, three meta-analyses that examined a wide range of interventions were reviewed. The first found that group interventions were less effective at reducing carer burden, depression and well-being than were individual and multi-modal interventions. The second found that one intervention (social skills training) produced a statistically significant reduction in carer burden, while interventions involving more frequent contact resulted in a statistically significant reduction in physiological distress. Psychosocial outcomes for carers were more likely to be improved by interventions that involved both the carer and care recipient, than by those involving the carer alone. The final meta-analysis looked at strategies to increase carer and care recipient knowledge about stroke and stroke-related services. Interventions that included the provision of educational materials alone were less effective than those which also included educational provision in the form of lectures or discussion.
Technology-based interventions
Of the two studies in this group, one investigated the use of a Computer Telephone Integrated System which enables online discussion, conference calls, voice messaging and other ways of keeping in touch and accessing community resources. The other examined a computerised telephone voice response system to provide dementia carers with weekly consultations, information and a personal voice mailbox to communicate with a professional and other carers. Although the second intervention produced minimal effects, technology-based interventions do seem to have potential for reducing carer burden, depression, anxiety and bother.
Authors' conclusions
Although carers’ needs and problems have ‘received a good deal of clinical attention’, more complex research, sampling and analytical methods are needed to strengthen the evidence base. There needs to be more research on non-White populations, more use of longitudinal designs, an extension of coverage beyond those caring for people with dementia, and the greater involvement of interdisciplinary teams.
Implications for policy or practice
No specific implications are discussed. The paper concludes with a ‘treatment resource appendix’ directed at American social workers.