Can enhanced support for spouse-caregivers of Alzheimer's patients reduce caregiver depression and prolong the time before institutionalization?

Family members who care for patients with Alzheimer's disease often experience psychological distress. Providing spouse-caregivers with enhanced counseling and support reduced their burden of depression compared with those who received usual supportive services; this positive effect was sustained over three years on average. Alzheimer's patients whose spouses received enhanced services were cared for at home nearly a year longer before being institutionalized.

Why is this important?

Family caregivers looking after relatives with Alzheimer's disease often experience a great deal of psychological distress, which may ultimately lead to depression and compromise their caregiving ability. A recent nationwide study found that 32 percent of family caregivers of patients with moderate to severe dementia reported six or more symptoms of depression or were classified as depressed (Covinsky et al. 2003).

Interventions

Four hundred and six spouses (average age 71 years) caring for patients with Alzheimer's disease at home were randomly assigned to receive either enhanced counseling and support or usual services from the New York University Alzheimer's Disease Center.

• Each caregiver in the intervention group was assigned a counselor who provided six individual and family counseling sessions and ongoing ad hoc counseling customized to the needs of each caregiver (e.g., techniques for managing difficult patient behavior and facilitating family communication).
• Caregivers in the intervention group attended weekly support group meetings for continuous emotional support and education.
• Usual services consisted of information and advice services and access to ad hoc counseling and support groups on request (Mittelman et al. 2004).

Findings

During their first year of enrollment in the study, those receiving enhanced services demonstrated a gradual decrease in symptoms of depression, whereas those receiving usual services showed an increase in depressive symptoms. Although the difference in depression scores decreased in magnitude with increasing time, caregivers in the intervention group had significantly lower depression scores than those in the usual care group more than three years (161 weeks) after enrollment (Mittelman et al. 2004).

Among 206 caregivers enrolled during the first three-and-one-half years of the study, the median time before Alzheimer's patients were placed in a nursing home (measured at seven-and-one-half years) was almost 11 months (329 days) longer for those being cared for by caregivers receiving the intervention than by those receiving usual services (Mittelman et al. 1996). The intervention effect was greater among male caregivers (551 days) than female caregivers (244 days).

Implications

A short course of intensive counseling and ongoing support can have long-lasting effects in reducing symptoms of depression among family caregivers of Alzheimer's patients. Alzheimer's patients in the intervention group were cared for at home longer before needing institutional care, an effect predicted both by caregivers' symptoms of depression and their reaction to troublesome patient behavior—another focus of the intervention (Mittelman et al. 1996).

The sustained effects of the intervention might be attributable to its flexibility and ability to help caregivers develop long-term coping skills and resources (Mittelman et al. 2004). Wider availability of interventions such as this might improve quality of life for the 25 million families caring for Alzheimer's patients and potentially reduce the family and societal costs of care for Alzheimer's disease.

Improvement Ideas and Resources

For more information on the intervention, visit the Web site of the New York University School of Medicine, Institute for Aging and Dementia. The Alzheimer's Association provides information andresources to support caregivers.

Measure:

The New York University Spouse-Caregiver Intervention Study was a randomized controlled trial that recruited subjects through the New York University Alzheimer's Disease Center, local chapters of the Alzheimer's Association, media announcement, and physician referrals. The patient or caregiver had to have at least one other relative living in the nearby area. A total of 406 spouse-caregivers (average age 71 years) was randomly assigned to receive either enhanced counseling and support treatment or usual care. Spouse-caregivers in the intervention group were more often wives (66% vs. 55%) and had lower depression scores.

Following a comprehensive battery of questionnaires answered at baseline, caregivers were interviewed in person or by telephone every four months during the first year and every six months thereafter to assess caregiver depression status and patient dementia status. Caregiver depression was assessed using the Geriatric Depression Scale. Follow-up interviews were conducted until two years after the death of the patient or until caregivers refused or were no longer able to participate. The first graph represents predicted values of the depression scores, controlling for covariates, using random effects growth curve modeling. Caregivers' mean-centered baseline depression scores and gender were included as covariates in the model to equalize rates at baseline. The best-fitting longitudinal change pattern was selected for the first year (logarithmic model) and follow-up years (linear model) (Mittelman et al. 2004).

The median time before nursing home placement is a weighted average of Kaplan-Meier survival estimates for men and women for 206 patients enrolled during the first three-and-one-years of the study, measured in mid-1995. A Cox proportional hazard model indicated that intervention group caregivers were two-thirds as likely as control group caregivers to place their spouses in a nursing home (Mittelman et al. 1996).

Limitations:

The cost-effectiveness of the intervention was not measured. Usual care might be more intensive than support services typically available to Alzheimer's caregivers, which would underestimate the effect of the intervention.

Source:

The New York University Spouse-Caregiver Intervention Study was based on caregiver interviews and conducted by researchers at New York University School of Medicine; the University of Alabama at Birmingham; the Institute of Aging, San Francisco; and the University of South Florida, Tampa (Mittelman et al. 1996; Mittelman et al. 2004).

References:

* Indicates source of data used in the chart(s).Covinsky, K. E., R. Newcomer, P. Fox et al. 2003. Patient and Caregiver Characteristics Associated with Depression in Caregivers of Patients with Dementia. Journal of General Internal Medicine 18 (12): 1006–14.

* Mittelman, M. S., S. H. Ferris, E. Shulman et al. 1996. A Family Intervention to Delay Nursing Home Placement of Patients with Alzheimer's Disease. A Randomized Controlled Trial. Journal of the American Medical Association 276 (21): 1725–31.

* Mittelman, M. S., D. L. Roth, D. W. Coon et al. 2004. Sustained Benefit of Supportive Intervention for Depressive Symptoms in Caregivers of Patients with Alzheimer's Disease. American Journal of Psychiatry 161 (5): 850–6.