An intervention tailored to meet individual needs and address the
multifaceted aspects of caring for a relative with dementia can improve
caregivers' quality of life and reduce the likelihood they will develop
depression, a new study has found.
The large multisite trial, titled Resources for Enhancing Alzheimer's
Caregiver Health II (REACH II), was coordinated by the University of
Pittsburgh and is the first randomized, controlled trial to look
systematically at the effectiveness of a multicomponent caregiver intervention
provided to ethnically diverse populations.
In REACH II, the researchers found the intervention was effective across
the range of racial and ethnic groups studied. The most significant
improvements were seen among Hispanic and white caregivers. In African
Americans, the intervention was significantly effective overall, however,
within subgroups the intervention was only significant in the subgroup of
spouse caregivers, not among caregivers who were caring for a relative other
than their husband or wife.
The intervention was based on findings from the first phase of the study,
REACH I, in which the team tested multiple caregiver interventions to identify
which were the most promising. In that study, researchers found that different
caregivers experienced similar problems at differing levels of intensity. As a
result, they recognized a need to develop an intervention that could address
the most troublesome problems for each individual caregiver.
Results of REACH II appear in the November 21, 2006, Annals of Internal
Medicine. The work was funded by grants from the National Institute on
Aging (NIA) and National Institute of Nursing Research (NINR).
REACH II enrolled 642 people who were primary caregivers for a relative
with Alzheimer's disease or a related disorder at sites in five U.S. cities.
Hispanics, whites, and African Americans were evenly represented. More than
200 participants in each ethnic group were randomized to receive either the
study intervention or a minimal intervention designed as a control.
Over the course of the study, trained project staff (with at least a
bachelor's degree and completion of specialized project training) visited the
caregivers in the intervention group at home nine times, talked with them
during three half-hour telephone calls, and offered five structured telephone
Project staff employed strategies with the caregivers that included
information sharing, instruction, role playing, problem solving, skills
training, stress-management techniques, and telephone support groups. Based on
the intensity with which each caregiver experienced problems in five key
quality-of-life areas, the intervention was tailored to meet his or her
individual needs, providing the skills necessary to cope better with the
stress of giving round-the-clock care and manage troublesome behaviors in both
the patient and himself or herself.
Before the services began and six months later, researchers assessed
caregivers' quality of life overall and in five quality-of-life areas:
depressive symptoms, burden of caregiving (such as the level of stress),
engagement in self-care activities (such as getting rest or seeing a doctor
when needed), level of social support available, and problem behaviors
exhibited by the person with dementia.
The investigators also measured the prevalence of major depression among
the caregivers and collected data on whether the care recipients had been
placed in institutions during the six-month study period.
Those in the control group received a packet of dementia education
materials, and staff completed two brief "check-in" telephone
Approximately 4.5 million patients with Alzheimer's disease currently live
at home in the United States. The study noted that previous surveys and
clinical research suggest that about 75 percent of those patients are cared
for by family members, according to the researchers.
"Caring for a loved one with dementia presents a number of challenges
that can seriously compromise the caregiver's quality of life," Richard
Schulz, Ph.D., a professor of psychiatry at the University of Pittsburgh
School of Medicine, and REACH II's corresponding author, said in a press
release. "For the millions of Americans who care for a loved one at
home, an intervention that can improve their quality of life and lessen the
burden of caregiving can make meaningful differences in their ability to
better care both for themselves and their loved ones."
Caregivers of all ethnic backgrounds experienced significant improvements
in quality-of-life measures. Large and clinically important improvements were
found for 45 percent of Hispanic caregivers, 40 percent of white caregivers,
and 28 percent of African-American caregivers in the intervention group,
compared with 7 percent, 13 percent, and 11 percent among Hispanics, whites,
and African Americans, respectively, in the control group.
For Hispanics, the intervention was most effective in reducing depressive
symptoms in caregivers and improving their ability to manage problem behaviors
in the patient. Among whites, the greatest impact was in the area of social
support, with significant increases in number of social contacts with
relatives or friends, and increased satisfaction in social support overall.
Among African Americans, there were positive effects in reducing caregiver
burden and improving self-care among spouse caregivers.
The research also showed that following the program, the rate of major
depression (measured using the Center for Epidemiologic Studies Depression
Scale) was significantly lower among caregivers in the intervention group
compared with those in the control group (12.6 percent and 22.7 percent,
respectively). The rate of institutionalization of loved ones being cared for
was lower in the intervention group than the control group (4.3 percent vs.
7.2 percent), but this difference was not statistically significant.
The researchers also collected data on how study participants viewed the
intervention. Caregivers in the intervention group reported that taking part
in the program helped them feel more confident in working with the patient,
made life easier for them, improved their ability to care for the person with
dementia, improved the patient's life, and helped them keep the patient at
home—potentially delaying the admission of the patient to a skilled
nursing facility. Many in the control group also said they benefited"
some" or "a great deal" from participating in the
study, suggesting that even minimal support and attention may be helpful to
"Family members and friends provide most of the care for millions of
people with dementia who live at home, often facing challenges that can
seriously compromise their own quality of life," noted NIA Director
Richard Hodes, M.D. "REACH II tells us that a well-designed, tailored
intervention can make a positive, meaningful difference in caregivers'
"This important research demonstrates that the intervention can
readily benefit the diverse communities of caretakers who provide care to
individuals with Alzheimer's disease," said NINR director Patricia
Grady, Ph.D. "It also underscores the substantial cost that caregivers
face—financially, physically, spiritually, and emotionally—and
helps to illustrate why caregiving research is a priority for NINR and
Sidney Stahl, Ph.D., chief of the Individual Behavioral Processes Branch
within NIA's Behavioral and Social Research Program, added that based on the
current study, the REACH program looks promising for widespread community use,
especially if the outcomes are replicated by other researchers and the program
proves cost-effective when compared with alternatives.
An abstract of "Enhancing the Quality of Life of Dementia
Caregivers From Different Ethnic or Racial Groups: A Randomized Controlled
Trial" is posted at<www.annals.org/cgi/content/abstract/145/10/727>.▪