Caregiver-Client Dynamics:
What Works
In 2000, Quayhagen and her colleagues conducted a study to determine what style of intervention is most effective in enhancing the wellbeing of both client and caregiver. The study included 103 family caregivers and their spouses with mild to moderate early-stage dementia. Pre and post measures of memory, verbal fluency, problem solving, behavioral functioning, marital satisfaction, emotional status, morale, physical health status, stress, coping, and social support were utilized. A program evaluation questionnaire was also sent as a follow-up measure two months after the intervention. The researchers strived to identify the most effective strategy for enriching the client-caregiver dynamics as well as individual effects for both parties. Both a couples and community-based group format were included. The interventions were divided into two categories: cognitive and affective. It was thought having 4 different intervention groups would allow for comparison of results.
The chart below shows the settings and type of intervention provided for each group for a duration of 8 weeks.
Home-based couples format Community-based group format
Cognitive Cognitive stimulation Early state day care
Caregiver working w/patient Supportive social environment for patient
1 hr. day/5x week inc. word including word games, exercise, outings,
vocabulary and comprehension special events.
Respite care, education and training for CG
Affective Dyadic counseling Supportive seminar
Couples counseling with problem First hour CG and client separate; next ½
identification, stress reduction, hour together. Coping w/memory issues,
anger management, conflict and strategies for daily living, self-esteem,
resolution health maintenance, social and family
relationships, legal and financial concerns
The results of the study were extremely interesting and not necessarily what the researchers had predicted.
For the cognitive stimulation group, the clients improved in verbal fluency (defined as the recall of words) and increased problem solving (the ability to generate alternatives.) Eighty percent of the participants reported enhanced communication and interaction; 55% reported mental stimulation. This group had the desired effect of improving the cognitive skills of the client. Caregivers in this group decreased depressive symptoms.
The dyadic counseling group had results in affective skills as predicted. The counseling enhanced the couple’s ability to talk freely and interact more effectively. Both the caregiver and client reported enjoyment in the program and elevated mood. The caregivers of the dyad enjoyed newly formed relationships with other caregivers as a result of the group setting. One major benefit of this intervention was the emotional involvement of the client in their own program, which increased as the intervention continued. As apathy can be one of the most frustrating symptoms of dementia for the caregiver, this positive progress in engaging the client was very encouraging. Ninety percent of the caregivers indicated the program was of value for them and 85% would recommend it to others.
The early-stage day care group had mixed results. Half of the participants reported improved communication. Sixty percent responded the client demonstrated more emotional involvement in their intervention program as it progressed. Test results showed the caregivers experienced decreased hostility, stress, and depression. This is an especially important finding and could be related to the perception of decreased role captivity in the caregiver. These results confirmed a previous study by Zarit et al (1998) that reported a decrease in depression, anger, and stress for caregivers with patients in day care.
In the fourth group, supportive seminar, the results were initially not encouraging. Both members of the dyad experienced a decrease in morale. The authors of the study felt this could be attributed to discussions about the reality of dementia and its progression. However, 56% reported they acquired insight and enjoyed building the relationship with their partner. In addition, 50% reported improved communication between the dyad. This group also exhibited a decrease in the use of negative coping strategies (including the use of diversionary activities) and less fantasy and self-blame pertaining to their situation and each other.
All groups maintained marital satisfaction and the use of problem-solving coping strategies. The number of reported physical symptoms remained constant (Quayhagen et al, 2000). Some of the limitations in the study were the inclusion of several types of dementia, the limited 8-week time frame for the intervention, and the absence of transportation to the day care group (which may have caused some attrition in sample size). This group included participants with a higher education level. Further studies are needed to support the validity of these interventions to enhance caregiver-patient interaction, insight, communication, and support.
A more recent dyadic approach is a strength-based combination of educational and cognitive rehabilitative skills training called ANSWERS – Acquiring New Skills While Enhancing Remaining Strengths (Judge et al, 2012). The caregiver and the individual with dementia are educated during six 90-minute guided sessions about dementia, types of memory, effective communication, staying active, and recognizing behaviors and emotions. Part of the second session involves an inventory that assesses each partner’s strengths. Results of this inventory are used to select, develop, and implement skills based on individual and dyadic strengths and to build upon what is currently working. One hundred fifteen dyads were included in the study; 60% were couples. At the start of the study, half of the dyads reported occasional difficult behavior and moderate difficulty with ADLs. Half of the individuals with dementia had mild to moderate AD.
The results of the study included lower levels of emotional health concerns, less relationship strain and decreased role captivity. Caregivers reported improved well-being including fewer symptoms of depression and anxiety. This illustrates the advantage of interventions that include both parties in a caregiver duo: difficult topics can be discussed in a supportive environment, skills are more consistently applied to the daily routine, and the significant cost benefit of addressing both parties at the same time. The involvement of the individual with dementia in any intervention appears crucial to its success.
What works in interventions for reducing caregiver burden and decreasing behavioral and psychological symptoms in dementia? According to the International Psychogeriatric Association Specialists Guide (2010), the most efficacious interventions for reducing caregiver burden and decreasing BPSD for which there is evidence include the following elements: addressing both the caregiver and the IWD, focusing on training and skill building in addition to education (education alone showed little or limited benefit), and individualizing strategies to address the needs of both the carer and the individual with dementia. There was some evidence for combining medications with the above factors and including information on topics of dealing with specific problem behaviors and methods for obtaining personal assistance (including telephone resources). Follow up assessments were also slightly beneficial.
Sources:
International Psychogeriatric Association. The IPA complete guides to behavioral and psychological
symptoms of dementia. Milwaukee, WI: International Psychogeriatric Association, 2010,
Judge K, Yarry S, Looman W, Bass D. Improved strain and psychosocial outcomes for caregivers and individuals with dementia: Findings from Project ANSWERS. The Gerontologist, 2012; 53(2):280-292.
Quayhagen MP, Quayhagen M, Corbeil R, Hendrix J, Jackson E, Snyder L, Bower D. Coping with dementia: Evaluation of four nonpharmacologic interventions. International Psychogeriatrics, 2000;Vol 12, No 2:249-265.
Zarit S, Stephens M. Stress reduction for family caregivers: Effects of adult day care use. The Journals of Gerontology, 1998; 53B:S267-S277.