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Evidence-based caregiver interventions in geriatric psychiatry |
Schulz R, Martire L M, Klinger J N |
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CRD summary The conclusion of this review was not explicitly stated. The authors stated that differences among studies made it difficult to draw definitive conclusions, although they did make recommendations for future research. Poor reporting of review methods, an inadequate quality assessment of the included studies and an inadequate summary of the studies make it difficult to evaluate the evidence.
Authors' objectives To evaluate psychosocial and behavioural interventions for family caregivers of psychogeriatric patients.
Searching MEDLINE, PsycINFO, CINAHL (all from inception) and evidence-based databases (from 1991), such as ACP Journal Club, the Cochrane Controlled Trials Register, the Cochrane Database of Systematic Reviews and DARE, were searched for studies published in English between January 1999 and April 2005; the search terms were reported. The reference lists of reviews and articles were also screened.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials (RCTs) were eligible for inclusion.
Specific interventions included in the reviewStudies of psychosocial family caregiver interventions were eligible for inclusion. The review defined the eligible interventions as non-medical psychological, social or behavioural interventions that involved a member of an older patient's family or both the patient and family member. Most interventions used multiple components. For caregivers of patients with dementia, most interventions included educational materials, counselling and skills training, and only involved the caregiver. Most interventions for caregivers of stroke patients provided psychosocial interventions to both the caregiver and the patient. Control interventions varied amongst the included studies (details were reported).
Participants included in the reviewStudies of family members of older adults (60 years or older) with dementia caused by Alzheimer's disease or related disorders, stroke, or psychiatric illness were eligible for inclusion. The included studies involved family members (including spouses and adult children) of patients with dementia or stroke.
Outcomes assessed in the reviewStudies that presented quantitative measures for caregiver or caregiver and patient outcomes were eligible for inclusion. In the review, problem behaviour and placement of the patient in long-term care were classified as patient outcomes, while bother or burden of the behaviours were classified as caregiver outcomes. Outcomes varied amongst the included studies (details were reported).
How were decisions on the relevance of primary studies made?The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality The authors did not state that they assessed validity. However, aspects of validity, such as the power of studies to detect differences between the interventions, were highlighted.
Data extraction The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. Between-group differences were extracted for caregivers and for patients; the results were tabulated as significant (p<=0.05) or no significant difference between groups. The outcome data for the first follow-up assessment were extracted separately for caregivers and patient outcomes.
Methods of synthesis How were the studies combined?The studies were grouped by medical condition of the older patient; information about the included studies was tabulated.
How were differences between studies investigated?Differences between the studies were apparent from the tables.
Results of the review Fifty-one RCTs (n=12,723) were included: 41 RCTs involving caregivers of patients with dementia (n=10,792) and 10 RCTs involving caregivers of patients with stroke (n=1,931).
The studies had a number of methodological limitations: high drop-out rates, lack of intention-to-treat analysis, inadequate description of the intervention, and lack of reporting whether assessors were blinded. The authors stated that about half (51%) of the studies involving caregivers of patients with dementia were underpowered and that most studies involving caregivers of patients with stroke were adequately powered to detect 'at least a medium effect size'.
Interventions for caregivers of patients with dementia.
Studies showed most consistent effects in reducing depressive symptoms, burden and anxiety symptoms among caregivers. Six studies that evaluated the same intervention across six sites reported significant positive outcomes for burden and depression associated with the Resources for Enhancing Alzheimer's Caregiver Health (REACH) programme.
Interventions for caregivers of patients with stroke.
A few studies reported significant effects on measures of mental health such as anxiety and depression. Most studies either did not report positive effects of interventions on mental health outcomes or assessed other outcomes (the attainment of skills, use of effective coping strategies and knowledge about stroke). The authors report that, one of the 'strongest' studies reported that caregivers who received instruction about common stroke-related problems and training in their management reported less burden, anxiety and depression and a higher quality of life than caregivers who received usual care. Patients in the intervention group also reporting lower anxiety and improved quality of life and a higher quality of life than those in the control group.
Cost information One RCT reported that a training programme for caregivers (instruction about common stroke-related problems and training in their management) reduced the 1-year cost of patient care by $6,532 compared with usual care.
Authors' conclusions The authors' overall conclusions were not explicitly stated. However, the authors reported that there is no single, easily implemented, consistently effective method for caregivers of older adults with late-life mood disorder, and suggested that there is a consensus that caregivers are likely to benefit from enhanced knowledge about the disease, the caregiving role, and the resources available to them. The authors also stated that the diversity of the studies made it difficult to draw definitive conclusions, and made a number of recommendations for future research.
CRD commentary The review question was clear in terms of the study design, intervention and participants; inclusion criteria for the outcomes were broad, which raises the potential for selective reporting of the outcomes. Several relevant sources were searched but no attempts were made to reduce the potential for publication and language bias. The methods used to select studies and extract the data were not described, so it is not known whether any efforts were made to reduce reviewer errors and bias. Only RCTs were included; the quality of the included studies was not adequately assessed, although the authors broadly commented on aspects of methodological quality. Therefore, the results from these studies and any synthesis may not be reliable.
The number of outcomes assessed in each study, absence of raw estimates, and the lack of an examination of the validity of the methods used to assess outcomes limit the reader's interpretation of the results presented. The evidence from individual studies was not adequately synthesised: individual studies providing evidence of treatment effects were not referenced, so it was not possible to confirm the authors' statements about treatment effects. In addition, several studies were selected for more detailed description in the text without any adequate reasons given for their selection.
In view of the limitations highlighted, it was not possible to adequately assess the evidence or to determine what conclusions could be drawn about the effects of psychosocial and behavioural interventions for family caregivers of psychogeriatric patients.
Implications of the review for practice and research Practice: The authors stated that the treatment of patients with Alzheimer's disease, stroke or mental illness should be based on partnership with the patient and family. They stated that caregiving includes support and assistance but less tangible sources of distress also require attention.
Research: The authors stated that there is a need to develop a standardised method of classifying and measuring multi-component psychosocial interventions; to develop a consensus-based set of core outcomes to be assessed; and to determine what represents a clinically meaningful treatment effect size. Future studies should adhere to the CONSORT (Consolidated Standards of Reporting Trials) guidelines for conducting and reporting RCTs, should link interventions to desired outcomes, and involve patients with problems targeted by the intervention. Patient and caregiver outcomes, such as mood and quality of life for patients and burden and depression for caregivers, should be assessed.
Funding National Institutes of Health, grants NIMH P30 MH52247 and K01 MH065547, NHLBI P50 HL65111-65112 and R24 HL076852, NIA K07 AG000923 and U01 AG013305, NINR R01 NR008272 and NIH P60 MD000207.
Bibliographic details Schulz R, Martire L M, Klinger J N. Evidence-based caregiver interventions in geriatric psychiatry. Psychiatric Clinics of North America 2005; 28(4): 1007-1038 Indexing Status Subject indexing assigned by NLM MeSH Aged; Caregivers; Geriatric Psychiatry /methods; Humans; Mental Disorders /therapy; Mental Health Services /manpower AccessionNumber 12006003118 Date bibliographic record published 31/07/2007 Date abstract record published 31/07/2007 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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