Jennifer A. Abbey

Effectiveness of interventions that assist caregivers to support people with dementia living in the community: a systematic review

Objectives The objective of this review was to assess the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community. Inclusion criteria Types of participants Adult caregivers who provide support for people with dementia living in the community (non‐institutional care). Types of interventions Interventions designed to support caregivers in their role such as skills training, education to assist in caring for a person living with dementia and support groups/programs. Interventions of formal approaches to care designed to support caregivers in their role, care planning, case management and specially designated members of the healthcare team ‐ for example dementia nurse specialist or volunteers trained in caring for someone with dementia. Types of studies This review considered any meta‐analyses, systematic reviews, randomised control trials, quasi‐experimental studies, cohort studies, case control studies and observational studies without control groups that addressed the effectiveness of interventions that assist caregivers to provide support for people living with dementia in the community. Search strategy The search sought to identify published studies from 2000 to 2005 through the use of electronic databases. Only studies in English were considered for inclusion. The initial search was conducted of the databases, CINAHL, MEDLINE and PsychINFO using search strategies adapted from the Cochrane Dementia and Cognitive Improvement Group. A second more extensive search was then conducted using the appropriate Medical Subject Headings (MeSH) and keywords for other available databases. Finally, hand searching of reference lists of articles retrieved and of core dementia, geriatric and psycho geriatric journals was undertaken. Assessment of quality Methodological quality of each of the articles was assessed by two independent reviewers using appraisal checklist developed by the Joanna Briggs Institute and based on the work of the Cochrane Collaboration and Centre for Reviews and Dissemination. Data collection and analysis Standardised mean differences or weighted mean differences and their 95% confidence intervals were calculated for each included study reported in the meta‐analysis. Results from comparable groups of studies were pooled in statistical meta‐analysis using Review Manager Software from the Cochrane Collaboration. Heterogeneity between combined studies was tested using standard chi‐square test. Where statistical pooling was not appropriate or possible, the findings are summarised in narrative form. Results A comprehensive search of relevant databases, hand searching and cross referencing found 685 articles that were assessed for relevance to the review. Eighty‐five papers appeared to meet the inclusion criteria based on title and abstract, and the full paper was retrieved. Of the 85 full papers reviewed, 40 were accepted for inclusion, three were systematic reviews, three were meta‐analysis, and the remaining 34 were randomised controlled trials. For the randomised controlled trials that were able to be included in a meta‐analysis, standardised mean differences or weighted mean differences and their 95% confidence intervals were calculated for each. Results from comparable groups of studies were pooled in statistical meta‐analysis using Review Manager Software and heterogeneity between combined studies was assessed by using the chi‐square test. Where statistical pooling was not appropriate or possible, the findings are summarised in narrative form. The results are discussed in two main sections. Firstly it was possible to assess the effectiveness of different types of caregiver interventions on the outcome categories of depression, health, subjective well‐being, self‐efficacy and burden. Secondly, results are reported by main outcome category. For each of these sections, meta‐analysis was conducted where it was possible; otherwise, a narrative summary describes the findings. Effectiveness of intervention type Four categories of intervention were included in the review ‐ psycho‐educational, support, multi‐component and other. Psycho‐educational Thirteen studies used psycho‐educational interventions, and all but one showed positive results across a range of outcomes. Eight studies were entered in a meta‐analysis. No significant impact of psycho‐educational interventions was found for the outcome categories of subjective well‐being, self‐efficacy or health. However, small but significant results were found for the categories of depression and burden. Support Seven studies discussed support only interventions and two of these showed significant results. These two studies were suitable for meta‐analysis and demonstrated a small but significant improvement on caregiver burden. Multi‐component Twelve of the studies report multi‐component interventions and 10 of these report significant outcomes across a broad range of outcome measures including self‐efficacy, depression, subjective well‐being and burden. Unfortunately because of the heterogeneity of study designs and outcome measures, no meta‐analysis was possible. Other interventions Other interventions included the use of exercise or nutrition which resulted in improvements in psychological distress and health benefits. Case management and a computer aided support intervention provided mixed results. One cognitive behavioural therapy study reported a reduction in anxiety and positive impacts on patient behaviour. Effectiveness of interventions using specific outcome categories In addition to analysis by type of intervention it was possible to analyse results based on some outcome categories that were used across the studies. In particular the impact of interventions on caregiver depression was available for meta‐analysis from eight studies. This indicated that multi‐component and psycho‐educational interventions showed a small but significant positive effect on caregiver depression. Five studies using the outcome category of caregiver burden were entered into a meta‐analysis and findings indicated that there were no significant effects of any of interventions. No meta‐analysis was possible for the outcome categories of health, self‐efficacy or subjective well‐being. Implications for practice From this review there is evidence to support the use of well‐designed psycho‐educational or multi‐component interventions for caregivers of people with dementia who live in the community. Factors that appear to positively contribute to effective interventions are those which: Provide opportunities within the intervention for the person with dementia as well as the caregiver to be involved Encourage active participation in educational interventions for caregivers Offer individualised programs rather than group sessions Provide information on an ongoing basis, with specific information about services and coaching regarding their new role Target the care recipient particularly by reduction in behaviours Factors which do not appear to have benefit in interventions are those which: Simply refer caregivers to support groups Only provide self help materials Only offer peer support

Understanding the barriers to recognition and management of delirium in the acute post-surgical setting

Post-surgical delirium has been shown to be a significant problem in the elderly patient. However, it remains a disorder that is not well recognised nor wellunderstood by health care providers.1 The purpose of this study was to investigate current assessment practices as well as potential barriers to accurate assessment in relation to delirium, within a major Australian tertiary referral hospital. Patients aged 65 and over were recruited on, or close to, admission, from a pre surgical cohort over a six month period in 2007. After consent was gained, they were assessed by a nurse researcher, using a Mini Mental State Examination (MMSE)and Confusion Assessment Method (CAM) to determine their preoperative cognitive state and the presence or absence of delirium. Demographic data was also collected. The recruited patients were then assessed again by the researcher for delirium using the CAM, on both day one and day three post surgery. Patients’ charts were audited at the same times and again at discharge to see if, and how, delirium had been assessed, diagnosed and managed by the healthcare staff during the admission. Post surgical complications and prospective patient data were collected from medical records. Focus groups were also conducted with medical and nursing staff to ascertain what current and common practices were followed in relation to the assessment, diagnosis and management of delirium. Following the findings of the study, the authors then offer recommendations to improve outcomes for elderly surgical patients in this, and similar facilities.

Oral liquid nutritional supplements for people with dementia in residential aged care facilities

AIM: This systematic review investigated the prescription, administration and effectiveness of oral liquid nutritional supplements (OLNS) for people with dementia in residential aged care facilities (RACF). METHODS: A comprehensive search of relevant databases, hand searching and cross-referencing found 15 relevant articles from a total of 2910 possible results. Articles which met the inclusion criteria were critically appraised by two independent reviewers using the relevant Joanna Briggs Institute (JBI) appraisal checklist. Data were extracted using the relevant JBI extraction instruments. No data synthesis was possible due to clinical and methodological heterogeneity. RESULTS: Included studies examined a range of strategies, issues and results related to OLNS for persons with dementia in RACFs; however there appear to be significant gaps in the current body of research, particularly in relation to examinations of effectiveness. CONCLUSIONS: This review was unable to produce a definitive finding regarding effectiveness. OLNS may improve the nutritional state of residents with dementia and help prevent weight loss, and there is some suggestion that it may slow the rate of cognitive decline. However, in order for OLNS to be effective, nursing and care staff need to ensure that sufficient attention is paid to the issues of prescription and administration.