Elsevier

The Lancet Neurology

Volume 5, Issue 11, November 2006, Pages 961-973
The Lancet Neurology

Review
Dementia care: mental health effects, intervention strategies, and clinical implications

https://doi.org/10.1016/S1474-4422(06)70599-3Get rights and content

Summary

Caring for elderly people with dementia is associated with well-documented increases in burden, distress, and decrements in mental health and wellbeing. More severe behavioural, cognitive, and functional impairments in a patient are associated with higher levels of burden and distress. Distress increases with care hours per week, number of tasks, and declining coping and support resources. Demographic factors also affect levels of burden and distress. Promising, evidence-based interventions exist, but substantial economic and policy barriers preclude their widespread dissemination. Health-care policy makers should consider addressing these barriers; clinicians and families must campaign for reimbursement; and clinical researchers must develop more potent preventive interventions. In this article we review how dementia care affects the mental health of the carer and identify interventions that might be useful in mitigating carer burden and distress.

Section snippets

Carer outcomes

In this review we focus on the psychosocial effects of caring, including carer burden, symptoms of depression and anxiety, a reduction in subjective wellbeing, and positive experiences (panel 1).1, 19, 24, 25, 26 Carer burden is the effect on physical, psychological, social, spiritual, and financial wellbeing.27 The term encompasses both objective burden (events and activities associated with a negative caring experience and practical consequences of physical and behavioural changes of the

Carer interventions

The last decade has seen a substantial increase both in the number and the quality of carer interventions aimed to reduce both adverse outcomes of care and nursing-home placement of patients. Meta-analyses20, 21, 22, 23, 98, 99, 100 have provided a reasonably accurate assessment of the effectiveness of these interventions, though they vary substantially in numbers of studies reviewed, ranging from 24 to 120 studies. We base this discussion primarily on our meta-analysis of 78 intervention

Moderators of intervention effectiveness

Individualised interventions can be more easily adapted to the specific needs of the carers and may, therefore, be more effective in helping burden or distress for carers in general.20 However, group interventions are more effective at increasing social support127 and those that avoid dilution of the participant's active involvement will probably be as effective as individual settings.

Interventions applied for a long time are more effective than short-duration interventions22 at reducing

Why do interventions precipitate positive change?

The identification of which intervention components are effective can provide information not available when whole interventions are compared129, 130 and can identify parts of the stress process (figure) that are easiest to target. Recent studies that involve mediation analysis131 and task analysis132 have attempted to isolate parts of an intervention that work especially well so that future interventions can focus on implementing components that have the greatest likelihood of success figure).

Future research

Although it is well established that many carers suffer physically and emotionally when providing care, the protective factors that enable some carers to maintain low levels of distress are unknown. More longitudinal and prospective studies of factors that predispose carers to greater resilience or vulnerability are needed.

Published consensus guidelines support assessment of carers' emotional health and subsequent referral to community educational and support programmes for those in need.137,

Screening

Safety concerns must be identified and addressed. The patient's access to and use of stoves and kitchen equipment, motor vehicles, and firearms should be discussed. Carers should also be asked whether they feel physically threatened by patients (see Home Safety information on National Institute on Aging Website143).

The level of carer distress should be gauged. There are no relevant and valid screening methods for clinical use. However, two organisations have recommended clinical methods. The

Conclusions, policy, and advocacy issues

The extension of the human life span means that more people will be entering the role of a carer over the next few decades, providing substantial public health, policy, and economic challenges. One tangible barrier that currently limits the provision of services for carers is the lack of reimbursement for the time and effort spent assessing carer distress and implementing interventions.174

The extent to which available interventions can be implemented and paid for will depend on local

Search strategy and selection criteria

Data for this review were from previous meta-analyses9, 10, 17, 18, 19, 20, 21, 22, 23, 24 and a systematic narrative approach to the most recent literature in OVID MEDLINE (Jan 2003–June 2006) aimed at uncovering topics and interventions that were not addressed in the previous meta-analyses, either due to lack of sufficient literature or newness of the topic. We used the terms “caregiving”, “caregivers”, “carer”, “support provider”, “elderly”, “old age”, “intervention”, “trial”,

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