Meta-Analysis of Nonpharmacological Interventions for Neuropsychiatric Symptoms of Dementia
This article has been corrected.
VIEW CORRECTIONPublication: American Journal of Psychiatry
Abstract
Objective
Behavioral and psychological symptoms are common in dementia, and they are especially stressful for family caregivers. Nonpharmacological (or psychosocial) interventions have been shown to be effective in managing behavioral and psychological symptoms, but mainly in institutional settings. The authors reviewed the effectiveness of community-based nonpharmacological interventions delivered through family caregivers.
Method
Of 1,665 articles identified in a literature search, 23 included unique randomized or pseudorandomized nonpharmacological interventions with family caregivers and outcomes related to the frequency or severity of behavioral and psychological symptoms of dementia, caregiver reactions to these symptoms, or caregiver distress attributed to these symptoms. Studies were rated according to an evidence hierarchy for intervention research.
Results
Nonpharmacological interventions were effective in reducing behavioral and psychological symptoms, with an overall effect size of 0.34 (95% CI=0.20–0.48; z=4.87; p<0.01), as well as in ameliorating caregiver reactions to these behaviors, with an overall effect size of 0.15 (95% CI=0.04–0.26; z=2.76; p=0.006).
Conclusions
Nonpharmacological interventions delivered by family caregivers have the potential to reduce the frequency and severity of behavioral and psychological symptoms of dementia, with effect sizes at least equaling those of pharmacotherapy, as well as to reduce caregivers’ adverse reactions. The successful interventions identified included approximately nine to 12 sessions tailored to the needs of the person with dementia and the caregiver and were delivered individually in the home using multiple components over 3–6 months with periodic follow-up.
It is projected that by 2050 there will be over 115 million people with dementia worldwide (1). The management of dementia may be complicated by the presence of behavioral and psychological symptoms (also known as neuropsychiatric symptoms), which include screaming, physical aggression, personality clashes (arguments between patients and caregivers), wandering, depression, resistance to help with activities of daily living (e.g., dressing, washing, toileting, and eating), suspiciousness, accusations, and not sleeping at night. Estimated rates of behavioral and psychological symptoms of dementia in community settings range from 61% to 88% (2–4). Behavioral and psychological symptoms rather than cognitive dysfunction, physical dependence, or functional impairment have been found to impose the greatest burden on family caregivers (5, 6) and to predict caregiver decisions to institutionalize persons with dementia (7, 8). Because of the significant role of family care in providing independence for people with dementia as well as relief for institutional care facilities, finding effective methods for managing behavioral and psychological symptoms of dementia in home care is both a public health and an economic priority.
Pharmacological treatments for behavioral and psychological symptoms of dementia have limited efficacy and can have adverse effects (9). Antipsychotic drugs in particular have been associated with an increased risk of stroke and death (9–12), and the performance of antidepressants has been disappointing (13, 14). Systematic reviews have demonstrated the effectiveness of nonpharmacological or psychosocial treatments for behavioral and psychological symptoms (15–17) as well as the lack of adverse effects (18). The terms “nonpharmacological” and “psychosocial” are commonly used interchangeably to describe interventions used to treat behavioral and psychological symptoms of dementia (16–18). In this review, we use “nonpharmacological,” which includes interventions addressing aspects of social and psychological behaviors and symptoms of dementia that do not involve drugs. Most nonpharmacological interventions have been tested in residential care, which does not address care in the community, where the majority of persons with dementia live. Our aim in this study was to review the effectiveness of family caregiver interventions in the management of behavioral and psychological symptoms occurring in people with dementia living in the community.
Method
Search Procedure
Searches were carried out in MEDLINE, Embase, PubMed, PsycINFO, and Scopus to identify experimental and clinical trials and single-case studies published from 1985 through July 2010. The search criteria combined condition (dementia or Alzheimer*), care provider (caregiver* or carer*), intervention (treatment*, therap*, counsel*, intervention*, support, support group*, psychosocial, or nonpharmacologic*), and symptoms (behavioral and psychological symptoms of dementia, BPSD, neuropsychiatric symptoms, aberrant motor behavior, aggression, agitation, anxiety, apathy, delusion*, depressi*, disinhibition, disturbing behavior, dysphori*, euphoria, hallucination*, irritab*, lability, screaming, sleep, or vocalization), using variations to include Commonwealth spellings. Terms were searched in titles and abstracts.
Outcomes
For persons with dementia, behavioral and psychological symptoms were rated on a variety of instruments measuring frequency (e.g., the Revised Memory and Behavior Problem Checklist) or severity (e.g., the Behavioral Pathology in Alzheimer’s Disease Rating Scale) or both (e.g., the Neuropsychiatry Inventory) (for the full list, see Table S1 in the data supplement that accompanies the online edition of this article). For caregivers, outcomes were their reactions to these behavioral and psychological symptoms, usually rated on subsidiary scales embedded within those used for rating the symptoms (e.g., the Neuropsychiatry Inventory, the Revised Memory and Behavior Problem Checklist). Improvement for persons with dementia could be reduction in the frequency and/or severity of symptoms, and for caregivers, reductions in the severity of their reactions to the symptoms.
Selection Criteria for Review
We searched peer-reviewed journals with English-language studies that tested nonpharmacological interventions involving family caregivers. Studies were selected if they reported outcomes relevant to the frequency or severity of behavioral and psychological symptoms of dementia or caregiver reactions or distress attributed to these symptoms. Respite care interventions, drug trials for the treatment of behavioral and psychological symptoms of dementia, and review articles were excluded. Databases were searched for published or in-press articles that reported empirical research findings. Studies met criteria if they included more than five participants with a diagnosis related to dementia. The primary caregiver had to be a family member living with the person with dementia.
When two or more articles based on the same data and outcomes or similar studies by the same authors were available, the better or best study was selected for inclusion—that is, the most recent, the most relevant to behavioral and psychological symptoms of dementia, or the most complete study, or the one with the greater number of participants. Articles were excluded if the study included five or fewer participants, if care recipients had schizophrenia or bipolar disorder, or if outcomes relevant to behavioral and psychological symptoms of dementia were not assessed separately or quantitatively.
Methodological Quality Assessment
To establish interrater reliability, a second reviewer independently rated the methodological quality of 15 studies according to the National Health and Medical Research Council criteria for rating studies to assess the effectiveness of interventions (19, 20). Level I evidence, the highest level, is produced by a systematic review of level II studies; a level II study is a randomized controlled trial. Level III-1 is a pseudorandomized controlled trial, level III-2 a comparative study with concurrent controls, and level III-3 a comparative study without concurrent controls. Level IV, the lowest level, is a case series with either posttest or pretest-posttest outcomes. Design characteristics, such as the use of randomization and control groups, were considered when rating studies. Because our analysis included only articles with original data and excluded systematic reviews, the highest level of evidence for an intervention in this review was level II. Only high-quality randomized (level II) or pseudorandomized (level III-1) studies were included.
Meta-Analysis
Meta-analysis was performed using Review Manager, version 5 (Cochrane Collaboration, Oxford, England). Effect sizes for continuous data were calculated as the standardized mean difference (Cohen’s d) between treatment and control groups or between pre- and posttreatment assessments. Effect sizes were calculated for the most current follow-up assessment.
Results for random-effects models are displayed because tests for homogeneity and heterogeneity of studies under examination in terms of methods, type of intervention, sample characteristics, and outcome measures support the use of a random-effects model for most of the pooled estimates (21–23). Funnel plots, constructed for effects of interventions on behavioral and psychological symptoms of dementia and on caregivers, were symmetrical, indicating lack of publication bias (data not shown).
For studies that contained more than one control group with no post hoc differences, the control groups’ scores were pooled. When there were differences in sample sizes, control scores were averaged using weighted mean difference scores. When studies provided difference scores and no posttest scores, these were used to calculate effect sizes.
Interventions were categorized according to the schema shown in Figure 1, by consensus. Studies generally used multiple types of intervention (see Table S1 in the online data supplement).
Results
Of 1,665 articles identified, 23 met all review criteria (24–46) (Figure 2). These studies, which collectively included 3,279 dyads in their intent-to-treat analyses, used a variety of techniques, often in combination. Results were largely positive or partially positive, with only three studies reporting neutral findings for all behavioral and psychological symptom outcomes (25, 28, 29) and one reporting negative results (26). No study reported adverse effects. Durations of interventions ranged from 6 weeks to 24 months. Sustainability of symptom outcomes was reported in 10 studies (29, 35, 37–39, 41–44, 46), with follow-ups ranging from 3 to 24 months after trial entry. Participant numbers were characteristically moderate, with 14 studies recruiting at least 80 caregivers or dyads. All but three studies had interventions delivered individually to caregivers or dyads (28, 36, 46). Two studies were telephone-based interventions with no face-to-face contact (37, 45).
Sixteen of the 23 studies met criteria for a randomized controlled trial (19, 20). Another seven that reported randomization but for which the method was not stated, was not obtained by correspondence with the author, was unclear, or was inadequate to conceal group allocation were classified as pseudorandomized.
Effect sizes for symptom outcomes for studies ranked level II and level III-1 are listed in Figure 3. The medium pooled-estimate effect size for these 17 studies, 0.34 (95% CI=0.20–0.48, z=4.87; p<0.01), suggests a positive overall effect of caregiver interventions on behavioral and psychological symptoms in persons with dementia.
FIGURE 3. Efficacy of Interventions for Behavioral and Psychological Symptoms of Dementia
a Frequency of behavioral symptoms in dementia.
b Black/African American group.
c Hispanic/Latino group.
d White/Caucasian group.
e Severity of deterioration of behavioral symptoms in dementia.
f Severity of behavioral symptoms in dementia.
g Presence or absence of behavioral symptoms in dementia.
h Depressive symptoms.
i Symptomatology and severity of behavioral symptoms in Alzheimer’s disease.
j Effect size calculated as pooled estimates from two control group scores that had no significant between-group differences.
k Frequency and severity of psychiatric symptoms in dementia.
l Effect size calculated as change from pretest to posttest mean scores within the intervention group.
m BT-PE=behavior therapy with pleasant events.
n BT-PS=behavior therapy with problem solving.
Effect sizes for caregiver outcomes related to behavioral and psychological symptoms of dementia for studies ranked levels II and III-1 are listed in Figure 4. The low but significant pooled-estimate effect size for these 13 interventions, 0.15 (95% CI=0.04–0.26, z=2.76; p=0.006), suggests that caregiver interventions were effective in improving caregivers’ reactions to these symptoms.
FIGURE 4. Efficacy of Interventions for Caregiver Outcomes Related to Behavioral and Psychological Symptoms of Dementia
a Bother associated with behavioral symptoms of dementia.
b Stress associated with troublesome behavioral symptoms of dementia.
c Anglo group.
d Latino group.
e Distress associated with behavioral and psychological symptoms in dementia.
f Self-efficacy in managing behavioral symptoms of dementia.
g Upset associated with behavioral symptoms of dementia.
h Confidence managing most distressing behavioral symptom of dementia.
i Management of behavioral symptoms of dementia.
Discussion
While the negative effects of behavioral and psychological symptoms of dementia on caregivers are well documented, there is little appreciation of caregivers’ ability to influence the occurrence and severity of these symptoms. This meta-analysis reveals that caregiver interventions can significantly reduce behavioral and psychological symptoms in the person with dementia as well as the caregiver’s negative reactions to these symptoms. Ayalon and colleagues (18) reported that nonpharmacological interventions that addressed behavioral issues and included caregivers were more likely to be efficacious for managing behavioral and psychological symptoms of dementia, but the authors stressed the need for confirmatory studies. The present review found significant benefits for behavioral and psychological symptoms of dementia from high-research-quality interventions that targeted these symptoms and included the family caregiver. The availability of 23 high-quality trials from just the past two decades effectively delivering a wide range of interventions in the community indicates how the field has advanced. These effects are at least comparable to those of antipsychotics. From a report by Yury and Fisher (47) on behavioral and psychological symptoms of dementia treatment, a net effect size of 0.13 can be calculated from their findings of 0.45 (95% CI=0.16–0.74) for atypical antipsychotics and 0.32 (95% CI=0.10–0.53) for placebo. Similarly, Schneider and colleagues (48) reported an effect size of 0.18 (z=3.43; p=0.0006) in favor of antipsychotics in the treatment of behavioral and psychological symptoms of dementia. Unlike with antipsychotics, however, caregiver interventions had no adverse effects on caregivers or persons with dementia. In the only study with negative effects, behavior deteriorated over time but to similar degrees in the intervention and control groups (26). The three studies with no treatment effects on symptoms still had other positive outcomes for caregivers, namely, a reduction in caregiver depressive symptoms (28), a decrease in caregiver burden (29), and an increase in caregiver general well-being (25). Of these three studies, one (25) had a behavior management component in both the intervention and control groups and found improvements in both groups in the measure “bother associated with care recipient behaviors.”
Limitations
Our findings are subject to several limitations. First, the use of multicomponent strategies and omnibus behavior rating scales prevented identification of which specific elements of interventions were effective for which behaviors. Second, not all interventions targeted behaviors; for example, Chang (26) focused on care generally. Third, the choice of instruments may have mitigated demonstration of effects. For example, about a third of the items in the Revised Memory and Behavior Problem Checklist concern activities of daily living, a third depressive symptoms, and a third other behaviors. Even if interventions had significant benefits for nondepressive behaviors, these effects would have been diluted by the nonbehavioral items. Fourth, caregivers’ variability in knowledge, skills, and supports prior to intervention affect their capacity for improvement. Where outcomes were adjusted for caregivers’ scores on these variables at baseline, those with the lowest scores benefited the most (37). For example, in phase 2 of the Resources for Enhancing Alzheimer’s Caregiver Health study of three different ethnic groups, the Latino-Hispanic group may have benefited significantly more because the intervention was provided in Spanish and may have been the first time participants had received such assistance (24).
Fifth, the quality of research and sample sizes varied. While there is clearly room for improvement, the cost of such trials and the difficulty in recruitment of representative samples of caregivers and people with dementia are considerable. Sixth, nonpharmacological intervention studies appear to recruit patients with less severe behavioral disturbances than do drug trials and usually exclude psychotic patients. Seventh, a limitation of nearly all pharmacological and nonpharmacological studies is the reliance on reports of behaviors, which may be biased, rather than on direct observation. Finally, for many of the interventions, we were unable to calculate the effect size or the sustainability of outcomes. Of the 10 studies that reported follow-up (29, 35, 37–39, 41–44, 46), symptomatic and/or related caregiver improvements were maintained in eight studies (35, 37, 39, 41–44, 46).
Implications
Fine-grained questions regarding which elements of interventions are effective for which behavioral and psychological symptoms of dementia delivered by which caregivers to which persons with dementia require further attention. Questions about the optimal duration, frequency, and setting of interventions cannot be answered empirically from these data. Successful interventions included approximately nine to 12 sessions tailored to the needs of the person with dementia and the caregiver and were delivered individually in the home using multiple components over 3–6 months interspersed with telephone sessions and subsequent individual or group telephone follow-ups. Behaviors more likely to respond to such interventions appear to be agitation, aggression, disruption, shadowing, depression, and repetitive behaviors rather than psychosis. From the emerging pattern for success, we recommend adopting interventions that are multicomponent, tailored to the needs of the caregiver and the person with dementia, and delivered at home with periodic follow-ups.
The implications from this meta-analysis are extensive. For policy makers, our findings suggest that supporting programs to work with caregivers would be an efficient and potentially sustainable model. For clinicians, caregivers, and persons with dementia, there is a preference for trying nonpharmacological approaches first and avoiding or delaying the use of medications, which have the potential for serious adverse effects and high attrition (9). Despite the onus assumed by caregivers in these interventions, caregivers reported significant benefits to their own psychological health (24–28, 30–33, 35, 37, 38, 40, 43, 44), general health (35, 38), general well-being (25, 31, 33), overall quality of life (24, 35), caregiving burden (29, 33, 43, 45), and caregiving skills (30–32, 40, 41). For researchers, our findings suggest numerous questions that require investigation; in addition to those outlined above, information about cost-benefit and delay in institutionalization will be persuasive in advocating for funding for such interventions. Systematic reporting of sufficient data to allow comparative analysis should be complemented by at least one follow-up to test sustainability.
Acknowledgments
The authors acknowledge the statistical advice and assistance of Dr. Zhixin Liu and Dr. Lee-Fay Low and the assistance of Dr. Liu in preparing the Forest plots.
Footnote
Presented at the 26th annual Alzheimer’s Disease International Conference, Toronto, March 19–22, 2011.
Supplementary Material
Supplementary Material (appi.ajp.2012.11101529_ds001.pdf)
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References
1.
Alzheimer’s Disease International: Dementia statistics: numbers of people with dementia. 2010. http://www.alz.co.uk/research/statistics.html.
2.
Lyketsos CG, Steinberg M, Tschanz JT, Norton MC, Steffens DC, Breitner JCS: Mental and behavioral disturbances in dementia: findings from the Cache County Study on Memory in Aging. Am J Psychiatry 2000; 157:708–714
3.
Mega MS, Cummings JL, Fiorello T, Gornbein J: The spectrum of behavioral changes in Alzheimer’s disease. Neurology 1996; 46:130–135
4.
Ferri CP, Ames D, Prince Mthe 10/66 Dementia Research Group: Behavioral and psychological symptoms of dementia in developing countries. Int Psychogeriatr 2004; 16:441–459
5.
Pinquart M, Sörensen S: Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: a meta-analysis. J Gerontol B Psychol Sci Soc Sci 2003; 58:112–128
6.
Machnicki G, Allegri RF, Dillon C, Serrano CM, Taragano FE: Cognitive, functional and behavioral factors associated with the burden of caring for geriatric patients with cognitive impairment or depression: evidence from a South American sample. Int J Geriatr Psychiatry 2009; 24:382–389
7.
de Vugt ME, Stevens F, Aalten P, Lousberg R, Jaspers N, Verhey FRJ: A prospective study of the effects of behavioral symptoms on the institutionalization of patients with dementia. Int Psychogeriatr 2005; 17:577–589
8.
Chan D-C, Kasper JD, Black BS, Rabins PV: Presence of behavioral and psychological symptoms predicts nursing home placement in community-dwelling elders with cognitive impairment in univariate but not multivariate analysis. J Gerontol A Biol Sci Med Sci 2003; 58:548–554
9.
Ballard CG, Waite J, Birks J: Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database Syst Rev (online) 2006 1:CD003476
10.
Schneider LS, Dagerman KS, Insel P: Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of ran-domized placebo-controlled trials. JAMA 2005; 294:1934–1943
11.
Wang PS, Schneeweiss S, Avorn J, Fischer MA, Mogun H, Solomon DH, Brookhart MA: Risk of death in elderly users of conventional vs. atypical antipsychotic medications. N Engl J Med 2005; 353:2335–2341
12.
Brodaty H, Ames D, Snowdon J, Woodward M, Kirwan J, Clarnette R, Lee E, Lyons B, Grossman F: A randomized placebo-controlled trial of risperidone for the treatment of aggression, agitation, and psychosis of dementia. J Clin Psychiatry 2003; 64:134–143
13.
Weintraub D, Rosenberg PB, Drye LT, Martin BK, Frangakis C, Mintzer JE, Porsteinsson AP, Schneider LS, Rabins PV, Munro CA, Meinert CL, Lyketsos CGDIADS-2 Research Group: Sertraline for the treatment of depression in Alzheimer disease: week-24 outcomes. Am J Geriatr Psychiatry 2010; 18:332–340.
14.
Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, Baldwin R, Bentham P, Fox C, Holmes C, Katona C, Knapp M, Lawton C, Lindesay J, Livingston G, McCrae N, Moniz-Cook E, Murray J, Nurock S, Orrell M, O’Brien J, Poppe M, Thomas A, Walwyn R, Wilson K, Burns A: Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. Lancet 2011; 378:403–411
15.
Livingston G, Johnston K, Katona C, Paton J, Lyketsos CGOld Age Task Force of the World Federation of Biological Psychiatry: Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia. Am J Psychiatry 2005; 162:1996–2021
16.
O’Connor DW, Ames D, Gardner B, King M: Psychosocial treatments of psychological symptoms in dementia: a systematic review of reports meeting quality standards. Int Psychogeriatr 2009; 21:241–251
17.
O’Connor DW, Ames D, Gardner B, King M: Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards. Int Psychogeriatr 2009; 21:225–240
18.
Ayalon L, Gum AM, Feliciano L, Areán PA: Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Arch Intern Med 2006; 166:2182–2188
19.
NHMRC: How to Use the Evidence: Assessment and Application of Scientific Evidence. Canberra, National Health and Medical Research Council, 2000
20.
NHMRC: NHMRC Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines: Stage 2 Consultation. Canberra, National Health and Medical Research Council, 2009
21.
Normand SL: Meta-analysis: formulating, evaluating, combining, and reporting. Stat Med 1999; 18:321–359
22.
Engels EA, Schmid CH, Terrin N, Olkin I, Lau J: Heterogeneity and statistical significance in meta-analysis: an empirical study of 125 meta-analyses. Stat Med 2000; 19:1707–1728
23.
Hardy RJ, Thompson SG: Detecting and describing heterogeneity in meta-analysis. Stat Med 1998; 17:841–856
24.
Belle SH, Burgio L, Burns R, Coon D, Czaja SJ, Gallagher-Thompson D, Gitlin LN, Klinger J, Koepke KM, Lee CC, Martindale-Adams J, Nichols L, Schulz R, Stahl S, Stevens A, Winter L, Zhang SResources for Enhancing Alzheimer’s Caregiver Health (REACH) II Investigators: Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: a randomized, controlled trial. Ann Intern Med 2006; 145:727–738
25.
Burns R, Nichols LO, Martindale-Adams J, Graney MJ, Lummus A: Primary care interventions for dementia caregivers: 2-year outcomes from the REACH study. Gerontologist 2003; 43:547–555
26.
Chang BL: Cognitive-behavioral intervention for homebound caregivers of persons with dementia. Nurs Res 1999; 48:173–182
27.
Gallagher-Thompson D, Gray HL, Tang PC, Pu CY, Leung LY, Wang PC, Tse C, Hsu S, Kwo E, Tong HQ, Long J, Thompson LW: Impact of in-home behavioral management versus telephone support to reduce depressive symptoms and perceived stress in Chinese caregivers: results of a pilot study. Am J Geriatr Psychiatry 2007; 15:425–434
28.
Gallagher-Thompson D, Coon DW, Solano N, Ambler C, Rabinowitz Y, Thompson LW: Change in indices of distress among Latino and Anglo female caregivers of elderly relatives with dementia: site-specific results from the REACH national collaborative study. Gerontologist 2003; 43:580–591
29.
Gavrilova SI, Ferri CP, Mikhaylova N, Sokolova O, Banerjee S, Prince M: Helping carers to care: the 10/66 Dementia Research Group’s randomized control trial of a caregiver intervention in Russia. Int J Geriatr Psychiatry 2009; 24:347–354
30.
Gitlin LN, Corcoran M, Winter L, Boyce A, Hauck WW: A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia. Gerontologist 2001; 41:4–14
31.
Gitlin LN, Winter L, Corcoran M, Dennis MP, Schinfeld S, Hauck WW: Effects of the home environmental skill-building program on the caregiver-care recipient dyad: 6-month outcomes from the Philadelphia REACH Initiative. Gerontologist 2003; 43:532–546
32.
Gitlin LN, Winter L, Burke J, Chernett N, Dennis MP, Hauck WW: Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study. Am J Geriatr Psychiatry 2008; 16:229–239
33.
Gitlin LN, Winter L, Dennis MP, Hodgson N, Hauck WW: Targeting and managing behavioral symptoms in individuals with dementia: a randomized trial of a nonpharmacological intervention. J Am Geriatr Soc 2010; 58:1465–1474
34.
Gormley N, Lyons D, Howard R: Behavioural management of aggression in dementia: a randomized controlled trial. Age Ageing 2001; 30:141–145
35.
Graff MJ, Vernooij-Dassen MJ, Thijssen M, Dekker J, Hoefnagels WH, Olderikkert MG: Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: a randomized controlled trial. J Gerontol A Biol Sci Med Sci 2007; 62:1002–1009
36.
Hébert R, Lévesque L, Vézina J, Lavoie JP, Ducharme F, Gendron C, Préville M, Voyer L, Dubois MF: Efficacy of a psychoeducative group program for caregivers of demented persons living at home: a randomized controlled trial. J Gerontol B Psychol Sci Soc Sci 2003; 58:S58–S67
37.
Mahoney DF, Tarlow BJ, Jones RN: Effects of an automated telephone support system on caregiver burden and anxiety: findings from the REACH for TLC intervention study. Gerontologist 2003; 43:556–567
38.
Marriott A, Donaldson C, Tarrier N, Burns A: Effectiveness of cognitive-behavioural family intervention in reducing the burden of care in carers of patients with Alzheimer’s disease. Br J Psychiatry 2000; 176:557–562
39.
McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L: Nighttime insomnia treatment and education for Alzheimer’s disease: a randomized, controlled trial. J Am Geriatr Soc 2005; 53:793–802
40.
Moniz-Cook E, Elston C, Gardiner E, Agar S, Silver M, Win T, Wang M: Can training community mental health nurses to support family carers reduce behavioural problems in dementia? An exploratory pragmatic randomised controlled trial. Int J Geriatr Psychiatry 2008; 23:185–191
41.
Nobili A, Riva E, Tettamanti M, Lucca U, Liscio M, Petrucci B, Porro GS: The effect of a structured intervention on caregivers of patients with dementia and problem behaviors: a randomized controlled pilot study. Alzheimer Dis Assoc Disord 2004; 18:75–82
42.
Teri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner DM, Barlow WE, Kukull WA, LaCroix AZ, McCormick W, Larson EB: Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. JAMA 2003; 290:2015–2022
43.
Teri L, McCurry SM, Logsdon R, Gibbons LE: Training community consultants to help family members improve dementia care: a randomized controlled trial. Gerontologist 2005; 45:802–811
44.
Teri L, Logsdon RG, Uomoto J, McCurry SM: Behavioral treatment of depression in dementia patients: a controlled clinical trial. J Gerontol B Psychol Sci Soc Sci 1997; 52:159–166
45.
Tremont G, Davis JD, Bishop DS, Fortinsky RH: Telephone-delivered psychosocial intervention reduces burden in dementia caregivers. Dementia 2008; 7:503–520
46.
Ulstein ID, Sandvik L, Wyller TB, Engedal K: A one-year randomized controlled psychosocial intervention study among family carers of dementia patients: effects on patients and carers. Dement Geriatr Cogn Disord 2007; 24:469–475
47.
Yury CA, Fisher JE: Meta-analysis of the effectiveness of atypical antipsychotics for the treatment of behavioural problems in persons with dementia. Psychother Psychosom 2007; 76:213–218
48.
Schneider LS, Dagerman K, Insel PS: Efficacy and adverse effects of atypical antipsychotics for dementia: meta-analysis of randomized, placebo-controlled trials. Am J Geriatr Psychiatry 2006; 14:191–210
Information & Authors
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History
Received: 7 October 2011
Revision received: 7 February 2012
Revision received: 11 April 2012
Accepted: 23 April 2012
Published online: 1 September 2012
Published in print: September 2012
Authors
Funding Information
Prof. Brodaty has served as an advisory board member, consultant, or speaker for Baxter, Janssen, Lilly, Lundbeck, Merck, Novartis, and Pfizer, has received travel support from Janssen and Pfizer, and has received research grants from Janssen, Medivation, and Sanofi. Ms. Arasaratnam reports no financial relationships with commercial interests.
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