CRD summary

This review concluded that combined intervention programmes aimed at elderly people living at home with dementia and their caregivers may improve some aspects of functioning. Overall, differences between the studies, and methodological limitations of the primary studies and the review, mean that the authors' conclusions may not be reliable.

Authors' objectives

To determine the effects of combined intervention programmes for both individuals with dementia living at home and their informal caregivers.

Searching

MEDLINE, PsycINFO, EBM Reviews and the Cochrane Database of Systematic Reviews were searched from January 1992 to February 2005; the search terms were reported. The reference lists of studies and systematic reviews were screened for additional studies. Systematic reviews written in English, German and Dutch were considered. One study published before January 1992 was included in the review as a complementary publication to one published between 1992 and 2005, about the same intervention programme.

Study selection

Studies reporting the effects of combined intervention programmes aimed at both elderly patients with dementia living at home and their caregivers were eligible for inclusion. Interventions had to result in personal contacts between care professionals, caregivers and patients. Further inclusion criteria for the study design and outcomes were not reported. The included studies assessed a number of different intervention programmes which varied in their intensity, duration and the type participants included (e.g. mental health status of patients and carers, and the severity of dementia). Further details were reported in the review. Where stated, follow-up periods varied from 3 months to 8 years. The majority of studies used a published scale to assess the mental health of patients and/or carers. The outcomes used to assess carers included mental health scales and scales to assess carer burden and competence. Patient-related scales included those for assessing mental health, behavioural problems, and cognitive and physical functioning. Time to patient admission to institution and/or long-term care was also reported in a number of studies.

Two reviewers determined which studies met the inclusion criteria.

Assessment of study quality

The validity of the studies was assessed using Cochrane Collaboration criteria and each study was awarded a score. The range of possible scores and details of the exact criteria used were not reported. Studies scoring 8 or more points were regarded as good quality.

Two reviewers independently assessed validity.

Data extraction

The overall direction and significance of the intervention effects were reported. The authors reported that it was not possible to calculate standardised d scores in 12 of the 25 included studies.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

Methods of synthesis

The data were summarised narratively and in data tables, grouped according to outcome and whether the effects were on the caregiver or patients with dementia. The direction and significance of the effects were categorised as significant effects, heterogeneous effects and no significant effects.

Results of the review

Twenty-five publications assessing 22 programmes were included in the final analysis. The total number of participants is unclear, owing to multiple publications from what appear to be the same study or intervention programme.

The majority of the studies were non-randomised, but most included a control group and/or compared interventions with other interventions; only one study was uncontrolled. The quality scores ranged from 4 to 9 and 8 studies were rated as good quality.

Effects on caregivers.

The majority of studies assessing depressive symptoms reported heterogeneous results. Three of the 4 studies assessing general mental health found significant improvements associated with the intervention. Two of the 3 studies assessing overall well-being found no significant effects. The majority of studies assessing subjective burden found no significant effects. The majority of studies assessing the effects of the intervention on the competence of the caregiver reported heterogeneous results.

Effects on patients with dementia.

Three out of 5 studies reported significant improvements associated with the intervention for a variety of mental health aspects. The 5 studies assessing cognitive function reported conflicting results. Only one of the 9 studies assessing behavioural problems reported that the intervention group was associated with positive effects; the remainder reported no significant effects or heterogeneous effects. The majority of studies assessing behavioural problems and physical functioning reported no significant effects or heterogeneous effects. The majority of studies (8 out of 12) assessing admission to long-stay facilities (usually a nursing home) favoured the intervention group compared with the control group. Evidence on survival was reported in only 2 studies, with conflicting results.

Authors' conclusions

Combined intervention programmes may improve some aspects of functioning for the caregiver and the person with dementia.

CRD commentary

This review answered a broad research question with no defined inclusion criteria for the study design and outcome. Searches for relevant published studies were adequate, but there appeared to be some restrictions on language and it is unclear whether adequate attempts were made to identify unpublished studies. This suggests that some relevant studies might have been missed. It is also unclear why the authors placed date restrictions on their searches as they included one study which was published before their 1992 cut-off period, which suggests that studies published before 1992 may also be relevant. Attempts were made to reduce the risk of reviewer error and bias whilst selecting and assessing the validity of the studies, although the individual validity criteria and scores for each criterion were not reported. Limited details of the included studies were reported, particularly in relation to the study design and participant characteristics. However, the authors stated that the studies varied in a number of important aspects and also lacked sufficient data with which to calculate a standardised effect size, so precluding meta-analysis. This lack of information about study design, patient characteristics and the size of effects also makes it difficult to assess the reliability of the data. However, the authors reported a number of limitations of the included studies, which suggest that their data may not be reliable. Overall, differences between the studies, and the methodological limitations of both the primary studies and the review, suggest that the authors' conclusions may not be reliable.

Implications of the review for practice and research

Practice: The authors stated that, owing to the inconclusive evidence, it is not possible to make recommendations about the immediate large-scale implementation of combined interventions. Care professionals should define programme goals and target groups before advising clients on a combined programme.

Research: The authors state that future research should focus on the varying needs of different target groups in whom intervention programmes may be most effective.

Funding

Netherlands Organisation for Health Research and Development, grant number 13600006.

Bibliographic details

Smits C H, de Lange J, Droes R M, Meiland F, Vernooij-Dassen M, Pot A M. Effects of combined intervention programmes for people with dementia living at home and their caregivers: a systematic review. International Journal of Geriatric Psychiatry 2007; 22(12): 1181-1193. [PubMed: 17457793]

Indexing Status

Subject indexing assigned by NLM

MeSH

Caregivers /psychology; Cost of Illness; Dementia /nursing /psychology; Humans; Outcome Assessment (Health Care); Quality of Life; Social Support; Stress, Psychological

AccessionNumber

12008103013

Database entry date

01/12/2008

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.