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Family caregivers are estimated to reach 37
million by 2050, an 85 percent increase from
2000. Of these, about 20 percent provide
care to individuals with dementia. The number
of individuals needing dementia care
will rise from 4.5 million to 13.2 million by
2050. Of the 500,000 veterans with dementia,
155,000 sought care in 2006; this figure
is expected to increase to 218,000 by 2017.
Caregiving is characterized by diverse challenges.
Caregivers are at moderate risk for
adverse outcomes in multiple domains, but
not extreme risk in any one outcome. However,
these multiple risks erode health and
quality of life. Caregivers suffer more from
depression and mental health problems than
non-caregivers. Caregivers to individuals
with dementia report more emotional, physical,
social, and financial problems than
other caregivers, and have increased risk of
mortality.1
Dementia caregiving has been the focus of
recent federally funded studies and initiatives.
The National Institute on Aging (NIA) and
National Institute of Nursing Research (NINR)
project, Resources for Enhancing Alzheimer’s
Caregiver Health (REACH II), was the first
multi-site, randomized controlled trial to test
the efficacy of a multi-component intervention
for diverse racial/ethnic caregivers. The sixmonth
REACH II intervention of 12 individual
in-home and telephone sessions and
five telephone support group sessions targeted
areas linked to caregiver risk and quality
of life: burden, emotional well-being,
self-care/healthy behaviors, social support,
and patient problem behaviors. Control
caregivers received two brief phone calls.
Compared to controls, Latino/Hispanic and
White/Caucasian intervention caregivers experienced
significantly greater improvement
in quality of life, as did Black/African-
American intervention spouse caregivers.
Clinical depression prevalence was also significantly
lower for intervention caregivers.2
An underlying assumption was that the intervention
would reduce caregivers’ stress
and improve their ability to manage behavior
problems, leading to decreased time
spent in caregiving activities. At six months
there was a significant difference for intervention,
compared to control, caregivers in
reported hours providing care. The incremental
cost effectiveness ratio showed that
intervention caregivers had one extra hour
per day not spent in caregiving at a cost of
$5 per day.3
This time finding was borne out in the
HSR&D-funded Memphis VAMC CONNECT
study, a randomized clinical trial of
telephone support groups vs. usual care for
African-American/Black and Caucasian/
White dementia caregivers, who were either
providing care to a veteran or were themselves
a veteran. As in REACH II, the study
focus was on caregiver burden, emotional
well-being, self-care/healthy behaviors, social
support, and patient problem behaviors.
However, the intervention was delivered
through a low staffing, low technology telephone
support group model, with each
group including a group leader and 5 to 6
caregivers. The 14 one-hour sessions over
one year were semi-structured with education,
coping skills, cognitive restructuring,
and support components. On average, from
baseline, intervention caregivers reported
0.46 fewer hours of caregiving time per day
compared to usual care caregivers who reported
1.3 hours more.
In addition to caregiver outcomes, telephone
support also improves patient cost
outcomes. The HSR&D-funded, Telehealth
Education Program (TEP) dementia caregiver
telephone support/education intervention
in VISN 2 has shown a significant
health care cost savings of $2,768 per patient
at six months. TEP was composed of
10 weekly telephone support groups covering
topics similar to the REACH II trial but
focused on spousal caregivers living with
veterans with moderate to severe dementia.
Results from studies like these have encouraged
increased commitment by Congress
and the VA to support caregivers. The Office
of Geriatrics and Extended Care has
convened recent workgroups to develop
best practice recommendations for VHA
concerning dementia training materials, clinical
care, care coordination, and administrative
practices. In FY08, Congress and the
VA awarded nearly $4.7 million to eight
caregiver assistance pilot programs to expand
and improve health care education and
provide needed training and resources for
caregivers who assist disabled and aging veterans
in their homes. One of these projects,
REACH VA, is a clinical translation of the
REACH II study that will provide services
to 350 caregivers at 20 sites.
Finding better ways to support family caregivers,
who are the largest source of longterm
care services in the United States, is a
major public health challenge. These projects
highlight the VA’s commitment to caregivers
and VHA’s leadership in research implementation,
the translation of research findings
into clinical practice and personal behavior.
- Schulz R and L Martire. Family Caregiving of Persons
with Dementia: Prevalence, Health Effects, and Support
Strategies. American Journal of Geriatric Psychiatry 2004;
12:240-9.
- Belle S, et al. for the REACH II Investigators.
Enhancing the Quality of Life of Hispanic/Latino,
Black/African-American, andWhite/Caucasian Dementia
Caregivers: The REACH II Randomized Controlled
Trial. Annals of InternalMedicine 2006; 145:727-38.
- Nichols L, et al. The Cost Effectiveness of a Behavior
Intervention with Caregivers of Alzheimer’s Patients.
Journal of the American Geriatrics Society 2007; Dec 27
[Epub ahead of print].
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