Caregiving for individuals with dementia is an extremely stressful task that exposes caregivers to high levels of physical, mental, and financial strain. Over the past 40 years, a variety of psychosocial interventions have been developed to help caregivers cope with caring for family members with dementia. One of the most studied and effective interventions for caregivers of individuals with dementia is REACH II which served as the basis for its adaptation: REACH VA which is currently being rolled out within the VA. However, studies of even the most effective interventions suggest that a large proportion of caregivers continue to experience significant symptoms post treatment. There is no known research exploring potentially mutable factors that predict treatment outcome, nor are there interventions tailored to the needs of treatment non-responders.
The current study has two primary objectives: (1) identify predictors of response to REACH VA (2) develop and pilot a new intervention designed to address the unique characteristics of those who do not respond to REACH VA.
Participants in the study will be family members who serve as the primary caregiver of an individual with dementia. Participants will undergo an initial interview and will be asked to fill out questionnaires to obtain baseline information about themselves and the individual with dementia.
Phase I: 30 participants will receive REACH VA. Following the 3-4 month REACH VA protocol, preliminary analyses will be conducted to identify variables correlated with magnitude of treatment response. The identified predictors will guide development of the new intervention and non-responders from this phase will also serve as the first group of participants to pilot the new intervention.
Phase II: Non-responders from Phase I will be provided with the newly developed intervention protocol. Furthermore, an additional 20 newly recruited participants will be provided with REACH VA and non-responders will be provided with the new intervention.
Consistent with prior studies, REACH VA was found to positively impact the well being of caregivers. Reach VA was found to reduce caregiver depression (Cohen's d of .45, p<.05) and caregiver burden (Cohen's d =. 70, p<.001).
Quantitative Findings: Variables potentially associated with treatment remission were analyzed with the Wilcoxon rank sum test using SAS. Remission in caregiver burden was defined as Zarit <16. Remission in depression was defined as PHQ-9<5. The PAI was used only in cases when the measure was considered valid based on validity scales built into the measure.
Remission on the Zarit was significantly associated with social support with remitters reporting greater social support than non-remitters from friends and "a special person" than non-remitters. There were no significant differences by remission type for family support. Caregivers who remitted on the Zarit also reported significantly higher pre-dementia attachment security to their care-recipient and significantly lower mean T-scores on the Affective Instability subscale of the PAI than non-remitters.
Remission on the PHQ-9 was significantly associated with the PAI Borderline Affective Instability subscale with remitters reporting significantly less affective instability than non-remitters. The MSPSS Significant Other scale differed by remission status with remitters reporting greater support (trend level, p=.05) from "a special person" than non-remitters. Finally, remitters met fewer criteria (trend level, p=.05) for personality disorder diagnoses than non-remitters.
Qualitative Findings: Consistent with our quantitative findings, qualitative analysis of caregiver and interview data were used to identify six "types" of non-responders, those with: (1) emotion regulation difficulties, (2) limited support/difficulty asking for help, (3) difficulties implementing behavioral strategies, (4) a desire for more support and less structure in the treatment, (5) interpersonal difficulties, and (6) pre-existing knowledge of the information and strategies offered by REACH VA.
This research was the first to attempt to understand and identify factors associated with treatment non-response to REACH VA. It provided data necessary to clarify the ways caregiver factors impact capacity to be positively affected by REACH VA. Identifying these factors will help clinicians to provide the most appropriate services to caregivers. However, it is challenging for clinicians to identify these factors in an efficient manner, as the baseline assessment for caregivers in this study consisted of a battery of measures requiring nearly 4 hours to complete. The next project based on these data will develop a targeted assessment tool that clinicians can use to identify relevant interpersonal predictors of response and intervene on those predictors through a family intervention.
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