ACT on Alzheimer's



ACT on Alzheimer’s Alzheimer’s Disease CurriculumModule X – Caregiver SupportGUIDELINES FOR AND RESTRICTIONS ON USE OF CURRICULUM MODULESThis curriculum was created for faculty across multiple disciplines to use in existing coursework and/or to develop a stand-alone course in dementia. Due to the fact that not all modules will be used for all disciplines, topics have been divided into ten modules that can be used alone or in combination with other modules. Users may reproduce, combine and/or customize any module text and accompanying teaching slides to meet course needs. Our only restriction on re-use is that the modules not be sold in their current or modified form. NOTE: Recognizing that not all modules will be used with all potential audiences, there is some duplication across the modules to ensure that key information is contained in each module (e.g., screening module is completely duplicated in the diagnosis module because the diagnosis module is not appropriate for all audiences). ? 2012AcknowledgementWe gratefully acknowledge our funding organizations, which made development of this curriculum possible: The Alzheimer’s Association MN/ND Chapter and The Minnesota Area Geriatric Education Center (MAGEC), which is housed in the University of MN School of Public Health, and is funded by the Health Resources and Services Administration (HRSA).We also specially acknowledge the principal drafters of one or more curriculum modules, including Mike Rosenbloom, MD; Olivia Mastry, MPH, JD; Gregg Colburn, MBA; and The Alzheimer’s Association.In addition, we would like to thank the following contributors and the peer review team:Michelle Barclay, MATerry Barclay, PhDMarsha Berry, MA, CAEdSue Field, DNP, RN, CNEJulie Fields, PhD, LPJane Foote EdD, MSN, RNErin Hussey, DPT, MS, NCSHelen Kivnik, PhDKenndy Lewis, MSRiley McCarten, MDTeresa McCarthy, MD, MS, Lynne Morishita, GNP, MSNBecky Olson-Kellogg, PT, DPT, GCSJim Pacala, MD, MSPatricia Schaber, PhD, OTR/LJohn SelstadEricka Tung, MD, MPHJean Wyman, PhD., RN, GNP-BC, FAAN, FGSAThis curriculum is available for use and/or customization by anyone, as long as it is not sold in its current or modified form.This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under Grant Number UB4HP19196 to the Minnesota Area Geriatric Education Center (MAGEC) for $2,192,192 (7/1/2010—6/30/2015). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.Minnesota Area Geriatric Education Center (MAGEC)Grant #UB4HP19196Director: Robert L. Kane, MDAssociate Director: Patricia A. Schommer, MAOverview of Alzheimer’s Disease CurriculumThis module is part of the Alzheimer’s Disease Curriculum developed by ACT on Alzheimer’s. ACT on Alzheimer’s is a statewide, voluntary collaboration that includes over 50 organizations and 150 individuals seeking to prepare for the budgetary, social, and personal impacts of Alzheimer’s disease. All of the modules can be found online at Module I:Disease DescriptionModule II:DemographicsModule III:Societal ImpactModule IV:Effective Interactions Module V:Cognitive Assessment and the Value of Early DetectionModule VI:ScreeningModule VII:Disease Diagnosis Module VIII: Quality InterventionsModule IX: Dementia as an Organizing Principle of CareModule X:Caregiver SupportModule XI:Alzheimer’s Disease ResearchModule XII:GlossaryACT on Alzheimer's has developed a number of practice tools and resources to assist providers in their work with patients and clients who have memory concerns and to support their care partners. Among these tools are a protocol practice tool for cognitive impairment, a decision support tool for dementia care, a protocol practice tool for mid- to late-stage dementia, care coordination practice tools, and tips and action steps to share with a person diagnosed with Alzheimer's. These best practice tools incorporate the expertise of multiple community stakeholders, including clinical and community-based service providers:Clinical Provider Practice ToolElectronic Medical Record (EMR) Decision Support ToolManaging Dementia Across the ContinuumCare Coordination Practice ToolCommunity Based Service Provider Practice ToolAfter A DiagnosisWhile the recommended practices in these tools are not state-specific, many of the resources referenced are specific to Minnesota.? The resource sections of these tools can be adapted to reflect resources specific to your geographic area.?To access ACT tools visit: X: Learning ObjectivesUpon completion of this module the student should:Identify the difficult aspects of being a caregiver for someone who has dementia.Demonstrate an understanding of and distinguish between activities of daily living (ADLs) and instrumental activities of daily living (IADLs).Gain insight into the cost, stressors, and risks that affect caregivers, including the correlation between a caregiver’s health and well-being with the well-being of the person for whom they are caring.Recognize services that can be used to decrease stressors.Module XCaregiver SupportCase Study:Mr. Johnson, a 71 year-old man with a history of diabetes who currently lives alone, is brought into the clinic by his son, Dave. Mr. Johnson does not believe he has any significant memory problems, yet Dave describes 2.5 years of progressive memory deficits characterized by increasing late fees while paying bills and difficulty maintaining the household. Over the past three months, Dave has received repeated phone calls from his father in which he complains repeatedly about losing items around the household. At one point, he wondered whether somebody was stealing his keys and reading glasses. Originally, Dave suspected that his father was fixated on this topic but, over time, it became clear that he had forgotten about the original conversations. His cognitive review of systems is remarkable for forgetting appointments and becoming lost while driving in familiar neighborhoods. Dave mentions that he is worried about his dad’s driving as well. He denied any specific symptoms for depression.The past medical history includes diabetes and hypertension. He was previously on a more complicated medication regimen aiming for “tighter” blood sugar control. He is now taking metformin, which is taken two times a day, lisinopril, and a baby aspirin, which can be taken once a day. He will occasionally take Tylenol PM (with diphenhydramine) at night for sleep. The primary provider is hoping that simplifying the medication regimen will make it easier for Mr. Johnson to follow instructions accurately. Mr. Johnson is a retired janitor with a high school education. No active smoking or drinking. There is a family history of Alzheimer’s disease in his father who developed symptoms at age 81. Neurological exam was non focal. Neuropsychological screening showed a MoCA=21 (losing points for cube copy, 1/5 words after 5 minutes [could not recognize when given a list], orientation to date, clock draw). Laboratory studies showed normal complete blood count, electrolytes, LFTs, glucose, thyroid stimulating hormone, and B12 levels. A referral was made for neuropsychological testing: Mr. Johnson showed severe deficits in learning and memory, moderate deficits in visuospatial function, and mild executive impairments. The Geriatric Depression Scale score was 2 and within normal limits. Brain MRI was positive for bilateral hippocampal and parietal atrophy, but no evidence for stroke or focal lesions.Mr. Johnson was diagnosed by his primary provider with probable Alzheimer’s disease. Dave inquired about any interventions that can possibly slow or treat the disease process. It is clear that Dave is distressed about his father’s new diagnosis. He has many questions about his father’s safety and how he can proactively take steps to ensure his dad’s well-being.Pharmacological Intervention:Mr. Johnson is started on Donepezil 5 mg daily for 1 month, increasing to 10 mg daily thereafter. The primary provider explains that this medication only provides symptomatic treatment and does not slow the disease process. It is recommended that the patient avoid taking Tylenol PM due to the diphenhydramine’s anticholinergic effects, and he is prescribed trazodone 50 mg at night for insomnia. Since the patient had no evidence for depression by history and score on the Geriatric Depression Scale, there is no role for an antidepressant. Non-Pharmacological InterventionThe primary provider has a Family Meeting where he counsels Mr. Johnson and Dave about healthy lifestyle, safety concerns, maximizing his function, socialization, and ongoing education and support of Mr. Johnson and Dave, his care partner. This is the first time that Dave realizes that he is a “care partner.” Physical activity is the priority, given Mr. Johnson’s diabetes and literature supporting favorable impact of this intervention upon cognition. The patient was recommended to use his home exercise bike for 30 minutes at a time for 3 days weekly. After discussing options for increasing cognitive activity, the patient decides to meet friends to play cards at the senior center twice a week in addition to daily reading. He is also enrolled in a Brain & Body Wellness Program. He is provided a calendar to write down his appointments and activities. At the Brain and Body Wellness program, the health educators stress the importance of a daily routine. The primary provider has numerous safety concerns about Mr. Johnson’s living situation. In the setting of newly diagnosed Alzheimer’s disease, Mr. Johnson has an increased risk for mediation non-adherence. The primary provider recommends that he utilize a pillbox with daily reminders from his son. Dave feels he is able to visit his father once a week and set up two pillboxes indicating the days of the week, one marked “morning” and one marked “evening”; when he makes reminder calls, he can tell his father to take the pills from the appropriate box and indicate the day of the week so that the correct medications are taken. When Dave calls to remind Mr. Johnson about his medication, he will also review the day’s activities with him and write them on a white board on the back of his front door. Mr. Johnson and his son get along well. The primary provider discusses the importance of the care partner; Dave will accompany his father to follow-up appointments so that he will also hear the treatment plan, when the next appointment should be, and symptoms and signs to look for that would indicate a need for a more urgent visit.A home care nurse is arranged to go to the home to assess Mr. Johnson’s home situation for safety, assess if he is able to follow phone instructions from his son accurately, ensure that he is eating regularly, and ensure adequate housekeeping. Mr. Johnson and Dave decide that it might be a good idea to try putting a small table by the front door where he can leave his keys and a stand up glasses case can be placed next to his favorite reading chair. They will put a white board on the back of the front door indicating where the keys and reading glasses might be. If this doesn’t work, they will try another plan.In addition, it is suggested that Dave and his father discuss the possibility of Dave obtaining power of attorney and beginning to manage the patient’s finances. All bills are subsequently placed on autopay. Mr. Johnson has been responsible for his own meals. There have been no problems thus far with forgetting to shut off stove burners. The family is counseled about other options that include prepared meals and microwave meals as well as Meals on Wheels. Mr. Johnson’s primary provider shares Dave’s concerns about Mr. Johnson’s driving safety. Due to symptoms of disorientation in familiar places, the primary provider recommends a formal driving evaluation through occupational therapy. Mr. Johnson is instructed not to drive until this evaluation has been completed. Dave sets up transportation to and from the Senior Center for the card game sessions. They will find out if this senior center has meals, and if so, he may eat a warm lunch with his friends on card game days.The primary provider makes a referral to the Alzheimer’s Association to provide additional education regarding Alzheimer’s disease and information relating to community resources. Mr. Johnson and Dave begin care consultation to learn about the disease, what they might expect as a course of progression, and how to prepare to manage at later stages of the disease. The primary provider sees Mr. Johnson and Dave in follow-up appointments to see how they are coping at home with the new diagnosis. He is tolerating the donepezil without difficulty and adjusting well to his new schedule. His primary provider uses the opportunity to discuss Mr. Johnson’s overall healthcare goals, hopes, and fears about the future. Mr. Johnson would like both of his sons to be his joint health care proxies. He mentions his fears about losing his independence and goal of staying in his own home as long as possible. Given this information, they discuss the importance of identifying a health care proxy and writing an advance directive. They make a plan to see each other in three months for follow-up. The Nature of Caregiving for Individuals with DementiaCaregiving is a term that generally encompasses extraordinary care that exceeds the bounds of what is usually considered typical responsibilities for others (Zarit, 2009), (Alzheimer’s Association, 2014). This includes helping with one or more activities of daily living (ADLs), including dressing, bathing, incontinence, and feeding. It also includes providing help with instrumental activities of daily living (IADLs), such as shopping, meal preparation, transportation, medication management, and managing finances. In addition, caregiving includes providing emotional support, personal care, and case management (Zarit, 2009). Caregivers of individuals with dementia are more heavily involved with ADLs and IADLs and dedicate more time to these responsibilities (Alzheimer’s Association and National Alliance for Caregiving, 2004), (National Alliance for Caregiving and American Association for Retired Persons, 2009), (Zarit, 2009). Caregivers of those with dementia also face increased emotional and psychological challenges given that the individual they are caring for, usually a loved one, often loses the ability to recognize the caregiver and can exhibit challenging behaviors as a part of the disease process (Alzheimer’s Association and National Alliance for Caregiving, 2004), (Zarit, 2009). The Dementia CaregiverCaregivers of individuals with dementia are usually adult children, spouses, or other relatives of the individual with dementia (Gitlin & Schulz, 2012), (National Alliance for Caregiving and American Association for Retired Persons, 2004, 2009). Most caregivers are women who have had some college education, manage work and career at some point in their lives, and spend an average of 20 or more hours per week providing unpaid care to someone 50 years or older (Bouldin & Andresen, 2010). Caregivers of people with dementia are more likely to provide a higher level of care for a longer period of time, greatly increasing their sense of burden (National Alliance for Caregiving and American Association for Retired Persons, 2009), sometimes providing more than 80 hours of care per week (National Alliance for Caregiving and American Association for Retired Persons, 2004). While all caregivers are at risk for both physical and psychological hardships (Alzheimer’s Association, 2014), female caregivers in this category are especially at risk for health problems (Zarit, 2009).For education videos on caregiver issues, view: ; on Alzheimer’s Tool: The After a Diagnosis Tool offers Action steps and tips medical and provider professionals can share with individuals and their family when a diagnosis of Alzheimer's or dementia is made.The Managing Dementia Across the Continuum Tool offers a flow chart reflecting the importance of identifying, assessing and supporting the dementia caregiver from at the outset of the care and support process.)The Risks Associated with CaregivingOver two decades of research has shown family caregivers to be a vulnerable and at-risk population that the health and long-term care system often neglects (National Family Caregiver Alliance, 2012), (Schulz & Sherwood, 2008). There are many risks associated with caregiving for individuals with dementia including physical, social, psychological, and financial risks.Physical Risks. Caregiving is laden with physical risks. The prolonged distress and physical demands of caregiving compromise caregivers’ physiological functioning and increase their risk for health problems. Caregivers tend to have less time to rest when sick and less time to exercise or to get adequate rest (Zarit, 2009). Caregivers consistently report decreased overall health and increased health problems (National Alliance for Caregiving and American Association for Retired Persons, 2009), which can also contribute to increased rates of depression (Schulz, et al., 1995). Research has shown that female caregivers providing more than eight hours of caregiving per week were twice as likely as non-caregivers to have coronary heart disease, likely due to elevated blood pressure, increased risk for hypertension, and poorer immune functioning (Lee, et al., 2003). Caregivers are also less likely to engage in preventive health behaviors and exhibit increased cardiovascular reactivity (Lee, et al., 2003), and they have a greater prevalence of chronic illnesses and higher mortality risk than non-caregivers (Schulz, et al., 1995), (Pinquart & S?rensen, 2003).Social Risks. In addition to physical risks, caregivers often face social isolation. Caregiving for individuals with dementia can be so time-consuming and demanding that many caregivers have less time for family and friends. Many caregivers report having to give up social activities and other personal pleasures and report higher levels of conflict among family (Ory, et al., 1999), (Alzheimer’s Association, 2014). These conflicts may further isolate caregivers from family and friends, which contributes to the feeling of being alone. Dementia caregiving can be especially challenging for spousal caregivers who report higher levels of marital conflict and decreased levels of positive interactions with their spouse (Narayan, et al., 2001). Dementia materially changes the nature of the marital relationship, which can be difficult for both spouses.Psychological Risks. Caregivers are also at risk of diminished emotional health and well-being. The psychological implications can be vast. Depression is a serious risk factor for caregivers and presents in multiple ways including stress, anxiety, fatigue, and insomnia (Gallagher-Thompson, et al., 1989), (Dura, et al., 1991). In 2009, a survey conducted by the National Alliance of Caregivers and AARP found that 40 percent of caregivers reported high emotional stress in their caregiving roles. Stress is consistently linked to depression, which can not only impact the caregiver, but also indirectly has negative consequences for the care recipient. This survey found that caregivers who reported high emotional stress tended to be women who were primary caregivers living with the care recipients and feeling that they had no choice in taking on the role of caregiver (National Alliance for Caregiving and American Association for Retired Persons, 2009; Alzheimer’s Association, 2014). Caregiving is also associated with anxiety disorders compared to others who are not in a caregiving role. Caregivers of people with dementia are 10 times more likely to meet criteria for an anxiety disorder compared to non-dementia caregivers (Dura, et al., 1991).Financial Risks. Caregiving poses financial burdens on caregivers. Caregivers make many financial sacrifices, including spending out of pocket on their care recipient’s needs, even if the care recipient is not a dependent of the caregiver. This may include making work adjustments, retiring early, losing job benefits, or going to work late, leaving early, or taking time off to provide care (National Alliance for Caregiving and American Association for Retired Persons, 2009), (Zarit, 2009), (Ory, et al., 1999). Caregivers also have increased costs due to their own health issues, which increase while in the caregiving role. In one study, caregivers’ overall use of health services increased by 25% and use of hospital and emergency room visits doubled in an 18-month study period (National Alliance for Caregiving, Schulz & Cook, 2011).Imperative for Supporting Caregivers Caregivers play a critical role in supporting individuals with dementia and without them the health care system could not sustain the costs of care for persons with dementia. Currently, 70% of individuals with Alzheimer’s disease and related dementias live at home. Eighty percent of care provided at home is delivered by family caregivers; fewer than 10 percent of older adults receive all of their care from paid workers. This results in over 15 million Americans providing unpaid care for those with dementia. In 2013, caregivers of individuals with dementia provided an estimated 17.7 billion hours of unpaid care, a contribution to the nation valued at over $220 billion (Alzheimer’s Association, 2014). This number represents an average of 21.9 hours of care per caregiver per week, or 1,139 hours of care per caregiver per year. With this care valued at $12.45 per hour, the estimated economic value of the care provided by family and other unpaid caregivers of people with Alzheimer’s disease and other dementias was $220.2 billion in 2013 (Alzheimer’s Association, 2014). Caregivers’ health and well-being is critical to their ability to continue to provide the vital caregiving role. For example, depression reduces a caregiver’s ability to continue to provide for an individual with dementia (Mok, et al., 2007) and may lead to increased depression in the care recipient, which can further impair health and function associated with dementia itself (Eisendorf, et al., 2003). Likewise, caregivers who report feeling stressed because of the impaired person’s behavioral symptoms are more likely to place their care recipient in a nursing home (Alzheimer’s Association, 2014). The close connection between caregiver health and well-being and caregiver ability to fulfill the caregiving role calls for assuring the availability of effective caregiver supports to assist caregivers in maintaining their health and well-being. Although caregivers acknowledge the challenges and difficulties of caregiving, they also report that there are many positive aspects of their caregiving role such as feeling useful, important, and competent (Boerner, et al., 2004), (Cohen, et al., 2002), (Zarit, 2012). While evidence is still emerging regarding a predictive profile of caregiver well-being, we have learned that a caregiver with a positive outlook on caregiving may experience less stress and physical ailments and be able to sustain the caregiver role longer (Cohen, et al., 2002). Caregivers who reported more positive feelings are less likely to report depression (Cohen, et al., 2002), even following bereavement (Boerner, et al., 2004). Thus, caregivers need support that will not only help them understand the challenges of dementia, but also help them maintain a positive outlook on their role. Types and Effective Components of Caregiver SupportGeneral types of caregiver support include information and assistance, respite, counseling, support groups, education, personal care, homemaker/chore services, legal or financial services, and care consultation. There is increasing evidence that caregiver assessment, education, and community resource referral can all lead to improved well-being and enhancements in quality of life for both caregiver and care receiver (Gitlin, et al., 2010), (Logsdon, et al., 2007), (S?rensen, et al., 2002). Likewise, increased social support has been linked to greater well-being (Atienza, et al., 2001), (Cohen, et al., 1986), (Cohen & Wills, 1985), and caregivers who have greater support from their spouses and families have a lower risk for depression (Atienza, et al., 2001), (Hooker, et al., 1998), (State of California, 2008). Core components of effective caregiver interventions have been synthesized and found to share the following characteristics (Zarit, 2009), (Rosalynn Carter Institute for Caregiving, 2012), (Cameron, et.al., 2008), (University of Michigan-Michigan Dementia Coalition Assessment, 2011). Assessment. Gathering information to identify caregiver needs, resources, and strengths is critical for determining appropriate goals and matching interventions most appropriate for the caregiver in achieving the desired goals. Caregiver needs will change as the disease progresses, thus periodic follow up assessment is also important to evaluate the effectiveness of the intervention (Schulz, 2005). A listing of caregiver assessments can be found at Clarification of Goals and Interventions Tailored to meet Specific Goals. It is important that health and community-based providers individualize treatment or care to the aspects of caregiving that are most troubling to a particular caregiver. This may be as simple as offering very specific skill-building or problem-solving tools rather than a more comprehensive intervention. Hence, to assure effectiveness, caregivers should be provided support to address only those areas of caregiving that are stressors to a particular caregiver. This will assure that treatable components of the caregiving stress process are addressed, fostering effectiveness, efficiency, and cost management (Zarit, 2009), (Mittelman, et al., 2004), (Sorensen, et. al., 2002), (Pinquart & Sorenson, 2006), (Etters, et al., 2008).Education about the disease/disability and its effects on behavior. Studies have shown that greater knowledge of the disease, its progression, and its effects on well-being increases feelings of competence, confidence, and less overall distress in caregivers (Blieszner & Roberto, 2010), (Graham, et al., 1997), (Hepburn, et al., 2007), (Zarit, 2009).Problem solving. Problem solving specific to and tailored for the unique circumstances and individuals (Zarit, 2009), (Hepburn, 2007), (Hepburn, 2003).Other supportive interventions. Other interventions might include direct support of the caregiver, family meetings, and respite (Zarit, 2009), (Hepburn, 2007), (Hepburn, 2003).Additionally, within supportive interventions, studies have shown that certain attributes of support lead to better results, including:Contact with a helper over time who is following specific intervention protocols. Receiving help from a consistent person over time has been shown to be important in effective caregiver support. It is also critical to assure that the helper is following protocols designed to meet the specific goals of the caregivers (National Institute of Nursing Research, 2001), (Teri, 1999), (Thompson, et al., 1996), (Schulz, et al., 2000).Multi-component interventions. Interventions that include a combination of knowledge, skill building, behavior and problem solving, and counseling have consistently been effective?(Brodaty, et al., 2012), (Carnevale, et al., 2002), (Grant, et al., 2001), (Lewis, et al., 2009), (Paun, et al., 2004), (Query, et al., 2003), (Schulz, et al., 2005).Interventions with higher intensity. Interventions that have high levels of frequency and duration have been shown to be more effective than those that do not (Schulz, et al., 2005).Service combinations. Using a combination of home-visiting, telephone follow-up, internet and telehealth technology to deliver?care and services has been shown to be beneficial (Davis, et al., 2004), (Eisdorf, et al., 2003), (Mahoney, et al., 2003), (National Institute for Nursing Research, 2001). Local programs. Programs developed and implemented locally and involving agency collaboration have been shown to be beneficial?(Fallcreek, 2003), (Tremethick, et al., 2004), (Volkov et al., 2011), (Wilken, et al., 1999).Evidence-Based InterventionsThere are four categories of empirically supported interventions for caregiver support: 1) multidimensional interventions; 2) behavioral interventions; 3) group interventions; and 4) respite services (Zarit, 2009). Family-focused interventions and those that train caregivers in behavior management have had the best outcomes to date (Zarit, 2009), (Hepburn 2007; 2003; 2001). 1) Multidimensional Interventions: These types of interventions are designed to address stress at multiple levels. Thus, they incorporate multiple component support protocols such as the following:Caregiver and family education about dementia and its effects on behaviorBehavioral problem solving training so that caregivers learn how to reduce the care recipient’s exposure to triggering events or conditionsFamily meetings to provide information about the disease and identify assistance that would be helpful to the caregiver and care recipientIndividual and family counselingSupport groupsCare managementStudies using a combination of the intervention elements listed above reflected decreased symptoms of depression and burden for caregivers in both the long and short term, lower appraisals of care stressors, improved quality of life, and in-home care for their relatives for a longer period of time (Mittelman, 1995), (Mittelman, 2004), (Mittelman, et al., 2006), (Belle, et al., 2006), (Gitlin, et al., 2012).2) Behavioral Interventions. Later in the disease process, it may be useful to focus on training caregivers to use specific techniques to manage targeted behavioral issues. The results of studies in this area indicate positive outcomes if caregivers of individuals with dementia are trained to more frequently offer and engage their care recipients in recreational activities, manage a healthy sleep schedule, and implement problem-solving strategies to address difficult behaviors. The person with dementia experienced positive outcomes such as reduced depression, increased physical functioning, and improved sleep. Caregivers in these studies also had less depression and subjective burden (McCurry, et al., 2005), (Teri, et al., 1997), (Teri, et al., 2003). Further, a meta-analysis of 179 randomized controlled trials found that multi-component behavioral interventions had positive effects on cognition, ADLs, behavior, and mood that were at least as good as medication, and additionally, delayed institutionalization of persons with dementia (Olazaran, et al., 2010).3) Group Interventions. While support groups are popular and offer opportunities to engage caregivers and reduce social isolation, there is limited evidence of the effectiveness of the support groups. Those support groups that have been shown to have the most positive effects are those that focus on a limited set of outcomes, such as teaching particular skills or strategies (Zarit, 2009). This approach to support group results in more clear positive outcomes compared with groups that address a broad range of issues or let the participants direct the agenda (Coon, 2003), (Herbert, 2003).4) Respite Services. As the disease progresses and a person with dementia is less independent, respite can support caregivers to enable them to have time off. The goal of such care is to decrease both the emotional and physical burden on caregivers. While evidence is limited as to whether respite care achieves these goals, some studies establish that caregivers who use respite care consistently and for a prolonged period of time experience decreased feelings of overload and decreased depression (Zarit, 1998), (Gitlin, et al., 2006), (Droes, et al., 2006). However, recent evidence appears to support the potentially positive effects of respite care on emotional and physical burden. A study that examined blood levels of a biomarker of stress reactivity (DHEA-S) that is believed to protect against the physiologically damaging effects of stress showed an increase in DHEA-S following engagement of respite care versus no increase on days when no respite care was undertaken, and this was associated with daily positive mood (Zarit, et al., 2014).A description of dementia caregiver interventions can be found at compendium of Innovative Interventions for Persons with Alzheimer’s Disease and Their Caregivers can be found at X: Questions for ReviewCaroline is the primary caregiver for her 82-year-old mother; Ethel. Ethel was diagnosed with Alzheimer’s disease 5 years ago. She lived in her own home until 3 years ago when her daughter noted that Ethel was having difficulty preparing meals, keeping track of her medications, and managing her finances. Ethel has gradually required more and more assistance from her daughter. A year ago Caroline began to help her mother with taking a shower. In recent months Caroline has taken on the responsibility of assisting her mother with dressing every morning and using the toilet appropriately. Caroline notes that she has begun to limit her outside activities. She no longer sees her friends regularly and has had to quit the part-time job she enjoyed and relied on for supplemental income. She finds herself irritable and increasingly fatigued. Caroline notes that despite a good relationship in the past, she and her mother are arguing frequently about issues that are related to her mother’s forgetfulness. Caroline was recently diagnosed with hypertension and has had to take prescription medications for the first time in her life. She has not had a vacation since her mother came to live with her.Ethel moved in with Caroline due to deficits in: ADL functionIADL functionWalking abilityCurrently Ethel is demonstrating deficits in the following ADLs except:BathingDressing FeedingToiletingCaroline is dealing with caregiver stress in which realm(s)?PhysicalSocialPsychologicalAll the aboveBecause of Caroline’s caregiver stress, studies show that Ethel is at higher risk of:Nursing home placementFallsWoundsObesityWhat is a key characteristic of effective caregiver support interventions:They are done in the caregiver’s homeFinancial support is providedA detailed caregiver assessment is performed to identify goalsThe interventions are of low intensityThe most effective caregiver support programs studied to date are those that include family-focused interventions and train caregivers in behavior management.T/F ReferencesAlzheimer’s Association. (2012). 2012 Alzheimer’s Disease Facts and Figures. 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