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November 13, 2006

Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease

November 14, 2006 issue
67 (9) 1592-1599


Objective: To determine the effectiveness of a counseling and support intervention for spouse caregivers in delaying time to nursing home placement of patients with Alzheimer disease (AD), and identify the mechanisms through which the intervention accomplished this goal.
Methods: We conducted a randomized controlled trial of an enhanced counseling and support intervention compared to usual care. Participants were a referred volunteer sample of 406 spouse caregivers of community-dwelling patients who had enrolled in the study over a 9.5-year period. The intervention consisted of six sessions of individual and family counseling, support group participation, and continuous availability of ad hoc telephone counseling. Structured questionnaires were administered at baseline and at regular follow-up intervals, every 4 months for the first year and every 6 months thereafter. Cox proportional hazard models were used to test the effects of the intervention on the time to nursing home placement for the patients after controlling for multiple time-invariant and time-dependent predictors of placement.
Results: Patients whose spouses received the intervention experienced a 28.3% reduction in the rate of nursing home placement compared with usual care controls (hazard ratio = 0.717 after covariate adjustment, p = 0.025). The difference in model-predicted median time to placement was 557 days. Improvements in caregivers’ satisfaction with social support, response to patient behavior problems, and symptoms of depression collectively accounted for 61.2% of the intervention’s beneficial impact on placement.
Conclusion: Greater access to effective programs of counseling and support could yield considerable benefits for caregivers, patients with Alzheimer disease, and society.

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Eaker ED, Vierkant RA, Mickel SF. Predictors of nursing home admission and/or death in incident Alzheimer’s disease and other dementia cases compared to controls: a population-based study. J Clin Epidemiol 2002;55:462–468.
Stevens A, Owen J, Roth D, Clay O, Bartolucci A, Haley WE. Predictors of nursing home placement in White and African American individuals with dementia. J Aging Health 2004;16:375–397.
Mausbach BT, Coon DW, Depp C, et al. Ethnicity and time to institutionalization of dementia patients: a comparison of Latina and Caucasian female family caregivers. J Am Geriatr Soc 2004;52:1077–1084.
Gaugler JE, Edwards AB, Femia EE, et al. Predictors of institutionalization of cognitively impaired older adults: Family help and the timing of placement. J Gerontol B Psychol Sci Soc Sci 2000;55b:P247–P256.
Schulz R, Belle SH, Czaja SJ, McGinnis KA, Stevens A, Zhang S. Long-term care placement of dementia patients and caregiver health and well-being. JAMA 2004;292:961–967.
MetLife market survey of nursing home & home care costs. Available at: Accessed February 14, 2005.
Rhoades JA, Sommers JP. Trends in nursing home expenses, 1987 and 1996. Health Care Financ Rev 2003;25:99–114.
Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B. A family intervention to delay nursing home placement of patients with Alzheimer disease: a randomized controlled trial. JAMA 1996;276:1725–1731.
Pastor PN, Makuc DM, Reuben C, Xia H. Chartbook on trends in the health of Americans. In: Health, United States. Hyattsville, MD: National Center for Health Statistics; 2002.
Mittelman M, Roth D, Coon D, Haley WE. Sustained benefit of supportive intervention for depressive symptoms in Alzheimer’s caregivers. Am J Psychiatry 2004;161:850–856.
Mittelman MS, Roth DL, Haley WE, Zarit S. Effects of a caregiver intervention on negative caregiver appraisals of behavior problems in patients with Alzheimer’s disease: Results of a randomized trial. J Gerontol B Psychol Sci Soc Sci 2004;59B:27–34.
Haley WE, Levine EG, Brown SL, Bartolucci AA. Stress, appraisal, coping, and social support as predictors of adaptational outcome among dementia caregivers. Psychol Aging 1987;2:323–330.
McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA work group under the auspices of Department of Health & Human Services Task Force on Alzheimer’s disease. Neurology 1984;34:939–944.
Mittelman MS, Epstein C, Pierzchala A. Counseling the Alzheimer’s caregiver: A resource for health care professionals. Chicago, IL: AMA Press; 2003.
Social Security Death Index on the World Wide Web. Available at: Accessed February 2006.
Reisberg B, Ferris SH, de Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139:1136–1139.
Zarit SH, Orr NK, Zarit JM. Families under stress: caring for the patient with Alzheimer’s disease and related disorders. New York, NY: New York University Press; 1985.
Brink TL, Yesavage JA, Lum O, et al. Screening tests for geriatric depression: Geriatric Depression Scale. Clin Gerontol 1982;1:37–43.
Roth DL, Burgio LD, Gitlin LN, et al. Psychometric analysis of the Revised Memory and Behavior Problems Checklist: factor structure of occurrence and reaction ratings. Psychol Aging 2003;18:906–915.
Stokes JP. Predicting satisfaction with social support from social network structure. Am J Community Psychol 1983;11:141–152.
Duke Center for the Study of Aging and Human Development. Multidimensional Functional Assessment: The OARS Methodology. Durham, NC: Duke University Press; 1978.
Allison PD. Survival analysis using the SAS System: a practical guide. Cary, NC: SAS Institute; 1995.
Hosmer DW, Lemeshow S. Applied survival analysis: Regression modeling of time to event data. New York, NY: Wiley; 1999.
Strain LA, Blandford AA, Mitchell LA, Hawranik PG. Cognitively impaired older adults: risk profiles for institutionalization. Int Psychogeriatr 2003;15:351–366.
Yaffe K, Fox P, Newcomer R, et al. Patient and caregiver characteristics and nursing home placement in patients with dementia. JAMA 2002;287:2090–2097.
Cohen CA, Gold DP, Shulman KI, Wortley JT, McDonald G, Wargon M. Factors determining the decision to institutionalize dementing individuals: A prospective study. Gerontologist 1993;33:714–720.
Mittelman MS, Ferris SH, Shulman E, et al. A comprehensive support program: effect on depression in spouse-caregivers of AD patients. Gerontologist 1995;35:792–802.
Hebert R, Dubois MF, Wolfson C, Chambers L, Cohen C. Factors associated with long-term institutionalization of older people with dementia: data from the Canadian Study of Health and Aging. J Gerontol A Biol Sci Med Sci 2001;56:M693–M699.
Fisher L, Lieberman MA. A longitudinal study of predictors of nursing home placement for patients with dementia: the contribution of family characteristics. Gerontologist 1999;39:677–686.
Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001;134:663–694.
Berger VW. A novel criterion for selecting covariates. Drug Information J 2005;39:233–241.
Steyerberg EW, Bossuyt PM, Lee KL. Clinical trials in acute myocardial infarction: should we adjust for baseline characteristics? Am Heart J 2000;139:745–751.
Shrout PE, Bolger N. Mediation in experimental and nonexperimental studies: new procedures and recommendations. Psychol Methods 2002;7:422–445.
Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173–1182.
Judd CM, Kenny DA, McClelland GH. Estimating and testing mediation and moderation in within-subjects designs. Psychol Methods 2001;6:115–134.
Roth DL, Mittelman MS, Clay OJ, Madan A, Haley WE. Changes in social support as mediators of the impact of a psychosocial intervention for spouse caregivers of persons with Alzheimer’s disease. Psychol Aging 2005;20:634–644.
Satagopan JM, Ben-Porat L, Berwick M, Robson M, Kutler D, Auerbach AD. A note on competing risks in survival data analysis. Br J Cancer 2004;91:1229–1235.
Tai BC, Machin D, White I, Gebski V. On behalf of the EOI (The European Osteosarcoma Intergroup). Competing risks analysis of patients with osteosarcoma: a comparison of four different approaches. Stat Med 2001;20:661–684.
Skaff MM, Pearlin LI, Mullin JT. Transitions in the caregiving career: effects on sense of mastery. Psychol Aging 1996;11:247–257.
Mace NL, Rabins PV. The 36 hour day: A family guide to caring for persons with Alzheimer disease, related dementing illnesses, and memory loss in later life. New York, NY: Warner Books; 2001.
Aneshensel CS, Pearlin LI, Levy-Storms L, Schuler RH. The transition from home to nursing home mortality among people with dementia. J Gerontol B Psychol Sci Soc Sci 2000;55B:S152–S162.
Gitlin LN, Belle SH, Burgio LD, et al. Effect of multicomponent interventions on caregiver burden and depression: The REACH multisite initiative at 6-month follow-up. Psychol Aging 2003;18:361–374.
Sloane PD, Zimmerman S, Suchindran C, et al. The public health impact of Alzheimer’s disease, 2000–2050: potential implication of treatment advances. Annu Rev Public Health 2002;23:213-231.
Mant J, Carter J, Wade DT, Winner S. Family support for stroke: a randomised controlled trial. Lancet 2000;356:808–813.
Sörensen S, Pinquart M, Duberstein P. How effective are interventions with caregivers? An updated meta-analysis. Gerontologist 2002;42:356–372.
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.

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Published In

Volume 67Number 9November 14, 2006
Pages: 1592-1599
PubMed: 17101889

Publication History

Published online: November 13, 2006
Published in print: November 14, 2006


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Affiliations & Disclosures

Mary S. Mittelman, DrPH
From the Department of Psychiatry (M.S.M.), New York University School of Medicine, NY; School of Aging Studies (W.E.H.), University of South Florida; and Department of Biostatistics (O.J.C., D.L.R.), University of Alabama at Birmingham.
William E. Haley, PhD
From the Department of Psychiatry (M.S.M.), New York University School of Medicine, NY; School of Aging Studies (W.E.H.), University of South Florida; and Department of Biostatistics (O.J.C., D.L.R.), University of Alabama at Birmingham.
Olivio J. Clay, MA
From the Department of Psychiatry (M.S.M.), New York University School of Medicine, NY; School of Aging Studies (W.E.H.), University of South Florida; and Department of Biostatistics (O.J.C., D.L.R.), University of Alabama at Birmingham.
David L. Roth, PhD
From the Department of Psychiatry (M.S.M.), New York University School of Medicine, NY; School of Aging Studies (W.E.H.), University of South Florida; and Department of Biostatistics (O.J.C., D.L.R.), University of Alabama at Birmingham.


Address correspondence and reprint requests to Dr. Mary Mittelman, Department of Psychiatry, New York University School of Medicine, 550 First Avenue, New York, NY 10016; e-mail: [email protected]

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