NHA’S EFFECT ON THE CAREGIVER

REFERENCES

The taxpayer and the patient are typically the primary targets of consideration when examining the complexities of nursing home admission (NHA), and for good reason:• The cost of nursing home care for persons 65 years of age and over was estimated to be roughly 150 billion dollars by 2007 in the U.S., the majority of which is assumed by taxpayer-financed sources such as Medicaid or Medicare (Gaugler et al., 2007).

• For the patient involved, NHA is associated with a number of other problematic outcomes such as rapid declines in health and increased mortality (Gaugler et al., 2009).

For older adults with dementia or other cognitive impairments, spending the end of life in a nursing home is a common occurrence. A meta-analysis of 77 reports that used longitudinal designs and community-based samples to examine predictors of nursing home admission in the United States revealed that older adults were more than 2.5 times as likely (OR=2.54, 1.44-4.51) to be admitted to a nursing home if they had a cognitive impairment (Gaugler et al., 2007). As many as 90% of people with dementia reportedly become institutionalized before death (Yaffe et al., 2007). This dilemma often weighs heaviest, though, on the estimated 8.9 million (Gaugler et al., 2008) family caregivers of loved ones with dementia. For this population, NHA often becomes a necessary last resort.

CAREGIVER INTERVENTIONINTRODUCTION

Jason M. Sibson, BS, & Hannah J. Harris, MA

Project Sponsor: Brad Powers, PsyD

Nursing home admission: The complex dementia caregiver dilemma

Presented at the 2012 MOAMFT Annual Conference at the School of Professional Psychology at Forest Institute, April 28

Contact: jsibson@forest.edu

The New York University Caregiver Intervention (NYUCI)• Randomized controlled trial of an enhanced counseling and support program for spouse caregivers of persons with Alzheimer’s disease, conducted over 16-year period.

• The NYUCI consisted of three components:1. Six individual and family sessions with counselor (two with the spouse caregiver only and four with the spouse caregiver and at least one other family member)2. Weekly Alzheimer’s Association support group meetings3. Ad hoc counseling (caregivers free to contact study counselors by telephone at any time with concerns, crises, etc.)

• Impact of NYUCI on caregivers of people with Alzheimer’s disease during the transition to NHA:

• Patients whose spouses received the intervention experienced a 28.3% reduction in the rate of NHA compared with usual care controls (Mittelmann et al., 2006).

• Burden and depressive symptoms were significantly lower for caregivers who received the intervention than for the usual care controls at the time of and after NHA (Gaugler et al., 2008).

• NHA alone can reduce burden and depressive symptoms for the majority of dementia caregivers

• Specific factors, though, may lead to an increase in burden experienced by caregivers post-NHA, such as pre-NHA depressive symptoms of the caregiver, the pre-NHA use of adult day services or overnight hospitals, and greater pre-NHA health impairment of the caregiver

• Increased access to counseling and support group services, such as those offered by the Alzheimer’s Association, can significantly improve the dementia caregiver experience before, during, and after NHA

• Increased access to these services can also help delay the NHA transition for dementia caregivers and their loved ones

• Cognitive reframing appears to be a clinically viable treatment technique for dementia caregivers who are experiencing anxiety, depressive symptoms, and stress during difficult transitions.

• Reducing depressive symptoms of the dementia caregiver pre-NHA can reduce the likelihood of the caregiver experiencing increased burden feelings post-NHA

Consider the caregiver• “Perhaps the emphasis on preventing institutionalization is less appropriate than identifying the right time to make the placement decision or determining what types of support are optimal to reduce burden and depression during the period the person is cared for at home as well as during NHA.”

• Gaugler et al., 2010

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for caregivers of people with dementia. Journal of the American Geriatrics Society, 51, 657-664.

Dal Santo, T.S., Scharlach, A.E., Nielsen, J. & Fox, P.J. (2007). A stress process model of family caregiver service utilization: Factors associated with respite and counseling service use. Journal of Gerontological Social Work, 49(4), 29 – 49.

doi:10.1300/J083v49n04_03Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, R. L. (2007). Predicting nursing home

admission in the U.S.: a meta analysis. BMC Geriatrics, 7(13). doi:10.1186/1471-23187-13Gaugler, J. E., Mittelman, M. S., Hepburn, K., & Newcomer, R. (2010). Clinically significant

changes in burden and depression among dementia caregivers following nursing home admission. BMC Medicine, 8(85). Retrieved from:http://www.biomedcentral.com/17417015/8/85Gaugler, J. E., Roth, D. L., Haley, W. E., & Mittelman, M.S. (2008). Can counseling and support reduce burden and depressive symptoms in caregivers of people with Alzheimer’s disease during the transition to institutionalization? Results from the New York University caregiver intervention study. American Geriatrics Society, 56(3), 421-428. doi:10.1111/j.15325415.2007.01593.xGaugler, J. E., Yu, F., Krichbaum, K., & Wyman, J. F. (2009). Predictors of nursing home

admission for persons with dementia. Medical Care, 47(2), 191-198.doi:00257079/09/4702-0191Lee, H., & Cameron, M.H. (2004). Respite care for people with dementia and their carers.

Cochrane Database of Systematic Reviews 2004, 1. doi:10.1002/14651858.CD004396.pub2Mittelman, M. S., Haley, W. E., Clay, O. J., & Roth, D. L. (2006). Improving caregiver well-

being delays nursing home placement of patients withAlzheimer’s disease. Neurology, 67, 1592-1599. doi:10.1212/01.wnl.0000242727.81172.91Nikzad-Terhune, K. A., Anderson, K. A., Newcomer, R., & Gaugler, J. E. (2010). Do trajectories of at-home dementia caregiving account for burden after nursing home placement? A growth curve analysis. Social Work in Health Care, 49, 734-752. doi:10.1080/00981381003635296Schulz, R., O’Brien, A., Czaja, S., Ory, M., Norris, R., Martire, L.M., …, Stevens, A. (2002).

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2090- 2097. Retrieved from www.jama.com

The long-term, non-stop, draining nature of care required by people with dementia has led to the characterization of family caregiving as a “career” (Nikzad-Terhune et al., 2010). While some research suggests that NHA may result in increased guilt, anger, anxiety, and depression for caregivers of people with dementia (Gaugler et al., 2008), most of the studies with larger sample sizes support the notion that NHA significantly decreases the caregiver’s burden and depressive symptoms in the overall samples.• In an examination of data from a large longitudinal study of a counseling and support group intervention on burden and depressive symptoms in dementia caregivers, NHA was found to have the single most powerful effect in reducing burden and depression for spouse caregivers (Gaugler et al., 2008).

However, research by Gaugler et al. (2009, 2010) and Nikzad-Terhune et al. (2010) highlights specific pre-NHA factors that predict clinically persistent or even increased burden and depressive symptoms among caregivers following NHA:• Pre-NHA depressive symptoms were related to post-NHA increases in burden

• Overnight hospital use during the nursing home transition was associated with an increase in caregiving burden and depressive symptoms following NHA

• Caregivers who reported greater pre-NHA health impairment perceived greater burden after NHA

• Care recipients who were male or Caucasian had caregivers indicate greater burden after NHA

• Caregivers who were older or female were more likely to report an increase in depressive symptoms and burden post-NHA

• Increase in pre-NHA adult day service use led to a more difficult emotional transition for caregivers following NHA

• Note: In most studies, caregiver burden was assessed by the Zarit Burden Inventory

Cognitive interventions for dementia caregivers• Cognitive reframing “focuses on altering maladaptive, self-defeating or distressing cognitions and makes them more adapted to the situation” (Vernooij-Dassen, Draskovic, McCleery and Downs, 2011).

• Three different theoretical models for cognitive reframing exist: 1. The stress management model provides caregivers with information (1) to increase their understanding of dementia, (2) to help with behavior management of care receiver and (3) to assist with identifying other support to utilize in the future.2. The stress coping model involves a two-part appraisal process. During the primary appraisal, caregivers assess the level of stress or threat in a particular situation. In the secondary appraisal, caregivers assess their own ability to cope.3. The cognitive behavioral model seeks to confront and change the dysfunctional thoughts a caregiver may have in addition to helping the caregiver develop behavioral skills to aid in the decrease of any stress or anxiety they may have (Vernooij-Dassen, et al., 2011).• Vernooij, et al. (2011) conducted a systematic review of eleven randomized control trials which revealed significant beneficial effects of cognitive reframing interventions on caregiver psychological morbidity. These benefits were demonstrated specifically in regards to anxiety (SMD -0.21; 95% CI -0.39 to -0.04), depression (SMD -0.66; 95% CI -1.27 to -0.05) and subjective stress (SMD -0.23; 95% CI -0.43 to -0.04). However, there were no effects reported in regards to coping, appraisal of burden or reaction to relatives’ behavior.

CLINICAL CONSIDERATIONS