Mental Health Nursing - PDF

Running head: MENTAL HEALTH-NURSING
Effectiveness of support group and individual counseling for formal caregivers of people with
dementia
Name of the student:
Name of the University:
Author’s note

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Table of Contents
Abstract:...........................................................................................................................................2
Background:.....................................................................................................................................3
Review questions, objectives, PICO:...............................................................................................9
Review design:...............................................................................................................................12
Eligibility or inclusion criteria:......................................................................................................13
Search strategy:..............................................................................................................................15
Evidence Appraisal:.......................................................................................................................17
Analysis:........................................................................................................................................19
Rigor:.............................................................................................................................................20
Ethical consideration:....................................................................................................................21
Dissemination of findings:.............................................................................................................22
Timeline:........................................................................................................................................22
References......................................................................................................................................24

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Abstract:
Background: Dementia is a disease condition associated with great burden and poor quality of
life in both patients and their formal caregivers. Due to the presence of aggressive symptoms and
disruptive behavior, formal or paid caregivers are highly likely to suffer from psychological
stress and depression.
Aim: To investigate about the effectiveness of support group intervention compared to
individual counseling in reducing anxiety and improving well-being in formal carers of people
with dementia.
Method: Systematic review of recent research articles in accordance with PRISMA guideline
was done to evaluated research studies on the topic. Articles published between 2008 to 2018
were taken from MEDLINE, EMBASE, CINAHL, PsychInfo and PubMed databases for the
systematic review. The quality appraisal for the article was done by the use of CASP tool.
Significance: The findings of the study will be useful in evaluation the effectiveness of
counseling or support group intervention will help to reduce physical and psychological burden
of caregivers.

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Background:
Dementia is a disease condition that is regarded as both physical and mental illness and
research shows that both the burden and quality of life is worst for caregivers who take care of
patients with both physical and mental illness (Settineri et al., 2014). Paid caregivers or formal
caregivers of dementia patient plays a vital role in patient-centered care and meeting daily life
needs of patient. They are involved in administering medication, managing symptoms of patient,
facilitation communication and providing emotional support to patient. Although the number of
formal caregivers of dementia patient has increased, however the number of caregivers suffering
from care giving burden and depression has also increased (Liang et al., 2018). Lot of attention
has been given to care giving burden and psychosocial issues for informal caregivers of dementia
patient, however analyzing the extent of impact for formal caregiver has also become important
as they are also vulnerable to poor health outcome.
Various research studies have investigated about the characteristics of care giving burden
and its impact on health of caregivers. The studies have given evidence on low efficacy, poor
physical health and subjective well being in dementia caregivers compared to other caregivers.
Ali & Bokharey (2015) explored lived experience of caregivers of dementia patient by means of
interpretative phenomenological analysis. The analysis of interview transcript of dementia
caregiver stated that participants found care giving as troublesome and affecting their social and
familial life. These were indication of cognitive distortion in-patient. The second theme of
physical symptom gave the indication that symptoms of fatigue lack of motivation and sleep
disturbance is common in caregivers. Hence, the study gave indication about cognitive and
physical impact on caregivers of dementia patient. Ornstein & Gaugler (2012) also explained that

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behavioral and psychological symptoms of dementia (BPSDs) such as aggression, depression
and sleep disturbance have negative impact on caregivers.
While looking at the research problem of caregiver burden, it is essential that specific
correlated and potential causes of burden and its adverse impact is identified. Mohamed et al.
(2010) explored the relationship between burden and depression among caregivers to patient and
caregiver characteristics. The study directly measured caregiver burden, depressive symptom in
caregiver and symptoms related to distress. Perceived burden was found to be highly associated
with depression among caregiver’s behavior and psychiatric symptom in-patient. These factors
become important predictor of decrease quality of life and high burden and depression in
caregiver. Hence, with the examination such correlation between perceived burden and
depression in caregiver, evaluation of management strategies related to stress and psychological
morbidity is necessary to promote resilience and motivation of paid staffs to provide care to
dementia patient.
Another common challenges facing caregivers of dementia patient is that they are highly
likely to experience symptoms of anxiety and depression due to dementia patient. Level of
psychological distress has an impact of coping strategies taken by caregivers. This association
between coping strategies and psychological distress in dementia caregiver was shown by
García-Alberca et al. (2012) by conducting research with dementia patient and their primary care
givers. By the use of evidence-based tool such as State-Trait Anxiety Inventory, the Beck
Depression Inventory and Coping Strategies Inventory to measure anxiety, depression and
coping strategies respectively in caregivers, the research showed that majority of caregivers has
high anxiety and depression levels. Another important finding of the study was that it showed
that participants using disengagement coping strategies had high anxiety and depression level

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compared to those who used more engagement coping strategies. By this outcome, impact of
coping strategies on anxiety and depression in caregiver was observed. Hence, evaluating the
effect of intervention that can support caregivers to use optimal coping strategies may help to
reduce caregiver burden.
The prevalence of anxiety and depression in caregiver of dementia patient needs urgent
attention because this has an impact on well being of both patient and caregiver (Draženka et al.,
2014). Hence, motivational aspect of care giving and psycho-education is necessary to improve
coping and caring skills of caregiver. The evidence regarding level of anxiety and distress in
formal caregivers suggest the need to implement appropriate care intervention not only for
patient but also for caregivers. The manner in which prevalence of anxiety and depression in
caregivers can affect characteristics of patient and caregiver is understood from the fact that
prevalence of caregiver burden is associated with increase in duration and severity of dementia
(García-Alberca, Lara & Berthier, 2011). Hence, taking steps to identify effective intervention to
modify psychological state of formal caregiver becomes necessary.
Based on review of intervention to reduce stress and anxiety among caregivers, several
types of intervention have been implemented for caregivers. Some examples of this include face-
to-face intervention, telephone-based support program and computer based support program.
Although variation is found regarding the use and efficacy of telephone-based support program
and computer based support program, however programs that are individually tailored to a
caregiver is found to be most effective in reducing caregiver burden (Beinart et al., 2012).
Further investigation regarding such intervention suggest psycho-education, individual
counseling and support group programs as useful to provide individualized and tailor made
support to caregivers as per their challenges and severity of burden.

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Psychosocial intervention in the form of individual counseling or support group
intervention is imperative for dementia caregivers because of the presence of burden, stress,
anxiety and depression in caregivers. A cross-sectional study done in caregivers from
Alzheimer’s Clinic Research Unit revealed that depressive symptom was most commonly found
in caregivers followed by caregiver burden and anxiety symptoms. Psychological distress mainly
contributed to high caregiver burden (Medrano et al., 2017). Therefore, to promote health of
dementia patient, proper assessment and monitoring of caregiver aspects of psychic stress and
burden is also important.
Different types of psychosocial intervention have been developed to promote mental and
physical health of caregivers. The interventions are classified according to format or content. For
instance, interventions exist in individual or group format. In addition, the content of intervention
may differ such as it may focus psycho-education, building coping skills, behavior modification
and skills training (Lins et al., 2011; Parra-Vidales et al., 2017). The effectiveness and impact of
an intervention is also influenced by format and content of the intervention. In addition, Berwig
et al. (2017) suggested individualized support and structured multi-component intervention as a
promising intervention to reduce the burden of informal care giving. Although the research
proposal is focusing on formal caregivers of dementia patient, however the research done on
informal caregivers also gives important insight to reduce burden of care giving. By means of the
REACH I intervention, an individualized program that included multi-component interventions
like psycho-education, role playing, problem solving and skills training, the effectiveness of the
program was evaluated in dementia caregiver. Participants were randomly allocated to
intervention group and control group. The feasibility and acceptance of the program was
excellent and burden related to care declined slightly in the intervention group. Hence, this

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shows that multi-component intervention given in individualized format may work to reduce
anxiety and burden in caregivers of dementia patient. However, effectiveness of support group
intervention in reducing caregiving burden has also been proved (Küçükgüçlü et al., 2017).
Therefore, considering the effectiveness of both format is necessary to identify effective
intervention for formal caregivers.
The review of separate research literature on individual counseling and support group
intervention has revealed several limitations and need for future research. For instance, a
systematic review and meta-analysis of cognitive behavioral therapy (CBT) for depression and
stress in dementia caregivers revealed that cost per session is high and determining efficacy oon
terms of cost-effectiveness and health benefit is important in the private sector. The study
showed slight benefit of CBT on reducing stress and depression in caregivers, however cost-
effectiveness of the therapy could not be proved (Mallikarjun, 2018). Review of research
literature related to social support interventions has revealed that caregivers benefits from such
intervention, however results were inconsistent across studies. Some studies gave positive
outcome for dementia caregivers, however other studies reported no improvement on social
support variables (Dam et al., 2016). Accessibility issues were also observed that influenced
participation in support group intervention. Hence, the review of past research indicated the need
to conduct more social support intervention with the use of multi-component content to enhance
positive benefits for target population group. The consideration regarding increasing accessibility
to support intervention and delivering it in an simple format was necessary.
The review of research shows lack of research done in formal caregivers of dementia
patients. Studies exist regarding evaluation of formal support for informal caregivers providing
care to persons with dementia. Lethin et al. (2016) conducted an exploratory cross-sectional

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study to investigate about support needs for informal caregivers. The study showed counseling,
caregiver support and caregiver education as important types of support activities. However,
utilization of support group intervention was low among informal caregivers. Caregiver support
was available for all stage of disease except England and Estonia. Counseling was the
intervention that was widely utilized by caregiver compared to education and respite care.
Goeman, Renehan and Koch (2016) also showed lack of studies assessing cost-effectiveness of
interventions for dementia caregivers. Hence, by evaluating the efficacy of support group
intervention in terms of availability, utilization and professional support providers across several
countries, the study showed lack of appropriate method to make support group interventions
available to all informal caregivers. As the support is missing for informal caregivers, the
severity of the issue in formal caregivers is an area of future research interest. Analysis of past
research may help in structuring the research proposal and developing key aim and objectives to
enhance the quality of review and interpretation. Several limitations were found in research such
as methodological heterogeneity in studies was seen. Risk of bias was also seen in many
randomized controlled trial as features of randomization, blind and allocation concealment was
missing. Hence, for future research work, there was a need to evaluate effectiveness of both
tailored and non-intervention to enhance cost efficacy as well as feasibility of intervention for
dementia caregiver. Future research work should also focus on addressing methodological
limitation so that clinical efficacy of individual counseling and behavioral therapy can be
established (Kwon et al., 2017).
The main aim of the research proposal is to evaluate the effectiveness of support group
and individual counseling on reducing anxiety in formal caregivers of dementia patient.
Individualized counseling comes under individual program formal which is regarded as more

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effective than group intervention (Pinquart & Sörensen, 2006). However, support group
interventions target behavioral modification and problem solving approach and such strategies
are considered more effective than psycho-education (Berwig et al., 2017). Hence, as there exists
different benefits of individual and support group intervention, conducting systematic review is
important to understand whether individualized counseling or support group intervention is
beneficial in reducing anxiety in caregivers of dementia patient.
Review questions, objectives, PICO:
Research problem:
Dementia is a progressive and life-limiting mental illness that has significant impact on
the health outcome of affected individuals and associated with daily life challenges for both
patient and the care giver (Nehen & Hermann, 2015). Both formal and informal caregivers are
involved in meeting daily health needs of dementia patient. However, providing care for patient
with dementia is associated with high rate of emotional stress and depression, poor physical
health and high risk of mortality in formal caregivers (Springate & Tremont, 2014). The
psychological and financial burden of the disease increases due to such negative consequence of
care giving. The symptoms of dementia patient that are most predictive of caregiver burden
include disruptive behaviors like aggression and agitation followed by mood disturbance and
delusions. Chronic stress, anxiety and depression is a common issues faced by formal caregivers
that worsens physical health status of caregivers (Iavarone et al., 2017). The category or type of
stress of burden for caregiver is also dependent on level of care demands, coping skills of
caregiver and the presence of elevated psychiatric symptom in patient (Cheng, 2017). Hence,
negative health outcome of dementia caregivers is the main research problem and finding

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effective intervention to support dementia caregiver and increase their coping skills are necessary
to maintain health of caregivers.
Currently, there are many types of interventions available to support formal caregivers of
dementia patient. Some important interventions include individual counseling or support group
participation to reduce symptom of anxiety and depression in caregiver. Although evidence has
proved the effectiveness of individualized counseling on reducing burden of family caregivers
Shaw et al. (2015), however it is not clear whether support groups are effective in reducing the
risk of depression in dementia caregiver or not. Hence, the research question is centered on the
two interventions of individualized counseling and support group participation. Investigating
about the impact of one intervention over the other is essential to promote cost efficiency in
treatment and understand the intervention that can provide maximum health benefit to target
formal carer.
Review question:
The identified PICO in relation to the research problem are as follows
P (Population): Caregivers of dementia patient
I (Intervention): Support group
C (Comparator): Individual counseling
O (Outcome): reduction in anxiety and well-being
The PICO question for the systematic review is ‘Is participating in a support groups (I) is more
effective than individual counseling (C) for formal carers of people with dementia (P), in
reducing anxiety and improving wellbeing (O)?’

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Objectives of the review:
The main objective of the systematic review is as follows:
 To assess the effectiveness of support group and individual counseling for formal
caregivers of dementia patient
 To assess the impact of support group and individual counseling on health outcome and
quality of life of people with dementia
 To assess the efficacy of the two intervention in reducing anxiety and symptom of
anxiety in formal caregivers
 To recommend the most cost-effective and beneficial intervention to reduce anxiety and
improve well-being of caregivers
Significance of the study:
The systematic review related to effectiveness of counseling and support group
intervention to reduce anxiety in formal caregiver is necessary because outcomes of the study
may help in determining the most cost-effective way to reduce care giving burden for caregiver.
The significance of the study is also seen because of the prevalence of psychological damage and
depression in formal caregivers of dementia. Miyamoto, Tachimori & Ito, (2010) clarified the
variation in characteristics of the burden on formal carer compared to informal care. The study
explored the impact of behavioral, psychological symptoms and function performance on
perceived burden of formal caregivers. The study finding proved that aggression and irritability
is the most common cause of caregiver burden. In addition, the burden is high for formal
caregivers compared to informal caregivers because they are in charge of large number of
dementia patient compared to single patient. Hence, evaluating the effectiveness of counseling

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and support group intervention may help to manage aggressive behaviors of patients and reduce
the burden physical and psychological burden of caregivers.
Review design:
To get answer to the research question, a systematic review of studies will be conducted.
The format for the systematic review will be guided by PRISMA guideline. The PRISMA is an
evidence-based framework that defines list of items needed for reporting in systematic review. It
is the most trusted resource for behavioral, social and psychological science research. By the use
of PRISMA checklist, all the procedure can be implemented as per the guideline for systematic
review. It has 26 sub-items comprising the steps such as information about authors, structured
summary, review protocol and methods, search strategy, study selection process, assessment of
bias and data analysis (Shamseer et al., 2015).
The search process for articles related to the research question will be guided by specific
inclusion and exclusion criteria. Establishing inclusion and exclusion criteria will establish the
boundary for research process and systematic review. Extensive search strategy will also be
prepared to maximize the likelihood of retrieved good research articles to answer the research
question. Use of electronic and multiple database from the field of health care and social science
and specific search term will support getting maximum number of research article related to
study objective. In addition, certain Boolean operations and truncation will be applied during
literature search to get more focused and productive result. Apart from reviewing the title,
abstract and full-text of the articles, additional studies will be retrieved by looking at references
of studies. Data abstraction is also an important part of systematic review and this will be done
by categorizing data in terms of author, population, study design, target age group, strength and

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limitation, health intervention and health outcome. The quality and validity of research articles
will be judged by assessment of bias in studies (Moher et al., 2015).
Although the main focus will be to evaluated randomized controlled trials investigating
about individual counseling and support group intervention for dementia caregiver, however
evaluation of other types of research will be done to get complete idea about effectiveness of one
intervention over the other. Randomized controlled trial will be the preferred study type for
analysis. However, individual intervention based studies specific to individual counseling or
support group will be also included for analysis and review (Ingham-Broomfield, 2016).
Eligibility or inclusion criteria:
Research articles related to research question will be selected based on pre-specified
criteria which are as follows:
Study design: Randomized controlled trials will be the most preferred choices for inclusion
followed by intervention specific studies because randomized controlled trial are better quality of
studies compared to other studies according to hierarchy of research evidence (Ingham-
Broomfield, 2016).
Study participants: As the research question focuses on reducing anxiety and burden in formal
caregivers of dementia patient, all research articles must have formal caregivers (paid
professionals) like nurses, primary care staff or social worker as research participants.
Publication: Research articles published within 2008 to 2018 will be included in the systematic
review.

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Intervention: All included studies should have individual counseling or support group as the
main intervention for evaluation because our research question is focused on evaluating only
these two interventions.
Research question: The chosen research article must address the research question and it should
target anxiety, depression and well-being of dementia caregivers
Outcome variable: All included studies should have outcomes variables such as anxiety,
depression, caregiver burden, quality of life or physical and mental health because the research
question has anxiety and well-being as the outcome of the intervention.
Language: As per the guidelines for review, only that article will be included in systematic
review, which is published, in English language.
The exclusion criteria for the selection of articles were as follows:
 Studies published before 2008 will not be included in the systematic review
 Research studies which investigated about the impact of intervention on informal
caregivers or family caregivers of dementia patient will be excluded from systematic
review
 A research articles which does not has depression or anxiety or stress as an outcome
variable will not be included for review
 Studies investigating about intervention other than individual counseling or support group
intervention will not be included for analysis because the research question is concerned
with both these interventions only.

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Search strategy:
Search method:
The search for relevant research articles related to the research question will be done
from health care based databases like MEDLINE, EMBASE, CINAHL, PsychInfo and PubMed.
Medline and PubMed are databases that published recent and peer review biomedical literature
from around the world and these databases help to retrieved large number of research articles
relevant to the research question. As the research topic is mainly related to behavioral or social
intervention, PsychINFO has also been selected for literature search. The search process will be
refined by the use of specific search terms and date filters. The date for publication will be fixed
as per inclusion criteria and the types of resource will be updated to journal articles only. To
conduct search from PubMed and CINAHL databases, Boolean operators will be used such as
‘and’ and ‘or’. The rational for using ‘and’ will be to keep all search terms in the same reference
and the rational for using ‘or’ will be to combine terms similar in meaning. In addition,
appropriate filter or limit specific to database will be used to refine the search (Peters et al.,
2015).
Search terms:
The primary search terms that will be used to retrieve research articles include
‘effectiveness of support intervention and individual counseling intervention for formal dementia
caregivers’, ‘Support group versus individual counseling for dementia caregiver’ and ‘efficacy of
support group compared to individual counseling. Several Boolean operators like ‘OR’ and
‘AND’ will be applied to conduct searching from specific databases.
Stage 1

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The search for articles will be conducted on databases like PubMed and CINAHL
databases to identify relevant keywords contained in the titles, abstracts and subject descriptors.
The initial logic grid will be aligned with the PICO elements of the review in the following
ways:
Table 1: Logic grid aligned with PICO elements of the review
Population Intervention Outcome
Caregivers of dementia patient Support group Reducing anxiety and depression
Formal caregivers of dementia
patient
Individual counseling Reducing psychological
symptoms
Paid caregivers of dementia Support group and individual
counseling
Reducing depression and
improving the quality of life.
STAGE 2
The search will be performed in other databases using key words identified from the first
stage of search. Boolean operators like OR and AND will be used get similar research studies.
Data collection and analysis:
All records obtained by entering search terms in chosen database will be screened first
based on the suitability of titles and abstracts. Studies will be excluded in this stage if the
research does not have the intervention and desired population group for research. In addition,
studies which cover outcomes other than anxiety, depression and caregiver burden will be
excluded from analysis. After the initial screening by title and abstract and exclusion of
irrelevant studies, full-text screening will be done for remaining studies based on inclusion and

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exclusion criteria. After full-text screening, screening of references in the studies will also be
done to find relevant articles related to the research question. Any disagreement or confusion
regarding the eligibility of the study will be judged by taking opinion from other experienced
person in the field of research. As the inclusion criteria mentioned use of English language
publication in the review, the consideration for translation of resource will not be required.
Evidence Appraisal:
The main purpose of evidence appraisal in systematic review is to retrieved valid and
reliable research evidence to address research question. As systematic review aims to identify,
evaluate and summarize findings relevant to a specific topic, evidence appraisal technique is
important to minimize bias and include reliable findings to make conclusion about studies. The
basis criteria for evidence appraisal is that all selected or eligible studies must have clearly stated
research objective, easily reproducible methodology, meet all eligibility criteria and have
systematic presentation of research outcome. The critical appraisal process is guided by the use
of specific appraisal question or checklist. This may be framed manually or done by the
application of appropriate appraisal tools (Richards, 2010). A large number of tools are available
for critical appraisal and selection of appropriate tools as per study design will guide the
evidence appraisal process in this systematic review.
The most important aspect of the literature review will be to critical appraise research
literature on the basis of its quality and methodological strength. The Grade tool (Grading of
Recommendations Assessment, Development and Evaluation) will be used for assessment of
overall quality of studies. It qualifies the quality of studies on four levels such as high, moderate,
low and very low. In addition, the CASP tool (Critical Appraisal skills program will be used to

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assess the quality of each articles independently). The CASP tool has 10-11 item questionnaire
that judge the quality of research evidence on the basis of clear statement of study objective,
research design, recruitment method, strength of methodology, relationship between researcher
and participants, rigor in data analysis and ethical issues. Yes or no response to each set of
questionnaire will help to judge the quality and credibility of research work. As the main
preference will be to include randomized controlled trial (RCT) in analysis, the quality of RCTs
will be judged by questions on trial validity, randomization, blinding, similarity of the groups at
the start of the trial, equal treatment of group, treatment effect and application to local population
group (Elwood, 2017).
The main aim of quality appraisal will be to identify weakness in study methodology and
to improve interpretation of study findings. However, this will not be done for the purpose of
excluding research articles from the review. This is because studies rated low on methodological
criteria often give new insights related to the research question, however studies rated high on
methodological rigor are often found to have poor interpretation of study findings (McCabe, You
& Tatangelo, 2016). A study done regarding choice of tools for quality appraisal in systematic
review states that CASP is the most inclusive tool in relation to study quality. However, one
limitation of using CASP tool for quality appraisal is that presence of specific checklist makes it
difficult to take decision regarding quality. The combination of main question and sub-question
in reviews increases variability in answer (Voss & Rehfuess, 2013). Hence, taking subject
specific approach to selection question may help to increase the preciseness and reliability of
quality appraisal (Carlson & Morrison, 2009).

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Analysis:
Data collection and abstraction:
All included research articles will be extracted and categorized on the basis of study type,
author, type of intervention, health outcome, age group and population. The risk of bias in
studies will be judged by identifying limitations in reporting of finding, limitation in sample
recruitment or study selection and limitations in analysis of study findings. The number of
articles identified from data base search, number of articles screened by title and abstract,
number studies eligible for review and list of final excluded studies will be summarized in the
form of PRISMA flow diagram. This can good overview about the process used to identify and
assess research literature for systematic review (Booth, Sutton & Papaioannou, 2016).
Apart from categorization of research evidence on basis of criteria mentioned above,
another approach to synthesize data will be to conduct thematic analysis of included research
literature. The findings of the research article will be synthesized in the following ways:
 Assigning codes to significant statement: To get an understanding about the meaning of
the study, several codes like key words or phrases will be used to categorize research
studies having similar meaning. Generation of themes: After categorization of research evidence according to similarity
in meaning, major themes for the study will be developed based on the analysis of
research evidence by means of in-depth analysis. Generation of themes will help to
properly integrate findings of multiple studies. Thematic analysis is a tried and tested
method to establish link between selected studies and conclusion (Thomas & Harden,
2008).

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 Description of themes: After the generation of themes or sub-themes for the review,
details discussion of findings as per the themes will be done.
Rigor:
To improve rigor and reduce bias in the systematic review, the first strategy will be to
include research articles in the review by discussion with two or more authors. This will help to
minimize individual biases and differences of opinion in categorizing the research evidence. The
risk of bias assessment for included studies will be done by the use of the Cochrane
Collaboration Risk of Bias Tool and the risk of bias will be categorizes into high risk of bias,
unclear risk of low risk. The bias or limitation in study methodology will be identified through
presence of publication bias, selection bias and performance biases. The assessment of bias is
important in systematic reviews to enhance the reliability and credibility of review.
Methodological rigor is an element that affects the quality and transferability of research
evidence and like other research methods, systematic review is also vulnerable to many biases.
To ensure scientific rigor, taking strategic steps to identify or assess bias is necessary (Almeida
& Goulart, 2017).
McDonagh et al. (2013) suggest that setting effective inclusion criteria also plays a role
in avoiding bias in selecting studies. For example, identifying population of interest is important
to reduce ambiguity in population inclusion criteria. In addition, having clear specification about
research outcomes in included studies is important to reduce variation in study selection. Other
possible chances of bias during systematic review may occur due to conflict of interest of author
or staffs involved in review process. This can be addressed by discussion about the eligibility of
studies with a third person or by the use of specific tools that is reliable as well as sensitive to

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effectively categorize research evidence on the basis of quality. For this reason, the Cochrane
Risk of Bias Tool and the CASP tool will be included in the systematic review to enhance the
rigor of study and minimize potential biases during the process too.
Ethical consideration:
As answer to the research question will be obtained by systematic review and not primary
research with population of interest, ethical consideration related to informed consent and study
approval will not be applicable. However, ethical principles related to informed consent,
confidentiality and research approval can be done for selected research articles. Hence, while
evaluation research evidence for quality appraisal, report of ethical assessment will also be
included. For example, the studies can judged on the basis of goal related considerations such as
conflict of interest, justification, publication bias, safety consideration of participant, approval
from research ethics committee and appropriate use of comparators (Price et al., 2018).
Transparency is also important as part of ethical consideration and this will be done by
acknowledging those who worked on the project. Information about funding and all source of
funding is important. To ensure accuracy in the systematic review, planning accurate data
extraction process will be important. This will be done by including at least two reviewers during
the data extraction process (Wage & Wiffen, 2011). Hence, following general convention on
publication ethics and ethical guidelines may help to conduct systematic review in a transparent
and ethical manner.

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Dissemination of findings:
After the identification of relevant research evidence and discussion of key findings in
terms of research objective and research question, it is planned to disseminate the findings of the
review after taking approval from reviewer. After getting consent for dissemination of finding,
the research evidence will be disseminated in health care institutes, dementia clinic and research
organization related to dementia care. The findings may be disseminated in paper or digital
format.
Timeline:
It is planned to complete the systematic review within a 1 year time frame. The main
procedures that has been included in the systematic review includes preparation of study
protocol, planning research design, defining eligibility criteria for studies, developing search
strategy, identification of risk assessment and evidence appraisal method, synthesis of findings
and discussion of systematic review outcomes. The key activities for systematic review and time
requires for completing each procedures is mentioned in the Gantt chart below.
Stages of
systematic
review
Jan-
Feb
2018
Mar-
April
2018
May-June
2018
July-
August
2018
Sept-October
2018
Nov-Dec 2018
Preparation
of systematic
review
protocol

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Development
of eligibility
criteria
Search for
published
studies
Inclusion
assessment
Risk of bias
assessment
Validity
assessment
Data
collection
Data
analysis
Preparation
of review
report

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References
Ali, S., & Bokharey, I. Z. (2015). Maladaptive cognitions and physical health of the caregivers of
dementia: An interpretative phenomenological analysis. International journal of
qualitative studies on health and well-being, 10(1), 28980.
Almeida, C. P. B. D., & Goulart, B. N. G. D. (2017). How to avoid bias in systematic reviews of
observational studies. Revista CEFAC, 19(4), 551-555.
Beinart, N., Weinman, J., Wade, D., & Brady, R. (2012). Caregiver burden and
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