Systematic Review: Dementia Caregiver Support Group Effectiveness

This systematic review investigates the effectiveness of support group interventions compared to individual counseling in reducing anxiety and improving well-being in formal caregivers of people with dementia. The study employed a systematic review of research articles published between 2008 and 2018, using databases like MEDLINE, EMBASE, and PubMed, adhering to PRISMA guidelines and employing the CASP tool for quality appraisal. The review examines the burden and psychological stress experienced by formal caregivers, exploring the impact of caregiving on their physical and mental health, and the effectiveness of various interventions. The findings aim to inform strategies for reducing the physical and psychological burden on caregivers, considering factors such as coping strategies, anxiety, and depression. The research highlights the importance of tailored interventions, including psycho-education, individual counseling, and support group programs, to improve the resilience and motivation of caregivers, ultimately enhancing the quality of life for both caregivers and patients. The review also addresses the need for future research to overcome methodological limitations and enhance the cost-effectiveness and feasibility of interventions.

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