Thaíssa Thayara Machado Pinto; Mariana Asmar Alencar; Paula Maria Machado Arantes; Luciana de Oliveira Assis
OBJECTIVES: To identify and evaluate the effect of cognitive stimulation (CS) interventions for older adults with dementia on caregivers' health.
METHOD: This systematic literature review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) guidelines. A search was performed by two independent researchers in May 2018, using Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Science Literature Database (LILACS), Physiotherapy Evidence Database (PEDro), PsycINFO, and PubMed databases. The terms used were “dementia” AND “cognitive stimulation” and their equivalents in Portuguese and Spanish. For inclusion, articles should have been experimental, published from January 2007 to April 2018, with CS delivered to older adults with dementia by a professional or by a caregiver, and outcome measured in the caregiver. Quality of selected studies was assessed using the PEDro scale.
RESULTS: The sample consisted of 10 studies, and only two reported CS benefits to the health of caregivers of older adults with dementia.
CONCLUSION: This study found no consistent evidence of actual benefits of CS in older adults with dementia to their caregivers' health.
Keywords: caregivers; rehabilitation research; aged; dementia.
OBJETIVOS: Identificar e avaliar o efeito das intervenções de estimulação cognitiva (EC) em idosos com demências na saúde dos cuidadores.
MÉTODO: Revisão sistemática da literatura conduzida de acordo com as diretrizes do Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA). A busca foi realizada em maio de 2018, por dois pesquisadores independentes, nas bases de dados Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Escala da Base de Dados de Evidência em Fisioterapia (PEDro), PsycINFO e PubMed. Os descritores utilizados foram “dementia” AND “cognitive stimulation” e seus equivalentes em português e espanhol. Foram incluídos apenas artigos experimentais, publicados entre janeiro de 2007 e abril de 2018, que realizaram EC em idosos com demência, conduzida por profissional ou pelo próprio cuidador e cujo desfecho incidisse no cuidador. A qualidade dos estudos selecionados foi avaliada pela Escala PEDro.
RESULTADOS: A amostra foi composta de 10 estudos, sendo que apenas dois verificaram benefícios da EC sobre a saúde do cuidador do idoso com demência.
CONCLUSÃO: Este estudo não encontrou evidências consistentes sobre os reais benefícios da realização de EC no idoso com demência para a vida do seu cuidador.
Palavras-chave: caregivers; rehabilitation research; aged; dementia.
Dementia is a neurocognitive disorder characterized by overall and progressive deterioration of cognitive abilities leading to progressive functional loss.1,2 Managing dementia in older adults may be particularly challenging for caregivers, as they are exposed to higher care demands and increasingly stressful situations.3,4 Thus, there is a pressing need for interventions seeking to reduce the impacts of the activity on caregivers’ health status.5
The current literature describes non-pharmacological interventions aiming to increase care-related skills and improve caregivers’ quality of life (QoL), including psychosocial and psychoeducational groups.6 Other interventions, in turn, aim to decelerate the process of cognitive and functional loss in older adults with dementia and, as a result, contribute to reducing caregivers’ burden,4,7 such as cognitive stimulation (CS).
CS is defined as a series of activities and techniques whose overall objective is to improve cognitive and social functioning in older adults with dementia.8-10 The intervention has been extensively studied8-10, and there is robust evidence supporting that CS leads to cognitive improvement, including attention, memory, orientation, language, and overall cognitive function, as well as improvement related to self-reported well-being, QoL, communication, and social interaction in older adults with dementia.10 However, confirmation of CS benefits to the health of caregivers of older adults requires further investigation.
Understanding the health outcomes of CS in caregivers of older adults with dementia has become relevant. Such knowledge may help planning interventions that provide benefits both to older adults with dementia and to their caregivers.7 Therefore, this systematic literature review aimed to identify and evaluate the effect of CS interventions on the health of caregivers of older adults with dementia.
This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA) guidelines.11 Five databases — Latin American and Caribbean Health Science Literature Database (LILACS), Physiotherapy Evidence Database (PEDro), PsycINFO, PubMed, and Scientific Electronic Library Online (SciELO) — were searched using the following terms: “demência” OR “dementia” AND “estimulação cognitiva” OR “cognitive stimulation” OR “estimulación cognitive.”
Only randomized controlled trials in which CS targeted older people (aged 60 years or above) diagnosed with dementia and outcomes were measured in caregivers were included. Interventions should have been delivered individually or in groups by a professional or by a caregiver.
Articles in Portuguese, English, or Spanish published from January 2007 to April 2018 were considered eligible. Studies were excluded if CS was conducted concomitantly to a support group for caregivers of older adults with dementia.
Using the eligibility criteria, two researchers searched the databases independently, in May 2018. They selected articles for this review after screening titles and abstracts or full texts. There was no disagreement between the researchers regarding eligible articles. The results from different databases were cross-checked and duplicate studies were removed.
All articles meeting the inclusion criteria were submitted to the PEDro scale, which rates the methodological quality of trial reports using 11 criteria for internal validity.12 Because item 1 in the PEDro scale refers to external validity, it is not used to calculate the final score. Thus, the maximum quality score is 10.
The search yielded 395 articles, then 95 were excluded for being duplicate, resulting in 300 articles which were evaluated for eligibility. Of those, 124 articles were excluded after title and abstract screening (78 were review articles; 21 were pilot studies; 16 were editorials or letters to the editor; eight were written in languages other than those of the inclusion criteria; and one study conducted CS concomitantly to a caregiver support group). After full-text screening, 166 articles were excluded (143 did not report CS outcomes in caregivers; 19 were not randomized controlled trials; and four did not recruit older people diagnosed with dementia). Therefore, the final sample consisted of 10 articles included in this systematic review (Figure 1).
Most studies included in this systematic review presented moderate or high methodological quality. Eight trials scored 5 or higher in the PEDro scale (Table 1).
Characteristics of included studies
The 10 trials included in this review had sample size ranging from 17 to 261 older adults, recruited from community settings, adult day care centers, long-term care facilities, sanatorium, clinics, and geriatric or teaching hospitals. They were diagnosed with various types of dementia (Table 2). The criteria for diagnosing dementia varied among the studies. The most commonly used criteria were the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV),13-15 the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer’s Disease and Related Disorders Association Work Group (NINCDS-ADRDA),16-18 and the International Classification of Diseases, 10th Revision (CID-10).19 The Mini-Mental State Examination (MMSE)13,14,17-20 and the Global Deterioration Scale (GDS) were used for staging dementia.21 Seven studies included older adults with mild to moderate dementia,13-15,17,18,20,21 one included older adults transitioning to moderate stage,16 one included older adults with moderate dementia,19 and one did not specify dementia stage.7 The characteristics of the selected trials are shown in Table 2.
Characteristics of interventions
The characteristics of the intervention programs varied greatly in relation to number of sessions (8 to 144 meetings), duration (30 to 180 minutes), and frequency of care (1 to 5 times a week). Most CS interventions were conducted in groups7,16,18-21 and consisted of reality orientation (RO), reminiscence therapy, and other activities for stimulating cognitive functions and group interaction. Two studies developed multidomain intervention programs16,19 which also included physical exercises,16,19 music therapy,16 basic and instrumental activities of daily living,19 and occupational, art, and horticultural therapy.16 In two studies, CS was administered exclusively by trained caregivers of older adults, in the home.13,14 In another study, the caregivers from one of the intervention groups underwent training where they received general information on dementia and development of CS programs, and were encouraged to conduct those activities in the home.20
Effectiveness of interventions
Two studies reported that CS interventions produced positive effects both on the caregiver and the older adult.15,21 Regarding the caregiver, there was improvement in burden,21 perceived distress due to behavioral changes in older adults with dementia, and anxiety.15 Three studies found beneficial effects only in older adults.16,17,19 In four studies, there was no positive effect either on older adults or their caregivers.13,14,18,20 Another study did not evaluate CS outcome in older adults and found no significant changes in caregivers after the intervention.7
Only 10 studies met the inclusion criteria of this systematic review. The reviewed studies varied considerably in terms of characteristics of study population, place of sample recruitment, dementia staging, criteria used for diagnosing dementia, and intervention protocol. Such factors may have led to the great variability observed in the results of the studies.
Only two studies reported that CS in older adults had positive effects on caregivers’ health.15,21 Three studies found benefits exclusively to older adults,16,17,19 four studies found no benefits either to the caregiver or the older adult,13,14,18,20 and one study measuring only CS outcome in caregiver’s health found no statistically significant effect.7
The positive CS results observed in caregivers were inconsistent. In a study conducted by Alves et al.,21 there was a significant decrease in caregiver burden, which was assessed using the Zarit Burden Interview, from pre-intervention to post-intervention moment in the brief intervention group. However, burden scores were relatively low across the three assessment moments and no additional difference was found in the standard intervention group compared to the wait-list group. The researchers suggest that the observed absence of burden could be related to the fact that respondents were formal caregivers.21 In a study conducted by Paddick et al.,15 in turn, an assessment using the Neuropsychiatric Inventory found significant improvements in number and severity of psychological and behavioral symptoms of dementia as well as in caregiver distress due to those symptoms. However, reductions in caregiver burden as assessed by the Zarit Burden Interview were not significant. The authors claim that the burden assessment tool was developed for use in high-income countries and adjustments may be needed to make it more relevant in other settings.15
No common characteristics were found to justify the fact that both studies, Alves et al.21 and Paddick et al.,15 reported benefits to caregivers’ health. In Alves et al.,21 older adults were classified as mild to moderate dementia using the GDS and recruited from adult day care centers and long-term care facilities, while in Paddick et al.15 older adults were classified according to the DSM-IV and recruited from community settings. The type of caregiver, formal in one study21 and informal in the other,15 also differed. The intervention protocol used in Alves et al.21 consisted of 11 sessions, 60 minutes each, five times a week, while Paddick et al.15 conducted 14 sessions, twice a week, and did not inform duration. Alves et al.21 proposed a group intervention, while Paddick et al.15 used an individual intervention.
It is worth mentioning that some characteristics of participating caregivers, such as age, level of education, and type of relationship with older adults with dementia, could not be considered in the review because such information was unavailable in the reports. Those characteristics may have impacted the interpretation of the results of the reported studies and, therefore, of the present review.
There is an assumption that a cognition-based intervention delivered by a family caregiver may be more successful in having a positive influence on older adults and caregivers.7,22,23 However, the two studies that analyzed the effects of caregiver-delivered CS found no positive results in older adults or caregivers.13,14
Previous research suggests that non-cognitive dementia features are more likely to be associated with disturbances in caregivers.15,24 Of the three studies that reported positive CS effects on mood and behavior of older adults,15,17,19 only one found an indirect effect of the intervention on caregivers.15
This study has some limitations, including exclusion of reports in other languages and lack of assessment of the effect of CS conducted concomitantly to a caregiver support group. Studies seeking to increase the scope of this review may contribute to a better understanding of the topic.
Although some studies indicate that CS benefits could be extended to caregivers of older adults with dementia,15,21 evidence remains inconclusive. There was great variation in terms of population and method used in the reviewed studies. Further studies are needed to evaluate the potential benefit of CS to caregivers’ health.
This study found no consistent evidence of actual benefits of CS in older adults with dementia to their caregivers’ health. Interventional studies are required to evaluate the health of caregivers of older patients with dementia as a primary outcome. Although CS is much referred to as effective for older adults, it should be adequately scrutinized in order to ensure its effectiveness for caregivers’ health.
CONFLICT OF INTEREST
The authors report no conflicts of interest.
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October 15 2018.
Accepted em December 4 2018.
The authors report no conflicts of interest.