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 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

nclusion/Exclusion Criteria

eview/meta-analysis? 

......................................................... STOP............................................................... 

on within search strategy: __________

de non-professional caregivers of 

y severity? 

......................................................... STOP............................................................... 

tiveness, safety, or cost of any of the 

?

s ... .........................................................

ons.... .....................................................

. ..............................................................

..............................................................................................................................

s/education ..... .......................................

 home monitoring device .... .................

egiver assistance programs.... ..............

...............................................................

.. ........................................................................................................................... 

.......................................................STOP

the following caregiver outcomes?

ge problematic behavior.... ....................

/subjective well-being, depression, 

quality of life, etc.)..... ..........................

rcise, sleep)... ........................................

mptoms, medication use/

..............................................................

...............................................................

..........................................proceed to Q5

5. Does the study report on any of the following patient outcomes?

Use of psychotropic drugs.................................................................... Cognition .............................................................................................. Mood..................................................................................................... Behavioral disturbances........................................................................ Social function...................................................................................... Physical function .................................................................................. 

Hospitalizations, institutionalization, or other health care visits, 

including ER visits ............................................................................... Accidents.............................................................................................. Health-related quality of life ................................................................ Satisfaction with health care................................................................. Other, specify........................................................................................ None of the above.............................................................. proceed to Q6

6. Is the text of the article in English?

a. No................................................................................................ STOPb. Yes..................................................................................................... 

7. If this article meets no other criterion, should it be saved for background 

or discussion?

a. No................................................................................................ STOPb. Yes: narrative review with potentially useful references.................. c. Yes: primary study, possibly more recent than existing SRs............ 

d. Yes: clinical guidelines ..................................................................... e. Yes: other, specify ............................................................................ 

Key words, notes: Full text code:
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Interventions for Non-professional Caregivers of Individuals with Dementia Evidence-based Synthesis Program

APPENDIX B. QUALITY RATING CRITERIA 

FOR SYSTEMATIC REVIEWS*

Overall quality rating for each systematic review is based on the below questions. Ratings are 

summarized as: Good, Fair, or Poor:

• Search dates reported? Yes or No

• Search methods reported? Yes or No

• Comprehensive search? Yes or No

• Inclusion criteria reported? Yes or No

• Selection bias avoided? Yes or No

• Validity criteria reported? Yes or No

• Validity assessed appropriately? Yes or No

• Methods used to combine studies reported? Yes or No

• Findings combined appropriately? Yes or No

• Conclusions supported by data? Yes or No

Definitions of ratings based on above criteria

Good: Meets all criteria: Reports comprehensive and reproducible search methods and results; 

reports pre-defined criteria to select studies and reports reasons for excluding potentially relevant 

studies; adequately evaluates quality of included studies and incorporates assessments of quality 

when synthesizing data; reports methods for synthesizing data and uses appropriate methods 

to combine data qualitatively or quantitatively; and conclusions supported by the evidence 

reviewed.

Fair: Studies will be graded fair if they fail to meet one or more of the above criteria, but the 

limitations are not judged as being major.

Poor: Studies will be graded poor if they have a major limitation in one or more of the above 

criteria.

*Based on the following publications: 

Harris RP, Helfand M, Woolf SH, et al. Current methods of the US Preventive Services Task Force: a review of the 

process. Am J Prev Med. 2001:20(3S); 21-35. 

National Institute for Health and Clinical Excellence. The Guidelines Manual. London: Institute for Health and 

Clinical Excellence; 2006.

Oxman AD, Guyatt GH. Validation of an index of the quality of review articles. J Clin Epidemiol. 1991;44:1271-8. 
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Interventions for Non-professional Caregivers of Individuals with Dementia Evidence-based Synthesis Program

APPENDIX C. USPSTF Quality Rating Criteria for

Randomized Controlled Trials (RCTs) and Cohort Studies

Criteria

•	 Initial assembly of comparable groups: RCTs—adequate randomization, including 

concealment and whether potential confounders were distributed equally among groups; 

cohort studies—consideration of potential confounders with either restriction or measurement for adjustment in the analysis; consideration of inception cohorts

•	 Maintenance of comparable groups (includes attrition, cross-overs, adherence, contamination)

•	 Important differential loss to follow-up or overall high loss to follow-up

•	 Measurements: equal, reliable, and valid (includes masking of outcome assessment)

•	 Clear definition of interventions

•	 Important outcomes considered

•	 Analysis: adjustment for potential confounders for cohort studies, or intention-to-treat 

analysis for RCTs (i.e. analysis in which all participants in a trial are analyzed according 

to the intervention to which they were allocated, regardless of whether or not they completed the intervention)

Definition of ratings based on above criteria

Good: Meets all criteria: Comparable groups are assembled initially and maintained 

throughout the study (follow-up at least 80 percent); reliable and valid measurement 

instruments are used and applied equally to the groups; interventions are spelled out 

clearly; important outcomes are considered; and appropriate attention to confounders 

in analysis. 

Fair: Studies will be graded “fair” if any or all of the following problems occur, without 

the important limitations noted in the “poor” category below: Generally comparable 

groups are assembled initially but some question remains whether some (although not 

major) differences occurred in follow-up; measurement instruments are acceptable 

(although not the best) and generally applied equally; some but not all important 

outcomes are considered; and some but not all potential confounders are accounted for. 

Poor: Studies will be graded “poor” if any of the following major limitations exists: Groups 

assembled initially are not close to being comparable or maintained throughout 

the study; unreliable or invalid measurement instruments are used or not applied 

at all equally among groups (including not masking outcome assessment); and key 

confounders are given little or no attention. 
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Interventions for Non-professional Caregivers of Individuals with Dementia Evidence-based Synthesis Program

APPENDIX D. ABBREVIATIONS

AA African American

AD Alzheimer’s Disease

ADL Activities of daily living

ADRDA Alzheimer Disease and Related Disorders Association

AHRQ Agency for Healthcare Research and Quality

AoA Administration on Aging

BACS Beliefs about Caregiving Scale

BDI Beck Depression Inventory

BDRS Blessed Dementia Rating Scale

BEHAVE Behavioral Pathology in Alzheimer’s Disease Rating Scale

BMT Behavior management training

CES-D Center for Epidemiologic Studies Depression Scale

CG Caregiver

CMIA Cohen-Mansfield Agitation Inventory

CI Confidence interval

COPE Care of Persons with Dementia in their Environments

CQLI Caregiver Quality of Life Instrument

CR Care recipient

CSDD Cornell Scale for Depression in Dementia

CTIS Computer-Telephone Integration System

DRS Depression Rating Scale

DSC Dementia Steering Committee

ECR Elderly Caregiver Family Relationship

EPC Evidence Based Practice Center

ESP Evidence-based Synthesis Program

FIM Functional Independence Measure

GDRS Geriatric Depression Rating Scale

GDS Global Deterioration Scale

GPS Global Positioning System

GQ-SRs Good quality systematic reviews

HBPC Home Based Primary Care

HDLF Health and Daily Living Form

HDRS Hamilton Depression Rating Scale

HSR&D Health Services Research and Development

HTA Health Technology Assessment

ITT Intention-to-treat

IADL Instrumental Activities of Daily Living scale

ICT Information and Technology Intervention

LSIZ Life Satisfaction Index

LSNI Lubben Social Network Index

LTC Long-term care

MAACL Multiple Affect Adjective Checklist

MADDE Medicare Alzheimer’s Disease Demonstration and Evaluation program

MAI Multilevel Assessment Inventory

MBPC Memory and Behavior Problems Checklist
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Interventions for Non-professional Caregivers of Individuals with Dementia Evidence-based Synthesis Program

MMSE Mini Mental State Exam

MFW Minnesota Family Workshop

N Number

NHS National Health Service

NIA/NINR National Institute on Aging/National Institute of Nursing Research

NINCDS National Institute of Neurological and Communicative Diseases and Stroke

NPI Neuropsychiatric Inventory

NYU New York University

OARS Older Americans Resource and Services Multidimensional Functional Assessment

Questionnaire

OGEC Office of Geriatrics and Extended Care

PAC Positive Aspects of Caregiving scale

PAIS Psychological Adjustment to Relative’s Illness

PAVeD Preventing Aggressive Behavior in Demented Patients

PCI Patient Care Index

PDC Partners in Dementia Care

PHQ9 Patient Health Questionnaire-9 Item

PIC Partners in Caregiving

POMS Profile of Moods States

QALY Quality of adjusted life years

QOL/QoL Quality of life

RAGE Rating Scale for Aggressive Behavior in the Elderly

RCT Randomized controlled trial

REACH Resources for Enhancing Alzheimer’s Caregiver Health

RIL Record of Independent Living

RMBPC Revised Memory and Behavior Problem Checklist

RSCSE Revised Scale for Caregiving Self-Efficacy

SADS Social Avoidance and Distress Scale

SBP Stress-Busting Program

SF-36 Short-form health survey

SIP Sickness Impact Profile

SR Systematic Review

SSCQ Short Sense of Competence Questionnaire

STAI State Trait Anxiety Inventory

STAXI State Trait Anger Expression Inventory

T1 Timepoint 1

T2 Timepoint 2

TLC Telephone-Linked Care

Tx Treatment

UK United Kingdom

VA Veterans Affairs

VAMC Veterans Affairs Medical Center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

ZBI Zarit Burden Interview
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 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

WER COMMENTS AND RESPONSES

Response

cope, and methods for this review clearly described?

ritten document, and the authors have done a good job of reviewing the current 

d of dementia caregiver support literature - thought provoking and certainly leads 

is important topic to be studied more. It will be important to identify what works 

 burdened caregiver population. 

Noted.

he categories are sometimes very hard to distinguish why one study is one place 

ne particular problem I had was with the respite care section. The programs 

services (p. 15, line 1) are hard to distinguish from the institutional/overnight or 

support categories. Page 15, line 31 references basic respite care – does this refer 

rnight or some other category? 

ons of the studies, there do not appear to be consistent rules for mentioning au

requent and when it happened, I wondered if this was a particularly good study); 

as small; or including the number of subjects. The number of subjects was often, 

ed in the text for studies pulled from the AoA compendium. 

missing, maybe due to the studies, is ethnic and racial diversity in caregiver inter

 of the studies in this section did impact burden – line 13.

parably paced? Not sure what this means. Didn’t the intervention group get data 

me time, too? 

We have removed the sections on multi-dimensional respite care and respite care packages that offer various forms of respite care, in order to condense the sections on respite care, and to focus on clearly defined forms of respite that are offered by or potentially feasible in VA. The information about studies found in the AoA compendium was derived from abstracts that did not consistently report sample size.Because ethnic/racial differences were not specified in the key question, we didn’t target the search strategy for literature specifically in this area. However, we did mention findings when the studies reported differential results by racial/ethnic group. We have made the adjustments specified on page 28. 

ost comprehensive review of caregiver stress related to dementia that I have seen. 

ded document. This document should become available for widespread use. I 

ns to produce as a booklet, much as they did for a synthesis of the literature on TBI 

Noted.

s and scope were outlined initially, and formed the framework of the review. This 

ngth of the review. I appreciated that the review was thoughtful about considering 

ffects of interventions, even though the literature surrounding this topic is sparse. 

clear as well, but required more from the reader since a full understanding of the 

he reader to access the text, flowchart, and appendix. As I reader, I did need to 

f my reading to understand some methodological issues that I felt were key.

Noted.
65

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

on of bias in our synthesis of the evidence? 

Noted.

issue that is a focus of commercial interests. Therefore, it is relatively easy to be 

 bias. I did not detect any professional bias. The process of selecting studies was 

e. The synthesis of the information was appropriate and unbiased.

Noted.

ological bias but respite care does appear to be the favored intervention, despite 

with reported possible negative results. (I do realize that we are already doing 

 often has more information on it in a summary or discussion (see p. 57). For 

cussion, p 51, respite is the first intervention mentioned although it is not the first 

e text. I wondered if this was your ranking of the interventions. 

In an effort to condense the section on respite care, we have removed sections on respite care on multi-dimensional programs and packages, and selected only clearly defined forms of respite care that are currently offered or potentially feasible in VA. 

important topic to review, but also a very challenging topic. In some sense, the 

udies will always be arbitrary. For instance, I would not characterize a GPS inter

wandering to be similar to a tele-health (HealthBuddy) study, but these are catego

r technology. The review notes that prior systematic reviews were not consistent 

psychosocial studies. While I did not detect bias, I think that the review could 

rationale for the way that studies were categorized for this review.

Noted. For tech-based interventions, we followed the example of a previous review that included tracking devices as well as network-based communications technology, though we agree that these interventions are dissimilar and would warrant separate categories in a review that focuses specifically on these interventions. We discuss the reasons for and challenges in grouping of interventions.

 on interventions for caregivers of patients with dementia that we have overlooked? 

ge Noted.

l studies stop in 2005 before the 2006 publication of the REACH II trial, which 

n the two clinical translations, including the one done in VHA (REACH VA). 

 largest behavioral RCT for dementia caregiving funded by NIH looking at racial

verse caregiver. REACH is one of the evidence based programs that the Rosalynn 

Caregiving funds. AoA has just issued another funding announcement for states 

nce based programs and REACH II is one of them. 

ties page on the AoA website at http://www.aoa.gov/AoARoot/

rg45ioqbknvj))/Grants/Funding/index.aspx 

We have added two studies of the REACH intervention to the section on multicomponent interventions. These studies were published more recently than the systematic reviews we had initially identified. 

ays new studies coming out. I felt that all appropriate studies within the stated col

 included. Noted.

g from multiple past systematic reviews and the AoA catalog provides reason

e issue that I think stands out is that there are a few caregiver interventions that 

 prominence that I would have preferred the review make special mention of how 

iew. This happened to some extent with REACH, at least so far as the recent VA

f REACH are concerned. I would have appreciated some textual section that dealt 

 the New York University Counseling and Support Intervention for Caregivers, 

egiver Program fit into the review. (Note: I am not associated with any of these, 

mprise a special category at the Administration on Aging.)

Thank you for these suggestions. We have added 2 recent studies of the REACH intervention, and 1 study of the Savvy Caregiver program. The New York University Caregiver Intervention (NYUCI) was included in the initial report (Mittelman, et al.) and we have added a more recent 2007 publication of the NYUCI trial. 

nal suggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.
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 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

y p.vi, line 7, Individual Skills Training “CRs may benefit with slower declines in 

ls training includes a component targeting their activities of daily living.....” 

deration to suggest that individual skills training for the CR may be possible to do 

 ADHC in the VA.

Agree; revised accordingly. 

y p. vii, line 5, Multicomponent Interventions: The outcomes are equivocal across 

1 documenting differential treatment effects on an outcome of interest – time to 

 

“with 1 documenting differential treatment effects on an outcome” means? On 

stating that it “significantly delayed institutionalization”. Do not know if it needs 

re.

We have clarified this sentence as suggested. 

y, p. viii, line 12, Future Research Recommendations: The wide range of out

uate the effects of CG interventions reflects the diversity in what CGs and 

er effective. 

g the word important for effective. I think the researchers would design interven

k are effective and then would measure outcomes which they think are important. 

Agree; revised accordingly. 

...problems relating to daycare attendance acted as barriers to usage for some 

from the NHS report. But it is vague what this statement means. 

Agree; we have clarified by adding specific examples. 

There was some evidence that CRs returned home in a worse state, but also that 

 could be diagnosed during breaks.” 

rtant point—could recommend that we should look at the VA outcomes on this 

spective chart review. This would help pick up the new medical conditions diag

he worsening.

Agree; we have added this suggestion.

jor benefit to sleep..” 

ot mentioned in the Executive Summary

The original Exec Summ stated, “Institutional/overnight respite promoted better sleep patterns in CGs during the period of respite...” Therefore, we have not made any changes. 

“There was mixed evidence on the impact of services in relation to ADL, behav

y, but it is difficult to unravel the potentially negative effects of respite from the 

 of the disease.” 

from the NHS report. But would it not be unlikely that a 2 week respite place

g like that) would impact the CR ADL, behavior and dependency due to the natural 

disease. It is unlikely that the disease would progress enough to impact ADL, and 

duration.

We have added this discussion point to the overnight respite care section.
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 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

“A respite care model is feasible and already in place in the VA, with admission 

to skilled nursing or Community Living Center units for respite stays of approxi

bers available, may consider adding numbers here—e.g., last year there were 

ons in the VA nationally. Though not all respite admissions are for patients with 

Unfortunately I was not able to track down these figures. 

Another study reported no evidence that nursing case management delayed insti

he CR when compared to usual care. ...Miller et al, data base reported there was 

 strain, burden, or depression resulting from nursing case management interven

espite care, home care, and consultation, but did find that the intervention group 

use community services than the control group.” 

 that the intervention group was more likely to use community services than the 

at is not known is the impact of the use of community services mentioned above.

Noted; it would be difficult to distinguish whether beneficial effects resulted from the use of community services, which was greater among those who received the nursing case management intervention (but in this case, there was no effect on CG burden). Studies specifically on the effects of the use of community services would be needed.

Summary impact of case management interventions: Overall, there is little 

t that intensive nursing case management has a sustained impact on CG mood or 

es of institutionalization.” 

ring Committee Report (September 2008) has recommended that there be a case 

dementia patient. Recommendation #44 Funding for Dementia Care Coordinators 

N Leaders should allocate sufficient funds to VA facilities to ensure that veterans 

e] their care coordinated through Dementia Case Managers or Care Coordina

gement teams, or CCHT teams”. What do the lack of positive results using case 

 for this recommendation by the Dementia Steering Committee? Maybe the only 

e positive based on the literature is more use of community resources. 

Recent evidence from large, good-quality studies show significant benefit, although older studies offered little evidence to support that intensive nursing case management has a sustained impact on CG mood, strain, or rates of CR institutionalization. The 2 recent studies featured individualized assessment and care plans, and reported improvements in CG depression, stress, and confidence in caregiving, and reductions in CR problem behaviors. Although the findings are mixed across studies, there is some evidence of benefit in the most recent studies. 

“An uncontrolled pilot study of the TLC screen program examined user satisfac

 CG burden, health care utilization, and costs after 12 months.“ 

oping a Dementia Disease Management protocol (DMP) that is scheduled to be 

couple of months, and to be implemented nationally soon after that. It may be use

ommendation that the outcomes in terms of use of technology, and other outcomes 

d, maybe in a controlled trial. This has been mentioned on Page 57, line 1. But it 

dd here that this should be a priority, before interventions that are not supported 

 nationwide and a lot of money is spent on them.

Noted. Again, our stated purpose is to compile evidence that would help inform the decisions of policymakers. Making policy recommendations about specific interventions is beyond the scope of our report.

This may indicate that the definition of what constitutes meaningful change in this 

evaluated.” 

 Another one is about the instruments used not being sensitive to change. While 

ned in the Executive summary Page viii, lines 11-12 about the range of outcomes: 

f outcomes used to evaluate the effects of CG interventions reflects the diversity in 

archers consider effective”, maybe this point needs to be added to it.

Agreed. We have added the point regarding the sensitivity of instruments used.
68

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

 to see you come out with a rousing endorsement of something we need to imple

s a researcher and an anthropologist, I like the idea of doing more qualitative 

one who knows how great the need is for caregivers, I would like to say, “Let’s 

aybe that is the job of the person who gets the synthesis?

Noted. We concur that the goal of this evidence review is to help inform the decisions of policymakers, although we agree that for most caregiver interventions, the results were disappointing.

 articles might be of use to you in your Discussion? They are both about why we 

r why our effect sizes are so small with dementia caregivers. Have you consid

utcome – all these studies had an effect on a component of quality of life (such as 

on). That would at least give us a sense of what interventions did something. 

rt M, Duberstein P. How effective are interventions with caregivers? An updated 

ontologist 2002; 42: 356–372.

, Burns R, et al. Resources for enhancing Alzheimer’s caregiver health: Overview 

tcomes. Gerontologist 2003; 43: 514-520.

We have added a discussion of the REACH intervention that includes Schulz 2003. We considered Sorensen 2002 in our initial review of the literature, but excluded it because the included studies were not limited to caregivers of individuals with dementia. The Sorensen 2002 analysis determined, however, that the interventions overall “were less effective at improving caregiver burden, depression, subjective well-being, and ability/knowledge when all care receivers had dementia than when care receivers did not have dementia or when the sample was mixed.” This finding emphasizes that the needs of caregivers of demented individuals differ from other caregivers. Sorensen 2002 writes, “Dementia caregivers cope with unpredictable stressors, such as problem behaviors and personality changes. Because these may be more difficult to cope with and less modifiable than the stressors common to pure physical care (Birkel & Jones, 1989), it may be more difficult to effect change through intervention with this population.” 

ble thing to say but some people may just read the Discussion or that may be 

major quotes from. It might make it easier for them if you spell out acronyms 

(p. 51, line 21). I had to go back and look that one up myself!

We have added an appendix of abbreviations.

is not clear that you are talking about all the interventions and not just respite, 

t paragraph. 

We have clarified this sentence to read, “...among the variety of interventions for dementia caregivers.” 

g out what these six important outcomes are would be helpful to the reader (not 

) Would it be helpful to include them in your methods section so that readers 

for the big ones as they go through?

We have clarified the outcomes referred to in that section (depression, burden, coping, quality of life, and CR behavior problems), and we list these psychosocial outcomes in the methods. 

ine 1 1 and 12. Therapist may be a word that has psychological connotations to 

t be accurate for all the studies – perhaps interventionist? Line 12 – instrumenta

Have different impacts?) across sites. Line 26 – SR= systematic reviews? 

We have made the suggested corrections.
69

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

tions. Are the studies mentioned research or clinical translations? Different con

 translations – already trying to implement. Noted. We have changed “research” to “studies” to include both types. We have also specified “feasibility of implementation” to convey the need to assess interventions that 

are already being implemented in VA. 

h the document as a copy editor, so I do not have specific formatting issues to 

gestion is that this needs to be available to people outside of VHA as well as with

 already be the plan to publish this study as an HSR&D Evidence Based Booklet. 

o do so. This is a truly useful document.

Noted.

eview that should assist policy-makers and researchers to address logical next 

 describing relevance to the VA were concise and accurate.

Noted.

at the end of the sentence on line 12 pg. 54 We have made this correction. 

the executive summary difficult to follow and that it did not reflect the careful 

r writing found in the full report.

Noted: we have revised the exec summary to provide more detail. 

“We did not assess the quality of these studies, but noted whether these more 

 consistent with the synthesis of findings from previous studies.” Not sure what 

We proceeded to quality-rate the studies we selected from the AoA compendium.

...systematic reviews that had performed comprehensive, qualitative syntheses of 

re on these topics.” - Did you do an assessment of the quality of the reviews?

We rated the quality of systematic reviews using the criteria shown in Appendix B. 

The systematic reviews of psychosocial interventions contained 224 primary 

e identified 30 RCTs that met our criteria for study” - I would like to see a more 

n of the number of articles that came from reviews and from other sources and how 

d from each, etc. 

See response below (46C)

you go back and forth between systematic review and the primary articles. I am 

nce based synthesis that primary use the systematic review to help find the studies 

Because of the sheer breadth of this topic, we conducted this primarily as a review of existing systematic reviews – we took it a step further by actually going to the primary studies (the ones we felt were best quality within the reviews we examined). The benefit of such an approach is that we can cover quite a bit of ground in a systematic way and give a “bird’s eye view” of a vast/complex topic. This approach allows us to identify the types of interventions that have been studied, major gaps in the literature, and common methodologic issues in this area of study. The downside is primarily that, for any given subtopic, we are not able to do an up-to-date, complete systematic review of primary studies. 

ained reductions” - Are these mutually exclusive? We have added “and/or” to indicate that these are not mutually exclusive. 

eviews” - How many studies were included? We have added the number of studies, as suggested.
70

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

that aimed to increase patient safety and reduce CG stress including ??? We have made this correction.

“Implementation of exercise interventions within the VA setting might be feasible 

oup or possibly through the Home-Based Primary Care program.” - These sum

e not consistently used in each section.

We have removed the sections on feasibility from the Results sections, and added a brief section on feasibility and implementation in the Discussion.

“Studies in which BMT for the CG was augmented by CG self-care instruction” - 

?

We have clarified the number of studies, as suggested.

“The VA has provided an important training avenue for geropsychology” - Be 

this means.

We have removed the statements on feasibility from most sections, and this wording was removed in the process.

“Individualized training programs are feasible within the VA, although they 

e resources of staff to evaluate the dyad and generate a tailored program. Physical 

herapists and psychologists could appropriately deliver this kind of intervention.” 

sed to come to these conclusions? Feasibility determined by? What resources 

You say that PT, OT and psychologist could deliver the interventions, but is this 

vered in the studies?

We have removed the sections on feasibility from the Results sections. We have added a discussion on the considerations of feasibility and implementation of interventions in VA to the Discussion section, with substantial rewording.

 “A recently completed 6-month implementation study of the REACH VA inter

tive effects on CG burden and CR problem behaviors, and appears to be feasible 

 settings.” - I would argue that it is not truly low cost. It is delivered by psycholo

in home sessions.

We have removed “low-cost” from this statement, as suggested. Because individualized, resource-intensive interventions appear to be more effective, in the report we discuss the need to determine the cost-benefit of interventions that would be widely implemented in VA. 

 “systematic review of respite care” - # of studies? We have specified the number of studies, as suggested.

action: “and how frequently the study was included in systematic reviews.” - 

ce of this? 

The DSC had originally wondered whether there studies were widely cited but not very good evidence. We therefore sought to determine whether there were any studies that were widely known but were poor quality, and we mention this in the Discussion. We removed the data on how frequently studies were cited by other SRs from the tables, however, as we agree that this information is not obviously relevant within the tables.

hesis: We compiled a qualitative synthesis of the evidence on specific forms of 

tand what you mean by this, but I would like to know more about what went into 

hesis. Was this done by expert panel?

By this we mean that we compiled a descriptive synthesis of the evidence, as opposed to a quantitative synthesis that would combine numeric data from studies (e.g. metaanalysis). The synthesis of findings was conducted by the authors of the report, rather than the expert panel. 
71

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

earch: “A 6-month feasibility study of implementing the REACH VA interven

PC programs in the VHA system found decreases in CG burden, depression, and 

iving; as well as decreases in CR behavior problems. REACH VA is based on the 

 REACH II study, and provides CG support and skills training in safety, behavior 

elf-care via 12 in-home and telephone sessions, and 5 telephone support group 

ysis found that the VHA costs of delivering the full intervention would be $2.93 

nths, and that satisfaction and perception of benefit from the intervention were high 

nd CGs.” 

o a small number of HBPC patients by psychologists. Each HBPC psychologist 

ber of patients. It is not clear that VA current number of HBPC psychologists or 

gist would have capacity to deliver this intervention to many patients.

We agree and have emphasized that although individualized, resource-intensive interventions appear to be more effective, the need to determine the cost-benefit of interventions that would be widely implemented in VA. 

ussion is written much more than how the Executive Summary is currently written. Noted. 

 examined recently published studies, found in a compendium compiled by the 

Aging’s Alzheimer’s Disease Supportive Services Program, that were not captured 

atic reviews. We did not assess the quality of these studies.” - Why not?

We did not formally “include” the AoA compendium because it was not a systematic review in the traditional sense, so we could not quality rate it. However, it was a very valuable resource as it has an up-to-date bibliography. Our approach was to use it as an adjunct – we looked through the compendium for more recent studies that may have had a substantial impact on the body of evidence (e.g. larger RCTs). We proceeded to quality-rate the studies we selected from the AoA for the final report.

ure research recommendations: “Respite care is already implemented in skilled 

VA...” Why limit your comments to skilled care settings? VA offers respite in 

ttings, including home, as well as institutional (VHA Handbook 1140.02 Respite 

8).

excluded in-home respite and host-family respite care” 

? We’re interested in non-institutional interventions as well as institutional. VA

onal respite care, including in-home respite services. See VHA Handbook 1140.02 

10, 2008. 

We have made this correction and have added a section on in-home respite care.

 suggest you use “individual with dementia” rather than “dementia patient”; Sug

idual with Dementia” or “Care Recipient (CR)” instead of patient Done.

ntions: Add reference for REACH study Done.

ncealment” - Explain this item We have reworded “inadequate allocation concealment” to 

read “potential for selection bias.”

Respite programs – offer CGs, and CRs, a chance of combining together different 

re and short breaks 

nal CG-support packages – provide a range of services to CGs and CRs, including 

reak option”

n these 2 categories is not entirely clear.

We have deleted these sections in order to condense the respite care section to represent interventions that are most applicable to VA.
72

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

14: Overall, a day treatment model is feasible within the VA, and is currently de

al VA settings with other populations (e.g. substance abuse treatment, chronically 

id not find a VA-specific utilization/cost report for dementia day care, but commu

ams have demonstrated cost savings through dementia day care programs.14 

VA’s Adult Day Health Care in this discussion of “day treatment model”? Seems 

entioned. See VHA Handbook 1141.03 Adult Day Health Care, Sept. 29, 2009. 

SR&D evaluation of the ADHC program in the distant past, I believe – not demen

the program as a whole. 

We have removed the feasibility statements from the Results section and in the process, the text cited was deleted. 

tutional/overnight Services “This model appears suitable for a VA setting , “

option in VA.

We have made this correction. 

ograms Offering a Variety of Respite Services and Short Breaks”

ow this group differs from those in the next section.

We have added a description of the multi-dimensional CG support packages that distinguishes those interventions from respite services alone.

provide a variety of forms of respite to accommodate the needs and preferences of 

he range of services/studies a little more? Not sure what this group actually in

We have added a description of the different respite programs offered in the included studies.

del is feasible and already in place in the VA, with admission of eligible patients to 

Community Living Center units for respite stays of approximately one week.”

d nursing, so “or” seems wrong here; can you clarify meaning or wording? 

We have removed the sections on feasibility from the Results sections and in the process, this sentence was eliminated.

ulti-dimensional CG Support Packages

ntified 4 studies in which a range of services was provided, including a respite or 

”

he range of services/studies a little more? Not sure what this group actually includes.

We have added the description of the range of services provided by the NHS report.

lti-dimensional CG Support Packages: “This program would require more spe

within the VA system, and does not appear to have a clear advantage in long-term 

 respite care.” 

 by “this program”? You have not described a specific program.

We have deleted this section and condensed the respite care section to represent interventions that are most applicable to VA.

ventions – Exercise Training: Two studies evaluated exercise training (Table 1). 

participated in an exercise training program that successfully cultivated adherence 

participation”

CR or CG?

We have clarified this, as suggested, in the tables and text.

ventions – Case Management: 

k at the following two studies and see if they fit this or one of the other categories 

eviewing? These are multi-component care management models that may have 

CR. Callahan, Boustani, et al., 2006, JAMA 295(18);2148-57. Vickrey et al., 

Med 145:713-26.

We have added the suggested studies to the case management section. 
73

 Caregivers of Individuals with Dementia Evidence-based Synthesis Program

Response

CG outcome measures, so aren’t there CG results to report? We have clarified the tables to indicate whether CG (or 

CR) outcomes were measured as covariates only or analyzed as outcomes of the intervention. 

Future studies should use ... adequate duration of follow-up” - Did you mention 

itation?

We have changed “adequate” to “appropriate” duration of follow-up, given that benefit from some interventions may be short-term.

scussion (before references): “supportive” - Clarify what you mean by this term. 

ention types examined in this review, or just some types?

We have removed the term “supportive” to convey that we are referring to all CG interventions. 

ey of recently completed and ongoing research using VA e-mail listservs identified 

 of psychosocial interventions (REACH OUT57; REACH VA56; Stress-Buster’s 

chnology-based interventions (Telehealth Education Program60; TLC58) that 

ts in CG burden with some of the interventions, and short-term savings in health 

udy .” Add reference citation number (for last study)

Done.

ommendations: In this section or somewhere else in the Discussion – Do you 

ecific interventions that we don’t already provide are ready for wide-spread roll

n in VA?

It appears that the salient feature in effective interventions is the individualized assessment and construction of interventions that are tailored to the needs of the dyad. Multicomponent interventions appear to be more effective than single-intervention approaches. We have added this to the Discussion.

ommendations: At the end of this section, are there any more specific research 

o make? This final section seems almost all about respite.

We have removed some of the text in this section to deemphasize respite care.

ttempted to examine the performance of measures for CG depression, burden, and 

ems across the 30 studies reviewed here, but the samples were too small to derive 

about the hit rates of the measures.” 

ates)

We have replaced “hit rates of the measures” with “whether specific measures were more likely to detect improvements”. 

al ratings of distress and burden may not reflect the changes or possible benefits 

xperiencing. Yet these measures continue to be used widely.”

ative that should be used instead?

We discuss in Future Research Recommendations the need to develop/identify alternative measures to gauge the effectiveness of CG interventions, given the complexity in the needs of CGs.

d to search for recently published RCTs .” I don’t understand this reasoning. I 

earch for more recent ones!

We agree and have quality-rated the studies we selected from the AoA compendium.