CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION What is the effectiveness of a stress management program to address the occupational needs of caregivers for older adults? López, J., Crespo, M., & Zarit, S. H. (2007). Assessment of the efficacy of a stress management program for informal caregivers of dependent older adults. The Gerontologist, 47(2), 205 214. http://dx.doi.org/10.1093/geront/47.2.205 CLINICAL BOTTOM LINE: This study appraised the effectiveness of a psychological intervention program aimed to reduce stress and meet the needs of informal caregivers. Two different treatment formats were used to assess the usefulness of a traditional treatment versus a with minimal therapist contact. Overall, the immediate treatment interventions reduced everyday impairments associated with caregiving. Traditional intervention s were linked to reduced levels of anxiety, depression, burden, and maladaptation when compared to the minimal-therapist-contact, although the latter was identified to be useful for caregivers who had restricted times to partake in treatment. Limitations of the study include the lack of blind evaluators, intervention materials that required a higher literacy level, and the use of only one posttreatment measurement immediately after intervention. Future research should focus on the long-term effects of the two intervention formats to determine their usefulness and place in practice. RESEARCH OBJECTIVE(S) List study objectives. The objective of this study was to examine the benefits and impact of a psychological intervention program for stress management that was individually tailored to the needs of the caregivers. DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Multi (three-) experimental design with repeated pretreatment and posttreatment outcome measures; two-level randomized controlled trial 1
Limitations (appropriateness of study design): Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. SAMPLE SELECTION How were subjects selected to participate? Please describe. Participants were selected from organizations in Madrid, Spain that provided programs for older adults. Specific sample selection methods were not reported. Inclusion Criteria Inclusion criteria were: 1) being age 18 years or older; 2) being the informal caregiver for a dependent person age 60 years or older who held a score equal to or over 1 on the Katz Index of Activities of Daily Living; 3) living at the same residence as the care receiver; 4) being the primary caregiver for the care receiver; 5) having been a caregiver for a minimum of 6 months; 6) having received no other recent treatment.; and 7) having a score above 9 on the Beck Depression Inventory or score above 7 on the Anxiety subscale of the Hospital Anxiety and Depression Scale. Exclusion Criteria Caregivers with suicidal ideation were excluded from the minimal-therapist-contact. SAMPLE CHARACTERISTICS N = 91 caregivers % Dropouts 0% #/ (%) Male 13.2% #/ (%) Female 86.8% Ethnicity Disease/disability diagnosis Check appropriate : < 20/study 20 50/study 51 100/study 101 149/study 150 200/study INTERVENTION(S) AND CONTROL GROUPS Add s if necessary Group 1: Professionals Brief Description Four different types of professionals (social workers, nurses, doctors, and psychologists) were assigned to provide treatment to either the minimaltherapist-contact (MTC) or the traditional. The traditional 2
Setting Who Delivered? Frequency? Duration? treatment consisted of an 8-week wellness workshop for caregivers while the MTC treatment took place in three sessions over the course of 12 weeks, with 4-week intervals between each meeting. Both treatments followed a structure that addressed assertive communication, problem solving, coping techniques, and improving self-esteem. The professionals could only offer treatments to their assigned. Social workers, nurses, doctors, or psychologists The traditional therapists provided 8 weekly sessions. The MTC therapists provided three sessions with intervals of 4 weeks between each session. The traditional therapists provided 60-minute weekly sessions. The MTC therapists provided 90-minute sessions. Group 2: Immediate Treatment Group Brief Description Caregivers were randomly assigned to participate in either the traditional or minimal-therapist-contact. Both treatment s learned new skills or techniques to enhance their roles as a caregiver. Setting Who Delivered? Frequency? Duration? Social workers, nurses, doctors, or psychologists The treatment s were carried out individually over 8 weeks. The traditional received eight weekly sessions directly with the therapist. The minimal-therapist-contact received three sessions with intervals of 4 weeks between each session. The traditional received 60-minute weekly sessions directly with the therapist. The MTC received 90-minute sessions. Group 3: Waiting List Group Brief Description The waiting list was evaluated twice, with no treatment received between assessments. After the second assessment, they were offered the opportunity to participate in either the traditional or MTC. The results of their subsequent participation are not included in this study. Setting Who Delivered? Frequency? Duration? Twice with a 2-month interval between assessments 3
Intervention Biases: Circle yes or no and explain, if needed. Contamination Two levels of randomization for assigning professionals and caregivers to the traditional or MTC were used to prevent contamination. Co-intervention Timing Site The sites for neither the traditional nor the MTC were reported; however, the site could have a significant impact on treatment if one set of interventions were provided at the caregiver s home and the other set in the community or vice versa. Use of different therapists to provide intervention The professionals were randomly assigned to the traditional treatment or MTC treatment. Once assigned, the professional could only offer treatment to their designated. MEASURES AND OUTCOMES Complete for each relevant measure when answering the evidence-based question: reported in article yes/no/ [not reported]), and how frequently the measure was used. The Sociodemographic Information and History of Caregiving was used to gather information about the caregiver s personal characteristics, the care receiver characteristics, and the relationship between the care receiver and caregiver. Additional information about the caregiving situation was obtained. The validity, reliability, and frequency of use of this measurement were not reported. reported in article yes/no/ [not reported]), and how frequently the measure was used. The Katz Index of Activities of Daily Living measured the care receiver s level of impairment in six self-care activities. The Spanish version of this measure was identified to be reliable, and the frequency of use was not reported. reported in article yes/no/ [not reported]), and how frequently the measure was used. The Anxiety subscale of the Hospital Anxiety and Depression Scale measured the caregiver s anxiety symptoms. The reliability and validity of this measure were reported as satisfactory in the article, and frequency of use was not reported. 4
reported in article yes/no/ [not reported]), and how frequently the measure was used. The Beck Depression Inventory measured the caregiver s symptoms of depression. The reliability and validity of this measure with caregivers and the Spanish version were reported as appropriate, and frequency of use was not reported. reported in article yes/no/ [not reported]), and how frequently the measure was used. The Zarit Burden Interview measured the caregiver s feelings of burden. The Spanish version of this measure was reported as reliable and valid, and frequency of use was not reported. reported in article yes/no/ [not reported]), and how frequently the measure was used. The Maladaptation Scale measured the impact of individual problems and their subsequent impact on different areas of life. The Spanish version of this measure was reported to be valid and reliable, and frequency of use was not reported. Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. Blind interviewers were not used; however, the authors attempted to control this bias by utilizing self-reported instruments. Recall or memory bias. Circle yes or no, and if yes, explain. Others (list and explain): RESULTS List results of outcomes relevant to answering the focused question Include statistical significance where appropriate (p < 0.05) Include effect size if reported Caregivers in the traditional demonstrated higher compliance with tasks than the MTC : p <.001 Caregivers in the traditional demonstrated a notable decrease in levels of anxiety, depression, burden, and maladaptation: p <.001, p <.001, p <.05, and p <.05 respectively. Caregivers in the MTC demonstrated significant decreases in anxiety and burden: p <.05 and p <.05 respectively. Post-hoc analysis showed that anxiety was notably higher in the control in comparison to the traditional treatment : p <.001 5
Post-hoc analysis showed that depression in the MTC was notably higher in comparison to the traditional treatment : p <.05 Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. This study examined a general sample of 91 caregivers and was identified by the authors to meet standards of research on treatment efficacy; specifically, this study 1) randomly assigned participants to different experimental s; 2) included in-depth outcome measurements; 3) excluded participants with comorbidities; 4) clearly outlined the treatment and treatment protocols; 5) used a fixed number of treatment sessions; and 6) identified the clinical significance of the study results. Were appropriate analytic methods used? Circle yes or no, and if no, explain. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. Statistics were appropriately reported in both written and table format. CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. Interventions addressing assertive communication, problem-solving and coping techniques, and increasing self-esteem reduced functional impairments in the caregivers daily lives. In particular, the traditional intervention format reduced levels of depression, anxiety, and burden when compared to the MTC. However, both forms of interventions were determined to be beneficial in enhancing the caregiver s quality of life. Occupational therapists should consider and use these interventions to reduce functional impairments and caregiver burden, depression, and anxiety and to improve the caregiver s physical and mental well-being. In turn, this professional support will enhance the caregiver s role and ability to provide quality care to the care receiver. Primary limitations are generalization of results to caregivers in other countries and lack of delivery of interventions by occupational therapists. This work is based on the evidence-based literature review completed by Jessica Montgomery, MOTS, and Sclinda Janssen, PhD, OTR/L, Faculty Advisor, University of North Dakota. CAP Worksheet adapted from: Critical Review Form Quantitative Studies M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, 1998, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA.Contact: www.copyright.com 6