REACH was designed to examine the feasibility and effectiveness of multiple intervention approaches for family caregivers of individuals with dementia. Each site was conducted as a randomized trial with high levels of quality control, including formal treatment implementation procedures (Burgio et al., 2001
; Lichstein, Riedel, & Grieve, 1994
) and use of the intention-to-treat analytic strategy. This article reports the results of the combined effects of active interventions in comparison with control group conditions at 6 months on two outcome measures of importance in caregiver research: perceived caregiver burden and caregiver depressive symptoms. These measures have been extensively examined in caregiver research and are widely viewed as clinically meaningful indicators of caregiver status, as described in this issue by Schulz et al. (2003)
. Our basic assumption was that the combined effect of active interventions would result in less caregiver burden and caregiver depressive symptoms in comparison with controls at the first 6-month interval of the REACH initiative. Also, we examined on an exploratory basis, the relationship between treatment and caregiver characteristics, an expressed goal of the REACH initiative as described by Schulz et al.
Caregivers enrolled across the REACH sites had been providing care for an average of 4 years to individuals at the moderate to severe stage of dementia. Most caregivers reported a moderate level of burden associated with care-recipient behavior problems, and on average were slightly below the cutoff score (≥16) for being at risk for clinical depression.
Using meta-analysis, the combined effects of active versus control group conditions were examined. We found that the pooled treatment effect from the meta-analysis for RMBPC Burden was statistically significant (p = .022), albeit the difference was small. Overall, caregivers across the REACH sites in active interventions showed lower values in burden associated with the occurrences of behavior problems than caregivers enrolled in the control conditions. There were no statistically significant effects for any one intervention for the measure of burden, although for each site’s active intervention, burden scores were in the hypothesized direction.
In contrast to the RMBPC Burden results, the pooled treatment effect across sites for the meta-analysis for CES–D was not statistically significant (p = .095). Only one site, Miami, reported a significant reduction in depressive symptoms (p = .034) in the combined family therapy plus technology treatment condition compared with the control condition. The family-therapy intervention by itself did not have a significant effect on depressive symptoms. The unique feature of the combined therapy and technology intervention was that in addition to receiving in-home family therapy, caregivers were able to access local resources and participate in family conferences and online support groups using a simple computer-telephone technology. The technology may have enabled caregivers to receive additional needed individualized support without having to leave their homes. In addition, the availability of a telephone that enabled family conferencing may have facilitated the resolution of conflicts that arose in the context of in-person family therapy sessions.
Although REACH found only a modest overall intervention effect, this finding is consistent with the results of a recent meta-analytic review of the intervention literature (Sorenson, Pinquart, & Duberstein, 2002). The magnitude of the effect sizes for the combined active REACH interventions on caregiver burden (0.15 standard deviation units) and Miami’s FSMII + CTIS intervention on depressive symptoms (0.23 standard deviation units) fall within the range of effect sizes reported by Sorenson et al. (2002) in their review of 78 caregiver interventions reported in the literature. Overall, they found improvement ranging from 0.14 and 0.41 standard deviation units in caregiver burden, depressive mood, and other measures of well-being. Moreover, dementia caregivers in these studies benefited less from interventions than did caregivers of older adults without dementia. It is also noteworthy that most of these studies were not carried out as randomized clinical trials, nor were data analyzed using intention-to-treat statistical methods. This calls into question the reliability of findings previously reported in the literature. One multisite study, which was most similar to REACH in terms of overall design, reported similar small reductions in caregiver burden following a case-management intervention, and comparable to our findings, did not find consistent improvement across all sites (Newcomer, Yordi, DuNah, Fox, & Wilkinson, 1999
In a review of 43 recently published caregiver intervention studies, Schulz et al. (2002)
examined the issue of clinical significance to move the field forward in achieving more reliable and clinically meaningful outcomes. In comparison to existing caregiver intervention literature, the REACH program sets new standards with respect to the application of randomized clinical trial methodology. However, REACH was only somewhat successful in achieving clinically meaningful outcomes. As with most other caregiver intervention studies, the overall findings from REACH met one of the four criteria of clinical significance identified by Schulz et al.: social validity. Across sites, study participants consistently rated active interventions as more beneficial, helpful, and valuable than control conditions (data not reported). Nevertheless, the evidence for outcomes with public health significance are less compelling. For example, the magnitude of change on RMBPC Burden for the REACH combined active groups compared to control conditions was 10%. A 10% reduction in burden on the RMBPC (score range = 0–96) is equivalent to the decrease or elimination of two very bothersome behaviors, such as repetitive vocalization or waking at night.
One reason for the relatively small overall effects of REACH may be the complex pattern of significant outcomes observed for various subgroups. Across the REACH sites, for RMBPC Burden, women and those with high school or less education who were in active interventions reported reduced burden compared to the control conditions. In contrast, men and those with higher education levels did not show significant levels of benefit from the interventions overall. Across the REACH sites, for CES–D, caregivers in active interventions who were Hispanic, those who were nonspouses, and those who had less education reported lower 6-month scores than those with the same characteristics who were in the control group conditions. These findings suggest that the combined interventions had an effect for those caregivers in most need of support.
This study has several limitations that should be noted. First, the meta-analytic approach used here is unable to disaggregate which treatment elements within and across the interventions are most important for decreasing caregiver burden. This analytic approach does not fully take advantage of the power of REACH and its potential to yield information about the impact of specific components of interventions. To address this methodological issue, REACH developed a comprehensive classification system for characterizing and measuring caregiver interventions that captures the content, process, and goals of an intervention in a theoretically relevant manner. This classification system is presented in Czaja et al. (2003)
and Belle et al. (2003)
in this issue. The analyses based on the classification structure systematically extend the traditional analyses presented here and contribute to a fuller understanding of REACH treatment effects. A second limitation is that some of the REACH interventions did not have, as their primary goal, the reduction of caregiver depression (Birmingham, Boston, and Philadelphia). There may be other outcomes not measured in the REACH core batteries, which are more proximal to the goals of these interventions, that are sensitive to the positive benefits that may have occurred, and that are also clinically meaningful. These outcomes are examined in site-specific reports (Burgio et al., 2003
; Burns et al., 2003
; Eisdorfer et al., 2003
; Gallagher-Thompson et al., 2003
; Gitlin et al., 2003
; Mahoney et al., 2003
Another related consideration is the interval of data collection. The 6-month follow-up may have been too soon to detect change, particularly in depressive symptoms. Mittelman et al. (1995)
, in their study of the effects of a combined individual and family counseling intervention with spouses, found a significant reduction in depressive symptoms at 12 months but not at the 4- and 8-month follow-up assessments.
The results of the REACH initiative provide important insights for developing and testing future interventions for family caregivers. They confirm the conclusions from recent reviews of the caregiver intervention research that there is no single, easily implemented, and consistently effective method for eliminating the multiple stresses of providing care to persons with dementia. For example, although the Miami FSMII + CTIS intervention reduced depressive symptoms, it did not have a significant effect on burden associated with behavior problems. This suggests that a multicomponent intervention that includes elements that target different aspects of the caregiving experience (e.g., affective responses, behavioral burden, and unsafe physical environments) might be most beneficial. Moreover, the challenge for future research will be to match intervention approaches with specific target populations. The optimal match may vary as a function of the outcome measure, regional context (e.g., Northeast vs. Deep South), and characteristics of caregivers, including gender, race and ethnic identity, educational level, and relationship to care recipient. Intervention strategies may also need to be refined to address the needs of caregivers who, in this study, did not show consistent or significant improvements, such as men, spouses, and White or African American caregivers. Thus, future research is necessary to test a multicomponent intervention approach tailored to match specific characteristics of caregivers and their needs in order to maximize benefits.