The prevalence of depression among older adults in the United States has been estimated to be approximately 11% (Steffens, Fisher, Langa, Potter, & Plassman, 2009) and much greater than 15% for those age ≥65 years in nursing homes, hospitals, or with dementia (Geriatric Mental Health Foundation, 2019; Steffens et al., 2009). It has been estimated that 5.5 million people in the United States have Alzheimer's disease, and that number is projected to triple by 2050 (Alzheimer's Association, 2017; Karlawish, Jack, Rocca, Snyder, & Carrillo, 2017). Older adults with dementia struggle to preserve a sense of meaning in their lives (Holst & Hallberg, 2003). One method to alleviate depression among older adults is the provision of life review (LR) therapy. Providers of LR guide recipients through an examination of life themes, stages, and turning points. LR sessions aim to help recipients feel better about and find meaning in their lives and feel less depressed.
Life Review Theory
Based on the works of Butler (1963) and Erikson's (1950) Stages of Psychosocial Development theory, LR involves helping older adults recall and discuss memories in a way that fosters acceptance of their life as appropriate and meaningful. Erikson (1950) recommended conducting a LR during the last (eighth) stage of life to help in accepting one's life by integrating memories into a meaningful whole, thus avoiding despair, as LR can help people cope with negative emotions and cognitions associated with unpleasant memories and find meaning in their accomplishments (Haber, 2006).
LR also has been posited to offset disengagement and cognitive decline by fostering mental activity (Haber, 2006). Based on social-cognitive theory, Staudinger (2001) suggests that by reviewing older adults' life events with a trusted significant other, they can recall and reevaluate earlier events and their implications regarding how they feel about their life. The LR listener can facilitate cognitive reframing of negative cognitive distortions into a positive outcome (Webster & Haight, 2002). To be effective, LR should involve at least six weekly sessions. Sessions can last 1 or 2 hours unless physical frailty requires shorter sessions (Haber, 2006).
Empirical support for the effectiveness of LR in alleviating depression among older adults has been provided in meta-analyses (Bohlmeijer, Roemer, Cuijpers, & Smit, 2007; Bohlmeijer, Smit, & Cuijpers, 2003; Pinquart, Duberstein, & Lyness, 2006; Pinquart & Forstmeier, 2012). Based on these previous studies, LR can be as effective as antidepressant medications in reducing depression among older adults without the undesirable side effects of medication, can be delivered easily, does not stigmatize, and appears to fit the cognitive processes in older adults.
Haber (2006) believed that providing LR does not require extensive training and can be done by family members. In his study, Haber (2008) offered LR sessions to 13 cognitively intact older adults facilitated by 13 master's level students at one assisted living facility as a class project. Although caregivers participated in some research on LR as intervention recipients, none of the studies focused exclusively on caregivers alone as providers of LR.
As the Baby Boomer generation reaches old age, there is likely to be a shortage of resources to help alleviate depression among older adults. The Institute of Medicine (2017) predicts that by 2030 more than 72 million Americans will be age ≥65 years, and this population is likely to overwhelm the nation's mental health care system. Therefore, the current authors developed a novel depression intervention model, Caregiver-Provided Life Review (C-PLR) based on LR theory. The purpose of the current study was to explore the feasibility of helping caregivers of individuals with dementia provide LR to their care recipients.
The current study used a one-group pre-/post-study design. Participants were recruited primarily from agencies located in Houston, such as the Alzheimer's Association Houston Chapter, Sheltering Arms Senior Services, and Amazing Place, that provide community-based services for those who have memory-related issues. At the time of admission to their programs, those agencies administer cognitive assessments and place participants in appropriate levels of care within their programs. The centers were familiar with each participant's cognitive level, thus were able to refer the best fitted potential participants to the authors based on study criteria. Recruited participants identified additional potential participants whom they knew. The authors assessed eligibility in telephone interviews, asking caregivers and care recipients about their availability, willingness for study participation, signs of depression, and cognitive condition. In addition to being willing and available, potential participants were considered preliminarily eligible if during the interview the caregiver verified that the care recipient had early to moderate stage dementia, some symptoms of depression, and did not have any serious psychopathological symptoms. The authors visited those candidates who were initially screened as eligible to obtain informed consent from the caregiver and care recipient. During the visit, the authors also administered pretests of the levels of the care recipient's depression, caregiver burden, and the quality of the dyad's relationship. This process identified a few care recipients as ineligible for the study due to their advanced degree of cognitive impairment and they were unable to sign the consent form. The current study was approved by the authors' institutional review boards.
To be included in the current study, caregivers had to (a) be family members or close friends of the care recipients who provided caregiving voluntarily; (b) see the care recipient at least twice per week for at least 8 hours per week; (c) complete a 6-hour C-PLR caregiver training; and (d) commit to six LR sessions with the care recipient and participate in fidelity check-in calls and a post-intervention interview. Care recipients had to (a) live at home or in an independent/assisted living facility by themselves; (b) exhibit signs of mild depression (as reported by the caregiver); (c) have shown signs of dementia or been diagnosed with early to moderate-stage dementia by a medically licensed physician (as reported by the caregiver); and (d) have not been diagnosed with any psychotic disorder (as reported by the caregiver).
Thirty-five caregivers expressed interest in the study. After all screening processes, 19 caregiver–care recipient dyads were identified as eligible. The authors offered four rounds of caregiver training and C-PLR intervention from May to September 2018. Each training was conducted in a small group (four or six caregivers per session). The authors held three training sessions at the Alzheimer's Association because most participants were familiar with the location due to their involvement in the agency's early stage programs. The fourth session was held at a local continuing care retirement community where care recipients were residents.
Demographic Information. The authors collected data on each participant's gender, race/ethnicity, age, marital status, educational attainment, employment, and general health status.
Depression. Care recipients' depression level was measured by the Patient Health Questionnaire-9 (PHQ-9) (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is a 9-item self-administered depression module questionnaire with excellent internal reliability (Cronbach alpha between 0.86 and 0.89) and test–retest reliability. Possible scores range between 0 and 27. The lower the total score, the less depressive symptoms. The authors also asked caregivers to assess their care recipient's depression level using the same instrument from their perspective.
Caregiver Burden. The authors measured the level of caregiver burden using a 10-item Burden Scale for Family Caregivers, Short Form (BSFC-S), which has excellent reliability (Cronbach alpha = 0.92) (Graessel, Berth, Lichte, & Grau, 2014). Scores range from 0 to 30, with lower scores indicating less caregiver burden.
Relationship Quality. Caregivers' quality of relationship with their care recipients was assessed using four questions taken from the National Study of Caregiving (NSOC, 2017) Round 7, Aspects of Caregiving questions. These four questions are:
“How much do you enjoy being with your care recipient?”
“How much does your care recipient argue with you?”
“How much does your care recipient appreciate what you do for him/her?” and
“How often does your care recipient get on your nerves?”
Each question was followed by a 4-point Likert scale response from not at all, a little, and some to a lot. The higher the total scores, the more positive the relationship. The measures of depression, caregiver burden, and relationship quality were collected at pre- and post-intervention.
Once the informed consent and pretests were complete, all caregivers took the C-PLR 6-hour caregiver training (Week 1). From Week 2 to Week 7, each caregiver conducted weekly LR with their care recipient at home (interventions). During the week after each LR intervention, the research assistant (RA; S.W.) called each caregiver for fidelity check-ins and provided support and guidance as needed. Upon completion of the 6-week C-PLR intervention, the RA visited each dyad, administered the posttests (Week 8), and conducted interviews with caregivers regarding their C-PLR intervention experience.
Life Review Training
The 6-hour, 1-day caregiver training provided knowledge and skills to prepare caregivers to conduct LR with fidelity with their care recipients. LR education was based on the structure of LR by Haight and Haight (2007). Limiting the training group size ensured optimal active participation and provided ample time for individualized attention to specific caregiver needs. Content was presented from simple to complex learning with a purpose-driven strategy to teach the fundamentals of LR with a didactic approach followed by an interactive activity.
LR training comprised an overview of reminiscence and LR, a step by step instruction on conducting a LR session, consideration (e.g., care recipient activities, medications, meal times), skills of therapeutic listening and mindfulness, communication techniques (i.e., reframing and encouragement), and expectations of LR, including positive and negative responses from care recipients. Class time included practice sessions using the newly acquired interview and listening skills, as well as a brief experiential exercise on young adulthood. The didactic portion of the training addressed the topics to be covered in LR sessions (i.e., early childhood, family and home, adolescence, young adulthood, older adulthood, and reflections on life) followed by an abbreviated LR practice session.
Caregivers were given class materials including handouts of the slide presentations and a checklist that showed a summary of the LR topics by week. The content of the training session and the educational strategies were not modified throughout the current study.
Fidelity Check-In. Caregivers' level of LR intervention fidelity was checked by the RA's weekly telephone calls using a fidelity check-in sheet. The check-in sheet had two sections: Getting Prepared, with nine questions, and LR Session, with seven questions. The Getting Prepared section included questions such as providing a comfortable environment, privacy, noise level (e.g., hearing aids, television off, phone on silent), memory aids (e.g., photographs, medals, foods), and timing considerations (i.e., right day, right time). The LR Session included an introduction to each life stage, showing memory aids to care recipients, a list of open-ended questions to start the LR session, caregiver attentiveness and showing interest, and whether expectations of the LR were met.
Descriptive statistics were used to present the characteristics of caregiver–care recipient dyads, including sociodemographic background and global health. Care recipient's depression level, caregiver burden, and relationship with care recipient were summarized, stratified by pre and post C-PLR intervention using the mean (SD). The corresponding effect size was assessed by Cohen's d for pretest and posttest (paired) samples. Statistical significance was evaluated by a significance level of 0.05. Analyses were performed with SAS version 9.4.
Table 1 shows the characteristics of caregivers and care recipients in the current study. Caregiver age ranged between 43 and 74 years (mean = 63.6; SD = 8.3 years). Most participants were college-educated (88%), female (94%), and in good health (47%). Most caregivers were retired (71%) and lived with their care recipients, usually their parents. Most caregivers had other people who could provide caregiving assistance. Care recipient age ranged between 72 and 92 years (mean = 83.4; SD = 6.2 years). Most care recipients were single (71%), male (53%), and in fair health (53%).
Characteristics of Caregiver–Care Recipient Dyads (N = 17)
Caregiver-Provided Life Review Intervention Outcomes
Table 2 shows that the mean PHQ-9 scores of self-reported care recipient depression fell by 2 points from 9.8 at pretest to 7.7 at posttest, yielding a within-group (Cohen's d) effect size of 0.35, whereas the mean of care recipient depression reported by caregivers fell from pretest to posttest from 9.4 to 8.6, yielding a within-group effect size of 0.15. Mean caregiver burden scores fell from pretest to posttest from 16.4 to 15.2, yielding a within-group effect size of 0.29. As for the dyads' relationship quality, the mean scores remained approximately the same, yielding a within-group effect size of 0.12. None of the pretest to posttest improvements were statistically significant.
Results of Pre and Post Caregiver-Provided Life Review Intervention
Feasibility and Fidelity of Caregiver-Provided Life Review Intervention
At the start of the current project, 19 caregivers participated in and completed the caregiver training. However, during the third fidelity check-in calls, the authors found that two caregivers were not following the protocol of the intervention. The RA attempted to ensure that these two caregivers would follow the exact protocol; however, neither were able to follow the instructions, and therefore, they were asked to withdraw from the project. Thus, the total number of caregivers who completed the entire C-PLR intervention was 17 (89%) caregiver–care recipient dyads. Table 3 is the result of the caregiver fidelity check-in calls. All sessions resulted in a high-fidelity level (15.7 of 16 points), showing that all remaining caregivers were able to offer LR with apparent fidelity.
Results of Caregiver Fidelity Check-In Calls
The authors pilot-tested the feasibility of the C-PLR model with 17 caregiver–care recipient dyads. The model included a 6-hour caregiver training session and six weekly LR sessions at home. All 19 caregivers completed the training, and 17 caregivers finished six LR sessions with apparent fidelity. However, because the current pilot study lacked adequate statistical power, the authors were unable to provide conclusive evidence, and the outcome results have heuristic value only. But, because the aim of the current study was to test the feasibility of the C-PLR model in a convenience sample, the study met the purpose of feasibility testing. The authors believe that the feasibility of the C-PLR was high and promising among dyads of caregivers and care recipients with mild to moderate dementia.
A possible reason for the outcome results was that the severity of some care recipients' dementia had progressed as reported by caregivers during the intervention period, which made it harder for care recipients to recall their memories. This deterioration poses an understandable but challenging nature to this type of intervention. Future studies should monitor care recipients' cognitive status at the beginning, mid, and end points using a tool, such as the Montreal Cognitive Assessment (Nasreddine et al., 2005), which has been known to be sensitive to changes. Although none of the study participants became ill or were admitted to a higher level of care facility (i.e., skilled nursing), the possibility of health problems that might cause premature discontinuation of the intervention should be considered in a future study with a larger sample.
The authors used the PHQ-9 (Kroenke et al., 2001) to assess care recipients' depression level; however, some care recipients did not understand the PHQ-9 questions. Future investigators might consider a different instrument, such as the Geriatric Depression Scale (GDS) (Yesavage et al., 1982–1983). The GDS is another well-established tool used to measure depression level, with a high Cronbach's alpha of 0.94 (Yesavage et al., 1982–1983), and has been validated in people with cognitive impairments (Jongenelis, et al., 2005; Smalbrugge, Jongenelis, Pot, Beekman, & Eefsting, 2008).
Another possible explanation for the limited degree of outcome improvement is that the assessment of fidelity was limited to telephone check-in calls asking whether caregivers provided a comfortable environment, memory aids, proper timing, and an introduction to each life stage. During caregiver training, the authors allocated some time for role play; however, they did not assess the therapeutic acumen of caregivers, such as how skillful they were in expressing empathy or helping the recipient reframe undesirable cognitions associated with unpleasant memories. In future assessments of this model, the authors should try to record some LR sessions conducted by caregivers to assess these skills. In addition, perhaps those skills could be nurtured and assessed in role play training, in which the role play script for the LR care recipient includes some negative self-blame cognitions associated with unpleasant memories that the recipient regrets.
The authors offered caregiver training in English to a sample of English-speakers only. Future studies could examine its provision in different languages. For example, two caregivers were bilingual Hispanic individuals, but their parents were monolingual Spanish speakers. Both caregivers completed their training session in English, but they conducted their LR sessions in Spanish because their parents were most comfortable communicating in Spanish. Previous studies have shown that bilingual individuals tend to go back to their native language as they get older, even if they used to speak in English during their working years (McMurtray, Saito, & Nakamoto, 2009). Therefore, it might be preferable to conduct interventions in participants' native or most familiar, comfortable languages. Bilingual trainers can offer training sessions in languages other than English so that monolingual caregivers can attend, learn LR skills, conduct LR interventions with their monolingual care recipients with their familiar languages, and receive the same benefits.
Because many caregivers work and take care of their aging parent at the same time, their available time is limited. As most of the training sessions were offered at the Alzheimer's Association Houston Chapter, some caregivers needed to make special arrangements to be away from home for a 1-day training despite respite care for their loved ones at the training site. Training teams should travel to different locations where more caregivers can attend the training sessions easily.
Implications for Practice and Research
In the current pilot study, the authors found that caregivers were eager to seek resources for their family members with dementia. Caregivers were seeking help from the Alzheimer's Association, participating in support groups, and willing to try activities that could prolong the current cognitive state of their family members. They were eager to “do whatever is necessary” to maintain the cognitive health of their loved ones. Caregivers described that their family member's change from an independent person with full capacity to a person in a dependent state was depressing for them. Caregivers in the current study knew that their family member's loss of cognitive function was permanent. Caregivers witnessed the disruption of their family unit with changing roles, evolving responsibilities, loss of income, and social isolation. Caregivers were actively looking to health care providers for answers to ease their burden of physical, emotional, and social stresses. RNs specializing in gerontology, neurology, and mental health, as well as other health care providers, such as social workers, are uniquely positioned to care for a high volume of people with early or moderate dementia, and support and educate caregivers on the disease process, medications, and interventions to keep the person with impairment engaged in life activities and maintain cognition. Some community-based RNs and social workers make home visits to their clients on a regular basis so that they can provide an opportunity to offer LR interventions, especially if their clients are experiencing depressive symptoms. RNs take human development courses as part of the RN program, which includes education on theories of Piaget, Erikson, and Kohlberg. All accredited Master of Social Work (MSW) programs are required to include Human Behavior in the Social Environment courses, in which they learn Erikson's life stages; thus, MSW students are familiar with the theory of life stages. LR sessions can be offered in nursing and social work class sessions and supplemented with field practicums, enabling students to provide LR (or train caregivers to provide it) in their professional practice after graduating.
Results indicated that the acceptability of the C-PLR training and intervention was high among caregivers and care recipients. However, the authors did not assess how clinically skillful caregivers were in providing LR sessions. Further studies can attempt to determine the impact of deterioration in cognitive functioning on the effects of C-PLR and whether more clinically meaningful improvements in depressive symptoms can be observed when more attention is given to nurturing and assessing the clinical skills of caregivers potentially in a larger sample.
LR therapy is a noninvasive way to alleviate depressive symptoms among older adults. The current study assessed the feasibility of a 1-day caregiver training and caregiver provision of 6 weekly LR sessions, the fidelity of each intervention session, and the changes in care recipients' depressive symptoms, caregiver burden, and caregiver–care recipient relationship quality. The current study displayed that most caregivers were willing and able to provide the LR intervention in the prescribed manner. Leveraging lessons learned from the current pilot study, the next step can attempt to try a randomized controlled trial to measure the effects of the C-PLR intervention to alleviate care recipients' depressive symptoms with a larger sample.
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Characteristics of Caregiver–Care Recipient Dyads (N = 17)
|Variables||Caregiver n (%)||Care Recipient n (%)|
|Age (years) (mean, SD)||63.6 (8.3)||83.4 (6.2)|
| Female||16 (94.1)||8 (47.1)|
| Male||1 (5.9)||9 (52.9)|
| White||8 (47.1)||9 (52.9)|
| Black||4 (23.5)||4 (23.5)|
| Hispanic||3 (17.6)||2 (11.8)|
| Asian||2 (11.8)||2 (11.8)|
|Marital status (married)||11 (64.7)||5 (29.4)|
|Employment status (employed)||5 (29.4)||0 (0)|
| High school or less||2 (11.8)||5 (29.4)|
| Some college||8 (35.3)||2 (11.8)|
| College or higher||9 (52.9)||10 (58.8)|
| Fair||4 (23.5)||9 (52.9)|
| Good||8 (47.1)||2 (11.8)|
| Very good||2 (11.8)||5 (29.4)|
| Excellent||3 (17.6)||1 (5.9)|
|Household income (U.S. dollars)|
| <25,000||2 (11.8)||3 (17.6)|
| 25,000 to 50,000||5 (29.4)||5 (29.4)|
| >50,000||3 (17.6)||3 (17.6)|
| Declined to answer||7 (41.2)||6 (35.3)|
|Care Recipients (CR)|
| Living arrangement|
| Alone||6 (35.3)|
| With spouse||6 (35.3)|
| With adult children||5 (29.4)|
| Relationship to CR|
| Spouse||5 (29.4)|
| Daughter||12 (70.6)|
| Living distance from CR|
| With CR||10 (58.8)|
| 5 to 30 minutes away||5 (29.5)|
| Another city||2 (11.8)|
| Additional helper available (yes)||14 (82.3)|
| How often available (n = 14)|
| Occasionally/sometimes||6 (42.8)|
| Often/all the time||8 (57.2)|
Results of Pre and Post Caregiver-Provided Life Review Intervention
|Variable||Pretest (n = 17) Mean (SD)||Posttest (n = 17) Mean (SD)||p Value|
|Care recipient (CR)|
| Depressive symptoms|
| Reported by CR||9.8 (6.5)||7.7 (7.0)||0.13|
| Reported by caregiver||9.4 (5.7)||8.6 (5.6)||0.61|
| Caregiver burden||16.4 (6.7)||15.2 (7.1)||0.30|
| Relationship quality with CR||8.5 (2.4)||8.3 (3.1)||0.69|
Results of Caregiver Fidelity Check-In Calls
|Check-In Call Number||Caregivers (n)||Mean (SD) (Range)|
|1||17||15.7 (0.8) (13 to 16)|
|2||17||15.5 (0.8) (14 to 16)|
|3||17||15.7 (0.7) (14 to 16)|
|4||17||15.7 (0.8) (13 to 16)|
|5||16||15.7 (0.7) (14 to 16)|