Mohammed T. Abou-Saleh

766 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYtheir caregivers had 10 days’ respite. Those in the delayedtraining group received the dementia caregivers’ program afterapproximately 6 months. We calculated a sample size of over30 for each of the three groups as necessary for an interventionof moderate power (estimate 0.6) to produce a relevant effectsize (estimate 0.67) for a=0.5.AssessmentPatients were assessed on the Orientation InformationMemory Concentration scale [OIMC, range 0–37 (37=maximumcognitive functioning) 12 ]; the Dementia Scale [range=0–27 (higher score indicates worse function) 12 ]; the Mini-MentalState Examination [range 0–30 (30=maximum cognitivefunction, 517 indicated important deterioration) 13 ]; the 21item Problem Behaviour Checklist 14 [range 0–42 (0=noproblems, 42=all problems occurring frequently)]; the Activitiesof Daily Living [range 0–6 (0=completely independent,6=completely dependent) 15 ]; the Instrumental Activities ofDaily Living [range 1–4 (1=complete independence, higherscores indicate increasing dependence) 16 ]; the 21 item HamiltonRating Scale for Depression [range 0–64 (416 indicatesimportant depression) 17 ]; the Geriatric Depression Scale [range0–20 (410 indicates possible depression) 18 ]; and the ClinicalDementia Rating Scale for Dementia [range 0–3; (0=healthy,3=severely demented) 19 ].Carers completed the General Health Questionnaire [range0–30 (those with scores 44 probably were considered to havesignificantly psychological morbidity) 20 ]; and the Zung DepressionScale [range 20–80 (540 indicated importantdepression) 21 ] and were rated on the Hamilton DepressionRating Scale. They were asked to keep a health diary of allthe healthcare visits made and medications taken by them andthe patient over the 12 months of follow-up. They were alsoasked to keep a record of all visits to day centres and anydays in residential care. Completion of the diaries wasencouraged at the regular telephone conference sessions.Demographic data on all participants were collected andincluded the position on the Congalton scale for socioeconomicstatus [range 1–7 (1=highest status occupation,7=lowest) 22 ].RESULTSThe Sample DefinedOne hundred and one pairs of patients and caregivers enteredthe trial. Three of the 36 pairs in the immediate carers’ programhad insufficient follow-up data, and one of the 32 patients inthe memory retraining group (MRP) changed caregivers duringthe follow-up period. These four pairs were excluded fromfurther analyses. Two pairs in the delayed carers’ program(DCP) completed intake and pretraining assessments but electednot to proceed with the training. Their data from the initial twoassessments were included in the analyses at 0 and 6 months,but not subsequently. Otherwise all patients and caregivers whobegan the programs completed them.This left 33 pairs in the immediate DCP, 32 in the wait-list DCPand 31 in the MRP. Of the 96 carers, 89 were spouses, four weresiblings and three were children of patients. Forty-four caregiverswere men and 30 of the 87 who completed the question affirmedtheir membership of the Alzheimer’s Disease and RelatedDisorders Society. The caregivers’ mean age was 67.7 (SD=8.2years).Mean general health questionnaire scores87654Of the 96 patients, 50 were men, 70 had probable Alzheimer’sdisease, 19 had multi-infarct dementia, and seven had other causesof dementia. Their average age was 70.2 (SD=6.5 years; range49–79 years) and they had had 10.4 (3.6) years’ education and hadmild-moderate dementia [Clinical Dementia Rating Scale score1.1 (0.5)]. The duration of dementia, a mean of 3.8 (3.8) years, wassimilar in the three groups. The sample was predominantlymiddle-class (n=52), with 16 from the upper socioeconomicclasses and 25 from the lower socioeconomic classes. Data fromthree patients were missing. There were no significant differencesbetween the three groups, for caregivers or patients, on anysocioeconomic variable or initial measure of outcome at entry intothe trial.In later reports from the study, three subjects were excluded.One subject did not decline and he was subsequently rediagnosedas having benign forgetfulness; another subject who had undertakenthe memory retraining program was excluded because he andhis wife subsequently undertook a caregiver training program;and a third subject from the wait-list group did not providesufficient data. Otherwise, all subjects declined over time,confirming their diagnosis of a progressive dementia. Diagnoseswere able to be refined over time, so that of the 93 patients, 65were subsequently diagnosed with probable Alzheimer’s disease,21 with multi-infarct dementia, three with Pick’s disease and fourwith other uncertain cause of dementia (two subcortical dementia,one carbon monoxide poisoning and one diagnosis deferred).There were some slight differences in the baseline characteristics ofpatients and caregivers once these three pairs had been excluded,but these were trivial. Details can be found in the report fromBrodaty et al. 1Caregivers’ OutcomeDementia carers'programmeMemory retrainingprogrammeWait list3 0 3 6 9 12 15 18MonthsFigure 2 Mean General Health Questionnaire scores for carers in allthree groups. Standard deviations of each group at zero, three, six, andtwelve months respectively were 6.2, 5.8, 6.2, and 5.6 for the dementiacarers’ programme group; 6.3, 7.1, 8.4, and 9.4 for the memory retraininggroup; and 6.1, not available, 6.7, 6.6, and 7.7, at 18 months, for the waitlist group. From Brodaty and Gresham 2 , by permission of the BMJPublishing GroupCaregivers’ psychological morbidity, as judged by the GeneralHealth Questionnaire (GHQ-30) declined significantly over 12months in the immediate intervention but rose steadily in thememory retraining group. GHQ scores of those in the delayedtraining program remained steady (Figure 2). Scores on the ZungDepression Scale did not show this differential effect, probablyreflecting the low initial scores on that scale and the biologicalnature of many of its items 21 .