Faculty Bibliography

Objective To determine the long-term effectiveness of counseling for caregivers of patients with Alzheimer disease (AD). Design Randomized controlled trial with up to 8-years of follow-up. Setting Research center in New York, United States. Patients 206 caregivers (58% women) who had spouses with AD living at home and had primary responsibility for their care. Patients or caregivers had to have ? 1 relative living in the metropolitan New York area and could not be participating in another caregiver counseling or support group. Intervention Caregivers were allocated to an intervention group (H = 103) or a control group (n = 103). The intervention consisted of individual and family counseling sessions, weekly support group meetings, and continuous availability of counselors for helping caregivers deal with crises and the changing symptoms of the patients. Main outcome measures Time to nursing home placement of patients with AD and predictors of placement. Main results The unie to placement in a nursing home was longer for patients whose caregivers received the intervention than for patients whose caregivers received the usual services (median time at home adjusted for caregiver sex 1203 d vs 874 d, 95% CI for the median 329-d difference 47 to 611, P = 0.02). Univariate intention-to-treat analysis showed that female caregivers were more likely to place their spouses in nursing homes than male caregivers (relative hazard [RH] 1.48, CI 1.03 to 2.14, P = 0.04). Other predictors of placement were increasing patient age (RH 1.33, CI 1.05 to 1.68, P = 0.02); severity of dementia (RH for severe dementia 25.6, CI 3.53 to 185, P = 0.001); increasing depression in the caregiver (RH 1.05 CI 1.02 to 1.07, P = 0.001); and increased negativity of the caregiver toward troublesome behavior of the patient (RH 1.11, CI 1.08 to 1.14, P < 0.001). Patients with incomes of U.S. $100 000 were 62% less likely to be placed in nursing homes than patients with incomes of $10 000. Cox proportional hazard models that included!

OBJECTIVE: To determine the long-term effectiveness of comprehensive support and counseling for spouse-caregivers and families in postponing or preventing nursing home placement of patients with Alzheimer disease (AD). DESIGN: Randomized controlled intervention study. SETTING: Outpatient research clinic in the New York City metropolitan area. PARTICIPANTS: Referred, volunteer sample of 206 spouse-caregivers of AD patients who enrolled in the study during a 3 1/2-year period. All patients were living at home at baseline and had at least 1 relative living in the area. INTERVENTION: Caregivers in the treatment group were provided with 6 sessions of individual and family counseling within 4 months of enrollment in the study and were required to join support groups. In addition, counselors were available for further counseling at any time. MAIN OUTCOME MEASURE: Time from enrollment of caregivers in the study to placement of the AD patients in a nursing home. RESULTS: Using Kaplan-Meier survival analysis, we estimated that the median time (weighted average of estimates for male and female caregivers) from baseline to nursing home placement of AD patients was 329 days longer in the treatment group than in the control group (z=2.29; P=.02). The relative risk (RR) from a Cox proportional hazard model of nursing home placement (intent-to-treat estimate) after adjusting for caregiver sex, patient age, and patient income was 0.65 (95% confidence interval [CI], 0.45 to 0.94; P=.02), indicating that caregivers were approximately two thirds as likely to place their spouses in nursing homes at any point in time if they were in the treatment group than if they were in the control group. Treatment had the greatest effect on risk of placement for patients who were mildly demented (RR, 0.18; 95% CI, 0.04 to 0.77) or moderately demented (RR, 0.38; 95% CI, 0.17 to 0.82). CONCLUSIONS: A program of counseling and support can substantially increase the time spouse-caregivers are able to care for AD patients at home, particularly during the early to middle stages of dementia when nursing home placement is generally least appropriate

Hippocampal formation (HF) atrophy, although common in normal aging, has unknown clinical consequences. We used MRI to derive HF size measurements at baseline on 44 cognitively normal older adults entering a longitudinal study of memory function (mean age = 68.4 years, mean follow-up = 3.8 years). Only one subject became demented at follow-up. Multiple regression analyses controlling for age, gender, education, and diffuse cerebral atrophy revealed that HF size significantly predicted longitudinal change on memory tests previously found sensitive to decline in normal aging. These results indicate HF atrophy may be a risk factor for accelerated memory dysfunction in normal aging

OBJECTIVE: To examine the anticipated decisions to consent to or to forgo life-sustaining treatment by spouses of patients with Alzheimer's disease and to describe the relationship of spouse and patient characteristics to predicted decisions. DESIGN: Prospective quantitative study. SETTING: The Aging and Dementia Research Center (ADRC), part of an Alzheimer's Disease Center Core Grant, at New York University Medical Center. PARTICIPANTS: Fifty spouse caregivers of Alzheimer's disease patients, evaluated at the ADRC, who had a minimum Stage 4 on the Global Deterioration Scale. MEASUREMENTS: Spouses were presented with two conditions (critical illness and irreversible coma) and rated their agreement with, certainty of, and comfort with four treatments (resuscitation, breathing machine, feeding tube, and antibiotics). Data were also obtained as to patients' current quality of life, spouses' standard of decision-making, and spouse burden. RESULTS: Eighteen of 50 patients had a durable power of attorney for health care, 20 of 50 had a living will, and 26 of 50 had neither. In the face of critical illness, almost equal numbers of spouses would consent to or forgo CPR, 28 of 50 would forgo a breathing machine, 21 of 50 a would forgo a feeding tube, and 5 of 50 would forgo antibiotics. Five of 50 would forgo all four treatments, and 12 of 50 all but antibiotics. Spouses were significantly more likely to forgo treatment in the face of coma than for critical illness (P < .001). Spouses were more certain about decisions related to coma than to critical illness (P < .001), and there was a positive and significant correlation between certainty and comfort (P = .001). Those consenting to treatment were more comfortable than those forgoing treatment (for CPR and antibiotics P = .001). Spouses of patients with Stage 7 AD were more likely to forgo CPR than those with Stages 4 to 6 AD (P < .001). Only two of 50 spouses selected descriptors congruent with a purely substituted judgment standard of decision-making. An equal number of spouses rated patient quality of life as good, fair, or poor. For critical illness, the poorer the quality of life rating, the more likely the spouses were to forgo feeding tubes (P < .001). There was a trend for highly burdened spouses to consent to treatment. CONCLUSIONS: The results provide evidence that spouses of patients with AD anticipate forgoing life-sustaining treatments in the face of coma but are less sure about choices for critical illness. Although preliminary in nature, findings suggest that doctors, nurses, and social workers need to provide additional support to spouses choosing to forgo rather than consent to treatment and need to inquire as to what spouses perceive as the factors that are important to them in making a decision

Caregivers of Alzheimer's disease patients often suffer from depression. Using a longitudinal treatment/control study, we examined the effects of a comprehensive support program on depression in spouse-caregivers. This psychosocial intervention program treats the primary caregiver and family members over the entire course of the disease through individual and family counseling, the continuous availability of ad hoc counseling, and support group participation. In the first year after intake, the control group became increasingly more depressed, whereas the treatment group remained stable. By the eighth month, treated caregivers were significantly less depressed than those in the control group. These results suggest that enhancing long-term social support can have a significant impact on depression in caregivers

Although mild progressive memory impairment is commonly associated with normal human aging, it is unclear whether this phenomenon can be explained by specific structural brain changes. In a research sample of 54 medically healthy and cognitively normal elderly persons (ages 55-87, x = 69.0 +/- 7.9), magnetic resonance imaging (MRI) was used to derive head-size-adjusted measurements of the hippocampal formation (HF) (dentate gyrus, hippocampus proper, alveus, fimbria, subiculum), the superior temporal gyrus (STG), and the subarachnoid cerebrospinal fluid (CSF) (to estimate generalized cerebral atrophy). Subjects were administered tests of primary memory (digit span) and tests of secondary memory with immediate and delayed recall components (paragraph, paired associate, list recall; facial recognition). Separate composite scores for the immediate and delayed components were created by combining, with equal weighting, the subtests of each category. The WAIS vocabulary subtest was used as a control measure for language and intelligence. A highly significant correlation (P < 0.001), independent of age, gender, and generalized cerebral atrophy was found between HF size and delayed memory performance. No significant correlations were found between HF size and primary or immediate memory performance. STG size was not significantly correlated with any of the composite memory variables. These results suggest that HF atrophy may play an important independent role in contributing to the memory loss experienced by many aging adults

Spouse-caregivers of Alzheimer's disease patients were randomly assigned to either a treatment group (individual and family counseling, support group participation, and ad hoc consultation) or a control group (only routine support). In the first year after intake, the treatment group had less than half as many nursing home placements as the control group. This suggests that a comprehensive counseling program can reduce the socioeconomic impact of Alzheimer's disease. Nursing home placement also was affected by the patient's need for assistance with activities of daily living, patient income, and the age of the patients and caregivers