Intervention Summary

New York University Caregiver Intervention (NYUCI)

New York University Caregiver Intervention (NYUCI) is a counseling and support intervention for spouse caregivers that is intended to improve the well-being of caregivers and delay the nursing home placement of patients with Alzheimer's disease. The program also aims to help spouse caregivers mobilize their social support network and help them better adapt to their caregiving role. The program consists of four components, the first two of which are delivered within 4 months of enrollment in the study: (1) two individual counseling sessions of 1 to 3 hours tailored to each caregiver's specific situation, (2) four family counseling sessions with the primary caregiver and family members selected by that caregiver, (3) encouragement to participate in weekly, locally available support groups after participation in the intervention, and (4) ad hoc counseling, counseling provided by telephone to caregivers and families whenever needed to help them deal with crises and the changing nature of their relative's symptoms. The program is delivered by counselors with advanced degrees in social work or allied professions.

Descriptive Information

Areas of Interest	Mental health promotion
Outcomes	1: Caregiver physical health 2: Caregiver depressive symptoms 3: Caregiver social support 4: Caregiver appraisal of patient memory and behavior 5: Length of time to nursing home placement of care recipient
Outcome Categories	Family/relationships Mental health
Ages	55+ (Older adult)
Genders	Male Female
Races/Ethnicities	Asian Black or African American Hispanic or Latino White
Settings	Outpatient Home Other community settings
Geographic Locations	Urban
Implementation History	NYUCI has been implemented and evaluated in New York, New York; Sydney, Australia; and Manchester, England.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Selective

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Drentea, P., Clay, O. J., Roth, D. L., & Mittelman, M. S. Predictors of improvement in social support: Five-year effects of a structured intervention for caregivers of spouses with Alzheimer's disease. Social Science and Medicine, 63, 957-967.

Jang, Y., Clay, O. J., Roth, D. L., Haley, W. E., & Mittelman, M. S.. Neuroticism and longitudinal change in caregiver depression: Impact of a spouse-caregiver intervention program. The Gerontologist, 44(3), 311-317.

Mittelman, M. S., Ferris, S. H., Shulman, E., Steinberg, G., Ambinder, A., Mackell, J. A., et al. A comprehensive support program: Effect on depression in spouse-caregivers of AD patients. The Gerontologist, 35(6), 792-802.

Mittelman, M. S., Ferris, S. H., Shulman, E., Steinberg, G., & Levin, B. A family intervention to delay nursing home placement of patients with Alzheimer's disease: A randomized controlled trial. Journal of the American Medical Association, 276(21), 1725-1731.

Mittelman, M. S., Ferris, S. H., Steinberg, G., Shulman, E., Mackell, J. A., Ambinder, A., et al. An intervention that delays institutionalization of Alzheimer's disease patients: Treatment of spouse-caregivers. The Gerontologist, 33(6), 730-740.

Mittelman, M. S., Haley, W. E., Clay, O. J., & Roth, D. L. Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology, 67, 1592-1599.

Mittelman, M. S., Roth, D. L., Clay, O. J., & Haley, W. E. Preserving health of Alzheimer's caregivers: Impact of a spouse caregiver intervention. American Journal of Geriatric Psychiatry, 15, 780-789.

Mittelman, M. S., Roth, D. L., Coon, D. W., & Haley, W. E.. Sustained benefit of supportive intervention for depressive symptoms in caregivers of patients with Alzheimer's disease. American Journal of Psychiatry, 161, 850-856.

Mittelman, M. S., Roth, D. L., Haley, W. E., & Zarit, S. H.. Effects of a caregiver intervention on negative caregiver appraisals of behavior problems in patients with Alzheimer's disease: Results of a randomized trial. Journal of Gerontology, Series B, Psychological Sciences and Social Sciences, 59(1), P27-P34.

Roth, D. L., Mittelman, M. S., Clay, O. J., Madan, A., & Haley, W. E. Changes in social support as mediators of the impact of a psychosocial intervention for spouse caregivers of persons with Alzheimer's disease. Psychology and Aging, 20(4), 634-644.

Supplementary Materials

Mittelman, M. S. Community caregiving. Alzheimer's Care Quarterly, 4(4), 273-285.

Mittelman, M. S. Psychosocial intervention for dementia caregivers: What can it accomplish? International Psychogeriatrics, 15(Suppl. 1), 247-249.

Outcomes

Outcome 1: Caregiver physical health
Description of Measures	Caregivers were asked 3 questions adapted from the Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire to assess their physical health. Using 3- and 4-point scales, caregivers rated their current physical health, compared their current health to their health 5 years ago, and indicated how much their physical health problems hindered their activities.
Key Findings	Caregivers who received the intervention reported better physical health than members of the comparison group, who received resource information on request but did not receive individual and family counseling (p < .001). The effect was maintained for 2 years.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 2: Caregiver depressive symptoms
Description of Measures	The depressive symptoms of caregivers were assessed with the Geriatric Depression Scale, a 30-item, self-report questionnaire with a yes/no format that was developed specifically for use with older adults.
Key Findings	Caregivers who received the intervention averaged fewer depressive symptoms than members of the comparison group, who received resource information on request but did not receive individual and family counseling (p < .05). The effect was maintained for 3 years.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.7 (0.0-4.0 scale)

Outcome 3: Caregiver social support
Description of Measures	The social support of caregivers was measured using 3 questions from the Stokes Social Network Questionnaire. Using a 6-point Likert scale (from very dissatisfied to very satisfied), caregivers assessed their general satisfaction as well as their satisfaction with the assistance and emotional support they received from family and friends.
Key Findings	Caregivers who received the intervention reported higher levels of satisfaction with their social support network than members of the comparison group, who received resource information on request but did not receive individual and family counseling (p < .001). This effect was maintained for 5 years.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Outcome 4: Caregiver appraisal of patient memory and behavior
Description of Measures	The Memory and Behavior Problems Checklist (MBPC) was used to assess the caregivers' understanding of and reaction to the patients' problems with memory and behavior. Caregivers reported on the frequency of 30 memory and behavior problems and on the degree to which they found each of these problems upsetting or troublesome.
Key Findings	Caregivers in the intervention group reported being significantly less troubled by their spouses' memory and behavior problems than caregivers in the comparison group, who received resource information on request but did not receive individual and family counseling (p < .05). This group difference became significantly stronger across increasingly longer follow-up intervals.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Outcome 5: Length of time to nursing home placement of care recipient
Description of Measures	The length of time to nursing home placement was measured in days from enrollment in the intervention to nursing home placement of the care recipient. Dates of permanent nursing home placement and death were monitored throughout the project during regular follow-up interviews and telephone contacts with caregivers and family members. Dates of death were subsequently confirmed through the Social Security Death Index.
Key Findings	The average time from enrollment to nursing home placement of care recipients was 557 days longer with caregivers who received the intervention than with those from the comparison group, who received resource information on request but did not receive individual and family counseling (p = .02). Caregivers who received the intervention experienced a 28.3% reduction in the rate of nursing home placement compared with usual care controls (p = .025).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	55+ (Older adult)	60.1% Female 39.9% Male	90.9% White 6.4% Black or African American 2.5% Hispanic or Latino 0.2% Asian

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Caregiver physical health	4.0	3.3	3.0	4.0	4.0	3.0	3.5
2: Caregiver depressive symptoms	4.0	4.0	3.0	4.0	4.0	3.0	3.7
3: Caregiver social support	4.0	3.0	3.0	4.0	4.0	3.0	3.5
4: Caregiver appraisal of patient memory and behavior	3.5	3.0	3.0	4.0	4.0	3.0	3.4
5: Length of time to nursing home placement of care recipient	4.0	3.5	3.0	4.0	3.5	3.5	3.6

Study Strengths

The study design was a rigorous randomized controlled trial. The retention rate was remarkably good. Confounding variables were controlled through the design and statistical analysis. The measures used have high reliability scores.

Study Weaknesses

The dataset was analyzed several different times, each time for a separate paper. Thus, the results must be interpreted with some level of uncertainty (i.e., there were no statistical corrections for multiple comparisons across all outcomes). Although the study used good measures, some were not optimal. In addition, the outcome measure for social support is not commonly used.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Data collection forms:

Caregiver Evaluation of Ad Hoc Counseling
Caregiver Evaluation of Individual and Family Counseling Sessions
Caregiver Evaluation of Support Group
Caregiver Telephone Contact Log
Family Counseling First Caregiver Interview
Family Counseling Second Caregiver Interview
Family Counseling Summary Form

Description of enactment, adherence, and delivery of services

Explanation of evaluation forms

Mittelman, M., Epstein, C., & Pierzchala, A. Counseling the Alzheimer's caregiver: A resource for health care professionals. Chicago, IL: American Medical Association Press.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
2.0	0.8	1.5	1.4

Dissemination Strengths

The book recommended for counselors provides an excellent overview of issues and challenges faced by those caring for someone with Alzheimer's disease. Counselors from the research team implementing the program are available for consultation. Some good instruments are provided to collect feedback from caregivers and counselors.

Dissemination Weaknesses

Though the book does provide an educational foundation for the intervention, it does not provide sufficient implementation guidance. The relationship between assessment and intervention strategies is unclear. The intervention requires a high degree of clinical skill, knowledge about Alzheimer's disease, and competence in both individual and family treatment modes, but no formal training or coaching is available to ensure counselor confidence, competence, or treatment effectiveness. No outcome or fidelity measures are provided to support quality assurance.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Counseling the Alzheimer's Caregiver: A Resource for Health Care Professionals	$39.95 each	Yes
A Guide to Implementing the NYU Caregiver Intervention and The Minnesota Experience	Free	Yes
Multiphase training process and continued telephone consultation (includes initial training, follow-up training, regular case conferences with the developer, and ongoing support as needed)	About $30,000 per year plus travel expenses	Yes
Caregiver assessment form, counselor session summary form, ad hoc counseling calls form, and caregiver feedback form	Free	No

Additional Information

The total annual costs for this program were estimated in an independent analysis to range from $856 to $1,437 per caregiver.

Replications

No replications were identified by the developer.