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Objectives: The goal of this study was to develop and evaluate an intervention aimed at increasing cognitive empathy, improving mental health, and reducing inflammation in dementia caregivers, and to examine the relevant neural and psychological mechanisms., Methods: Twenty dementia caregivers completed an intervention that involved taking 3-5 daily photographs of their person living with dementia (PLWD) over a period of 10 days and captioning those photos with descriptive text capturing the inner voice of the PLWD. Both before and after the intervention, participants completed questionnaires, provided a blood sample for measures of inflammation, and completed a neuroimaging session to measure their neural response to viewing photographs of their PLWD and others., Results: 87% of enrolled caregivers completed the intervention. Caregivers experienced pre- to post-intervention increases in cognitive empathy (i.e. Perspective-Taking) and decreases in both burden and anxiety. These changes were paralleled by an increased neural response to photographs of their PLWD within brain regions implicated in cognitive empathy., Conclusion: These findings warrant a larger replication study that includes a control condition and follows participants to establish the duration of the intervention effects., Clinical Implications: Cognitive empathy interventions may improve caregiver mental health and are worthy of further investigation.

Objectives: Language accommodation is indispensable in making evidence-based interventions available and accessible to ethnic minorities with limited English proficiency. As part of the larger effort to culturally adapt the Savvy Caregiver Program for Korean American dementia caregivers, we first conducted linguistic adaptation, and the present study reports the preliminary findings on participants' changes in depressive Symptoms., Methods: The linguistically adapted program was delivered to two small groups of Korean American dementia caregivers (total n  = 13) by two Savvy-certified Korean-speaking trainers. Participants' depressive symptoms were assessed at three time points (pre-intervention, immediate post-intervention, and 6-month follow-up)., Results: Following the intervention, participants exhibited lowered depressive symptoms ( t  = 8.64, p  < .001, Cohen's d  = .89). This benefit was sustained at 6-month follow-up., Conclusions: Findings suggest that the therapeutic benefit of the Savvy Caregiver Program could potentially be shared with linguistic minorities when delivered in their native language., Clinical Implications: Although limited in its scope and nature, the pilot study with linguistic adaptation sheds light on efforts to close the gap in the evidence-based intervention delivery.

The purpose of this study was to evaluate the efficacy of the Residential Care Transition Module, a six-session, psychosocial, and psychoeducational telehealth intervention for family caregivers of cognitively impaired relatives living in a residential long-term care setting. Eligible participants (including care recipients, regardless of time since admission) were randomized to treatment or usual care control conditions. Survey data were collected at baseline, 4 months, 8 months, and 12 months ( N = 240). Primary analytic outcomes included caregiver subjective stress (a stress process mechanism) and depressive symptoms (a measure of global well-being). Secondary analytic outcomes included secondary role strains, residential care stress, caregiver sense of competence, and self-efficacy (additional mechanisms of action). General linear models tested for the main effects of the intervention at 4 months, and longitudinal mixed models examined the 12-month effects of the intervention. Post hoc analyses also examined the influence of moderators. No significant differences between the treatment and control groups for any primary analytic outcome were apparent. Caregivers in the treatment group whose relatives were admitted to residential long-term care in the prior 3 months were more likely to indicate reductions in depressive symptoms over the first 4 months of participation. Over the 12-month study period, caregivers in the treatment group who were employed reported increased self-efficacy over time. The heterogeneity of dementia care requires a broader consideration of key contextual factors that may influence the efficacy of nonpharmacological interventions. Aligning measures with the preferences, goals, and values of dementia caregivers may further demonstrate the direct benefits of interventions such as the Residential Care Transition Module. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Background: Nearly two-thirds of family caregivers of persons living with Alzheimer's disease or related dementias (AD/ADRD) provide complex care, including medical care. Family caregivers typically receive little to no training on how to provide this care. Furthermore, family caregivers simultaneously grapple with the presence of behavioral and psychological symptoms of dementia (BPSD), diminished communication abilities, and comorbidities such as diabetes. We developed Learning Skills Together (LST), a 6-week digitally delivered psychoeducational program, to facilitate family caregiver abilities to administer complex care tasks. The goal of the present study is to test the efficacy of LST and to reduce adverse outcomes associated with caregiving, such as depressive symptomology and negative appraisal of BPSD., Methods: To test the efficacy of LST, we will conduct a two-arm single-site randomized controlled trial (RCT) with N = 200 family caregivers of persons living with AD/ADRD. Eligible family caregivers will be randomly assigned to participate in either the LST intervention or a structurally equivalent control condition focused on healthy living. All family caregivers will complete four surveys, including a baseline survey administered prior to randomization, a post-intervention survey, and a 3- and 6-month follow-up survey to assess change in study outcomes. Between-group comparisons of each outcome will be evaluated using generalized estimating equation models. Mediation analyses will assess family caregiver self-efficacy as the intervention's mechanism of change in depressive symptomology and BPSD. We will also examine caregiver race, ethnicity, and gender as effect modifiers of the intervention., Discussion: LST findings will inform the field of AD/ADRD and caregiving regarding optimally supporting family caregivers in managing complex care tasks. If efficacious, the LST intervention will support family caregivers in preserving their own mental health while providing complex care., Trial Registration: Clinical Trials.gov NCT05846984 . This study was registered on May 6, 2023., (© 2024. The Author(s).)

Background and Objectives: Psychoeducation interventions using distance learning modalities to engage caregivers in active learning environments have demonstrated benefits in enhancing caregiving mastery. However, few of these programs have been specifically adapted to develop mastery in Black caregivers., Research Design and Methods: A multimethod approach was carried out to assess Caregiving While Black (CWB), including pre-post surveys and in-depth interviews. This psychoeducation course addresses the cultural realities of caring for a person living with dementia as a Black American. Caregivers engaged in online asynchronous education related to healthcare navigation, home life management, and self-care. Primary (caregiving mastery) and secondary outcomes (anxiety, depression, perceived stress, burden, perceived ability to manage behavioral and psychological symptoms) were assessed at baseline and post-course (10 weeks)., Results: Thirty-two Black caregivers from across the United States completed the course within the allotted time frame. Paired sample t test analyses revealed significant reductions in caregiver burden and role strain. Caregiver mastery from baseline to completion increased by 0.45 points with an effect size of 0.26 (Cohen's d). Twenty-nine caregivers participated in an optional post-course interview, and thematic analysis led to the construction of 5 overarching themes: Comfortability with a Culturally Tailored Course; Experiences Navigating the Course Platform; Utility of Course Resources; Time as a Barrier and Facilitator; Familial and Community Engagement., Discussion and Implications: Pilot findings convey a need to continue creating and receiving feedback on culturally tailored psychoeducation programs for dementia caregivers. The next steps include applying results to fuel the success of the next iteration of CWB., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: People living with dementia need increasing care over time, but 1 in 3 adults with cognitive impairment lives alone. The goal of this study was to explore the self-identified strengths and resources for future care needs of adults aging solo with early dementia., Methods: Semistructured interviews with 15 adults not living with a partner and with no children in the same state, who self-identified as having early dementia or mild cognitive impairment; hybrid inductive/deductive reflexive thematic analysis using a successful aging framework., Results: Participants placed a high value on maintaining independence and expressed concerns about preserving selfhood and becoming a burden to others. These values influenced how participants appraised financial and social resources available to address future care needs and strategies to preempt or respond to needs such as transportation, help with finances, or activities of daily living., Discussion: Adults without close family are heterogeneous and have variable resources available to address care needs associated with dementia progression. Common values of retaining independence and minimizing burden to others may be helpful in motivating adults aging solo to undertake planning and help-seeking early., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Sleep disturbance is prevalent in caregivers of persons living with dementia (PLwD). Tele-Savvy, a 7-week virtual psychoeducational intervention, enhances caregivers' competence and self-care, and reduces depression. While not explicitly designed to do so, Tele-Savvy can potentially improve caregivers' disturbed sleep. The present study aimed to examine the longitudinal effects of Tele-Savvy on caregivers' sleep quality and insomnia., Methods: This was a secondary data analysis of a 3-arm randomized control trial [Tele-Savvy (active treatment), Healthy Living (attention control), and usual care (waitlist control)]. Multilevel mixed modeling with intent-to-treat principles tested for group, time, and group-by-time effects. Effect sizes were estimated for all changes from baseline to the initial 6-month post-intervention point. Following completion of the 6-month post-randomization delay, we examined combined outcomes for Tele-Savvy., Results: Participants (n=137; mean age 64.7 years) were predominantly female (68.6%) and White (68.6%). We found no initial group-by-time effects for the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). For the combined Tele-Savvy group, there was a statistically significant improvement in ISI scores across time (p=0.050). The combined Tele-Savvy effect size for PSQI was d=0.126 and ISI was d=0.310., Discussion: Tele-Savvy resulted in a significant long-term reduction in insomnia symptoms in this sample of caregivers of PLwD and demonstrated a positive trend for improvement in their sleep quality. Since sleep disturbance is so prevalent among caregivers of PLwD, the inclusion of sleep health education into psychoeducation caregiver interventions may yield even better outcomes for caregivers., Competing Interests: Dr Glenna Brewster reports grants from National Institute on Aging, during the conduct of the study. Dr Donald L Bliwise reports personal fees from CliniLabs, personal fees from Eisai, personal fees from Ferring, personal fees from Huxley, personal fees from Idorsia, personal fees from Merck, outside the submitted work. The authors report no other conflicts of interest in this work., (© 2023 Brewster et al.)

Introduction: There is a need for resources to guide informal carers in medication management for people with dementia. Availability of resources on medication management guidance has yet to be explored., Areas Covered: A systematic search of MEDLINE, Embase, CINAHL and PsycINFO was performed in May 2022 to identify and evaluate resources for carers of people with dementia that provide guidance in medication management. Google and known repositories were also searched. Readability of text-based resources was examined using the Flesch-Kincaid reading level, the Flesch reading ease and the Gunning-Fog index. Resources were further evaluated using the Patient Education Material Assessment Tool (PEMAT or PEMAT-A/V)., Expert Opinion: Fifteen resources were identified, which largely focused on medication administration with limited discussion of shared decision-making. Current resources do not appear to have included people living with dementia or their carers in their development and did not address high-risk care settings. Codesign of resources with carers and people with dementia would ensure that resources are comprehensive and target their needs. Future research should therefore focus on development of readily available and understandable resources that provide medication management guidance for carers across different health settings, to comprehensively address the multi-faceted nature of dementia.

Background: Limited English proficiency (LEP) of dementia caregivers poses a critical barrier to these caregivers' access to evidence-based interventions. In an effort to make such interventions available and accessible to dementia caregivers with LEP, in the present study we use Barrera and colleagues' (2011) three-step model of cultural adaptation: (1) information gathering, (2) preliminary adaptation, and (3) full adaptation. Selecting Korean Americans as a target group and the Savvy Caregiver Program (SCP) as a target intervention, we demonstrate the sequential process of cultural adaption and report the outcomes on feasibility and acceptability., Methods: Preliminary adaptation with linguistic attunement was conducted by translating the SCP manual into Korean and certifying two lay individuals who were bilingual in English and Korean as Savvy trainers. The 6-week online SCP program was delivered by the two trainers in Korean with six to seven caregiver participants per trainer (N = 13). Feasibility and acceptability of the SCP for both caregiver participants and trainers were assessed using mixed methods, and their data then informed full adaptation., Results: Findings not only showed the initial efficacy of the linguistically attuned SCP but also suggested areas for further modification. Data-driven assessment yielded a list of recommended changes for full adaptation, which was reviewed by the SCP developer to ensure fidelity and by community and research partners to confirm contextual and cultural relevance., Conclusions: The adopted changes are broadly summarized as representing logistical, technical, and cultural issues. Given our refined set of educational materials and implementation guidelines, we discuss future directions for research and development., (© 2022. The Author(s).)

Dementia caregivers are responsible for the daily care and management of individuals who are among the most vulnerable to the serious consequences of COVID-19. This qualitative study explores the experience of Black dementia caregivers during the COVID-19 pandemic in the United States. Nineteen Black dementia caregivers were recruited to participate in semi-structured focus groups held in April 2021. Four overarching themes were constructed during analysis: social isolation , decreased well-being , the good and bad of telehealth , and challenges fulfilling health care needs . The results indicate the experience of Black dementia caregivers overlaps with existing literature on the experiences of dementia caregivers of other races during COVID-19. These results can assist in addressing the specific needs and improving the experiences of dementia caregivers in current and future public health crises.

In reports of randomized controlled trials, thorough description of the attention control condition has been recommended, yet is frequently lacking. The Tele-Savvy Caregiver program for informal caregivers of persons living with dementia was tested in a randomized controlled trial with an attention control condition. The purpose of this trial was to test Tele-Savvy's efficacy in reducing the negative effects of caregiving on caregivers, promoting quality of life for persons living with dementia, and improving caregiver mastery. We describe the design and implementation of and examine the outcomes associated with the attention control condition. Caregivers were randomized to the immediate Tele-Savvy (active condition), Healthy Living (attention control), or waitlist. The attention control content was focused on healthy lifestyle and was not intended to affect the outcomes that Tele-Savvy targeted. The attention control group was similar to Tele-Savvy in the intervention structure and duration: it consisted of seven weekly group videoconferences and 36 video lessons. Data on outcomes of caregivers and persons living with dementia were collected at baseline and 3 and 6 months postbaseline. Multilevel mixed effects models were used to determine changes in the outcomes. One hundred and eleven caregivers were randomized to the attention control condition (attrition 21.6%). Eighteen formative assessment interviews focusing on caregivers' experience in the attention control condition were conducted. The attention control condition completers had no statistically significant changes in the variables that Tele-Savvy targeted. These results may be used in the design and implementation of attention control conditions in behavioral intervention research., (© 2022 Wiley Periodicals LLC.)

Family caregivers to persons living with dementia increasingly provide complex care tasks, though most (53%) do so without any training. "Complex care" includes medical/nursing tasks, as well as personal care tasks that require disease knowledge. Of the 67% of dementia caregivers who provide complex care, nearly half worry about making a mistake. To help caregivers feel more confident when providing complex care tasks, we developed and conducted a pilot study of the 4-week Learning Skills Together psychoeducation program (LST; N=35). Participants in LST reported high satisfaction with the program and found the information shared about complex care was easy to understand. Pre- and post-test data demonstrated improvements in mean caregiver self-efficacy at both 4-weeks and 8-weeks post-intervention (mean difference (MD)=1.0, SD= 1.6, p-value=0.004 and MD= 1.0, SD=2.2, p-value=0.038, respectively). Results demonstrate the potential for a brief psychoeducational program to prepare caregivers to provide complex care to persons living with dementia., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background and Objectives: Family caregivers will grow in number as dementia prevalence increases, underscoring the continued importance of equipping these individuals for their new roles and ameliorating the adverse effects of caregiving., Research Design and Methods: A three-armed, waitlist, randomized trial design tested Tele-Savvy, an online adaptation of a successful in-person psychoeducation program, the Savvy Caregiver. Tele-Savvy is delivered over 43 days to groups of 6-8 caregivers in 7 weekly synchronous sessions accompanied by 36 brief asynchronous video lessons. We enrolled 23 cohorts of 15 eligible caregivers (N = 261), randomized 2:2:1 to active, attention control, and usual care arms. We assessed caregiver psychological well-being and caregiving mastery at baseline and 3, 6, 9, and 12 months. Multilevel linear models assessed outcomes over the 3 time points examined. The trial was slightly truncated, with Data and Safety Monitoring Board approval, because of the apparent confounding psychological effects of coronavirus disease 2019 restrictions., Results: Study findings indicate statistically and clinically significant benefits to Tele-Savvy arm caregivers (with moderate to large effect sizes) in the areas of depression, perceived stress, reaction to care recipients' behaviors, and enhancement of caregiver mastery. Expected benefits for caregiver burden and anxiety were not found., Discussion and Implications: Findings attest to program efficacy and the viability of employing distance means to improve family caregivers' emotional well-being and sense of mastery in the caregiving role over a 6-month period. Next steps entail finding alternate ways to deliver the program to those with connectivity and/or time constraint problems., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In addition to numerous care responsibilities, family caregivers are expected to navigate health systems and engage in healthcare management tasks on behalf of their persons living with dementia (PLWD). These challenging tasks pose additional difficulties for Black dementia caregivers. Due to the centuries-old, disadvantaged social history of Black Americans, several unique stressors, vulnerabilities, and resources have emerged which inform and affect Black dementia caregivers' experiences and well-being. Focus groups were held with Black caregivers (N = 19) from the United States to explore the unique experiences and perspectives of this population navigating the U.S. health system on behalf of their PLWD. Five overarching themes were constructed during thematic analysis: Forced Advocacy, Poor Provider Interaction, Payor Source Dictates Care, Discrimination, and Broken Health System. Black dementia caregivers unanimously concurred that the health system that they experience in America is "broken." Gaps in the health system can lead to people [as one caregiver passionately expressed] "falling between the cracks," in terms of care, services, and resources needed. Caregivers agreed that class, sex, utilizing public health insurance, and being a "person of color" contribute to their difficulties navigating the health system. Caregivers perceived being dismissed by providers, forcing them to advocate for both themselves and their PLWD. Healthcare providers and researchers can utilize these findings to improve the experiences and healthcare outcomes of Black persons living with dementia and their caregivers. Additionally, these findings can lead to the development of culturally tailored caregiver education programs., (© 2022 The American Geriatrics Society.)

Background: The population of persons living with dementia (PLWDs) is increasing, although mainstream dementia care quality is suboptimal., Purpose: To identify characteristics associated with: (1) PLWDs' neuropsychiatric symptoms and quality of life; and (2) distress from neuropsychiatric symptoms and well-being among their family caregivers (N = 49)., Methodology: Cross-sectional single-group examination of PLWD and caregivers when they enrolled into a nurse-led dementia-centered primary care clinic. Pearson correlations were run between characteristics of PLWD and caregiver and variables representing PLWD's neuropsychiatric symptoms and quality of life and their caregivers' well-being. Statistically significant correlations were reported via Cohen d statistics., Results: Caregivers' characteristics associated with higher distress from neuropsychiatric symptoms and diminished well-being included Black race, female gender, younger age, caring for a parent with dementia, and being employed. Characteristics of PLWD associated with caregivers' higher distress and diminished well-being included longer time since dementia onset, higher Charlson Comorbidity Index, and non-Alzheimer dementia. Caregivers' characteristics associated with higher neuropsychiatric symptom burden included Black race, female gender, younger age, caring for parent PLWD, and being employed. Characteristics of PLWDs associated with higher neuropsychiatric symptom burden included non-Alzheimer dementia, longer time since dementia onset, more comorbidities, and higher Charlson Comorbidity Index. Finally, a longer time since dementia onset was associated with PLWDs' lower quality of life., Conclusions: Black race, caring for caring for a parent with dementia, younger age, and being employed were characteristics linked to PLWDs' higher neuropsychiatric symptom burden and caregivers' diminished well-being., Implications: Clinicians must assess and intervene with unpaid caregivers who may not appear obviously distressed., Competing Interests: Competing interests: The authors report no conflicts of interest., (Copyright © 2022 American Association of Nurse Practitioners.)

The Integrated Memory Care Clinic is a patient-centered medical home led by advanced practice RNs (APRNs) who provide dementia care and primary care simultaneously and continuously. We explored the experiences of 12 informal caregivers of persons living with dementia during their first year at the Clinic. Data were analyzed via directed content analysis. Caregivers described the Clinic as "the only place you should go to for dementia [care]." Caregivers felt a sense of belonging to the Clinic, valued APRNs' competence and staff's dedication, and round-the-clock telephone access to APRNs. Caregivers also acknowledged that "we're all out here swimming on our own." They expressed their sense of being overwhelmed and needing more services and medical and non-medical resources, and more prognostic information on dementia. Although the Clinic is beneficial for caregivers, caregiving demands exceed the supply of services and resources at the Clinic. [ Research in Gerontological Nursing, 14 (2), 69-78.].

The " Great Village ," a cultural adaptation of a psychoeducation intervention the " Savvy Caregiver " for African American caregivers of persons living with dementia (PLwD), aims to develop caregivers' skills and improve the quality of the lives of both the PLwD and their caregivers. The goal of this study was to determine the effectiveness of the Great Village on depressive symptoms, anxiety, burden, and mastery in African American caregivers ( N = 142). A three-arm randomized control trial ( Great Village, Great Village + exercise, and attention control) was conducted over a period of 6 months. Caregivers who received either Great Village or Great Village + exercise reported significant reduction in depressive symptoms and improvement in mastery. Caregivers who received only Great Village reported a reduction in anxiety. Receiving no intervention worsened caregiver burden. African American caregivers should receive culturally tailored interventions to support their health and well-being and improve their competence in caregiving.

Background: Families do not fully disengage from care responsibilities following relatives' admissions to residential long-term (RLTC) care settings such as nursing homes. Caregiver stress, depression, or other key outcomes remain stable or sometimes increase following a relative's RLTC entry. Some interventions have attempted to increase family involvement after institutionalization, but few rigorous studies have demonstrated whether these interventions are effective in helping families navigate the potential emotional and psychological upheaval presented by relatives' transitions to RLTC environments. The Residential Care Transition Module (RCTM) provides six formal sessions of consultation (one-to-one and family sessions) over a 4-month period to family caregivers who have admitted a relative to a RLTC setting., Methods: In this embedded mixed methods randomized controlled evaluation, family members who have admitted a cognitively impaired relative to a RLTC setting are randomly assigned to the RCTM (n = 120) or a usual care control condition (n = 120). Primary outcomes include reductions in family members' primary subjective stress and negative mental health outcomes; secondary role strains; and residential care stress. The mixed methods design will allow for an analysis of intervention action mechanisms by "embedding" qualitative components (up to 30 semi-structured interviews) at the conclusion of the 12-month evaluation., Discussion: This evaluation will fill an important clinical and research gap by evaluating a psychosocial intervention designed for families following RLTC admission that determines whether and how the RCTM can help families better navigate the emotional and psychological challenges of residential care transitions., Trial Registration: ClinicalTrials.gov (NCT02915939, prospectively registered).

Background: Despite the importance of persons with dementia (PWDs) engaging in advance care planning (ACP) at a time when they are still competent to appoint a surrogate decision maker and meaningfully participate in ACP discussions, studies of ACP in PWDs are rare. Objective: We conducted an intervention development study to adapt an efficacious ACP intervention, SPIRIT (sharing patient's illness representations to increase trust), for PWDs in early stages (recent Montreal Cognitive Assessment [MoCA] score ≥13) and their surrogates and assess whether SPIRIT could help PWDs engage in ACP. Design: A formative expert panel review of the adapted SPIRIT, followed by a randomized trial with qualitative interviews, was conducted. Patient-surrogate dyads were randomized to SPIRIT in person (in a private room in a memory clinic) or SPIRIT remote (via videoconferencing from home). Setting/Subjects: Twenty-three dyads of PWDs and their surrogates were recruited from an outpatient brain health center. Participants completed preparedness outcome measures (dyad congruence on goals of care, patient decisional conflict, and surrogate decision-making confidence) at baseline and two to three days post-intervention, plus a semistructured interview. Levels of articulation of end-of-life wishes of PWDs during SPIRIT sessions were rated (3 = expressed wishes very coherently, 2 = somewhat coherently, and 1 = unable to express coherently). Results: All 23 were able to articulate their end-of-life wishes very or somewhat coherently during the SPIRIT session; of those, 14 PWDs had moderate dementia. While decision-making capacity was higher in PWDs who articulated their wishes very coherently, MoCA scores did not differ by articulation levels. PWDs and surrogates perceived SPIRIT as beneficial, but the preparedness outcomes did not change pre-post. Conclusions: SPIRIT engaged PWDs and surrogates in meaningful ACP discussions, but requires testing of efficacy and long-term outcomes.

African American caregivers for persons living with dementia frequently experience emotional strain, burden, social isolation, and depression. One source of support for them when in distress is their church community. However, many African American churches do not have programs to support families and congregants living with dementia. Dementia often restricts persons living with dementia and their caregivers from attending church. Both become increasingly uncomfortable in church settings due to fear of embarrassment, uncertainty about the behavior of the person living with dementia, and shame. Church attendance and religion has been shown to be beneficial for caregivers and elders living with dementia. However, there is little work exploring how involvement in religious practices together (caregivers and persons living with dementia) might enhance the quality of life for these families. This protocol is written to detail the designing and testing of the feasibility and preliminary efficacy of a dementia-friendly faith village worship service. In the study, we will examine how dementia-friendly faith village worship services support the well-being of caregivers and care recipients in three African American churches through observation, interviews, and surveys. A sample of 30 dyads of African American caregivers and persons living with dementia will be asked to attend six modified worship services together over 6 months. In this study, we hope to demonstrate the significant role of churches in the lives of African American family caregivers and persons living with dementia and show that a faith-based, family-oriented approach can promote a greater quality of life for African American families living with dementia., (© 2019 Wiley Periodicals, Inc.)

The population of individuals living with dementia and their caregivers and the need to provide caregiver training will increase in the next several decades. In-person caregiver educational programs are delimited by logistical and resource boundaries that could be overcome with online programs. The purpose of this qualitative descriptive study was to explore the acceptability and ways to improve the content and delivery of an online 7-week psychoeducational pilot program-Tele-Savvy. Thirty-six caregivers who completed the pilot were interviewed about their experience with Tele-Savvy and their suggestions for its improvement. Conventional content analysis allowed for the identification of three themes: barriers and facilitators to establishing rapport with participants and instructors, content enrichment and diversification, and structural refinement. These lessons learned directly from the caregivers provide evidence to guide the refinement of analogous online interventions and highlight the need for their wider availability.

The Integrated Memory Care Clinic (IMCC) is a patient-centered medical home as defined by the National Committee for Quality Assurance directed by advanced practice registered nurses (APRNs) caring for persons living with dementia (PLWD); physicians provide specialty consultation but do not direct care or care planning. The IMCC incorporates geriatric nursing, social work, and APRNs from neurology, gerontology, palliative care, and geriatric psychiatry. APRNs provide comprehensive, coordinated primary care for dementia, other chronic conditions, and minor acute illnesses. Partnering with PLWD and families and taking a palliative-oriented, dementia-informed medical home approach, the IMCC aims to reduce dementia burden. This study describes the first 12 months of IMCC's operation with 139 enrolled PLWD-caregiver dyads. All patients have a diagnosis of dementia or mild cognitive impairment; most have Alzheimer's disease (53.2%). Patients have an average of 5.8 medical conditions and 6.9 prescriptions; 38.1% have an advanced directive, a medical power of attorney, or a living will. Mean age is 78.6, 63.3% are female, and 30.9% are African American. Mean Montreal Cognitive Assessment score is 12.6. Most require assistance in activities of daily living. Many display neuropsychiatric symptoms. The most prevalent comorbidities are hypertension, dyslipidemia, and depression. The rate of ambulatory-sensitive hospitalizations declined from 6.7% in December 2015 to less than 1% in May 2016. Caregivers were highly satisfied. We observed nonsignificant improvements in neuropsychiatric symptom severity (p=.07), caregiver distress (p=.69), and caregiver competence (p=.18). IMCC is a novel care model for PLWD and their caregivers and may be a more sustainable model than traditional primary care for this growing vulnerable population. J Am Geriatr Soc 66:2401-2407, 2018., (© 2018, Copyright the Authors Journal compilation © 2018, The American Geriatrics Society.)

Caregivers of individuals with dementia are at risk for chronic stress and social isolation. These exogenous factors may lead to perceived stress and perceived loneliness-psychosocial endogenous (subjective) elements of caregiving experience. Chronic stress and perceived loneliness may disrupt neuroendocrine and neuroimmunological regulation, creating low-grade systemic inflammation, promoting proinflammatory gene expression, and expediting cellular aging (endogenous physiological factors). These disturbances may enhance caregivers' risk for chronic conditions of inflammatory pathogenesis. Thus, caregivers' perceived stress and perceived loneliness may form a symptom cluster that can serve as a marker of risks for physical and mental illness. Due to the overwhelming reliance on family caregivers within the increasing population of individuals with dementia, it is essential that clinicians inquire about caregivers' perceived stress and perceived loneliness, are competent in supporting and educating caregivers, and are knowledgeable about specific resources for caregivers. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 36-43.]., (Copyright 2018, SLACK Incorporated.)

Introduction: This study examined the feasibility and efficacy of Tele-Savvy, an online version of the Savvy Caregiver Program, a psychoeducation program for caregivers caring for a person with dementia., Methods: A convenience sample of 22 caregivers from the Atlanta VA and 42 caregivers from 14 different states enrolled in Tele-Savvy. Pre- and post-program evaluations assessed caregiver burden, caregiver competency, and frequency of behavioral and psychological symptoms of dementia (BPSD)., Results: Fifty-seven caregivers completed the 6-week Tele-Savvy program. Caregivers whose care recipients exhibited higher average BPSD frequency at baseline demonstrated significantly greater burden decreases post-program. Caregivers of care recipients in more advanced dementia stages demonstrated a significantly greater improvement in caregiver competence., Discussion: The results point to the feasibility of achieving significant results in caregivers' well-being and care recipients' BPSD with a fully online program. Tele-Savvy may be particularly efficacious for caregivers whose care recipients exhibit higher BPSD frequency and are in later dementia stages.

People in the early stages of Alzheimer's disease and related dementias (ADRD) are encouraged to engage in advance care planning (ACP) while they are still competent to appoint a surrogate decision maker and meaningfully participate in ACP discussions with the surrogate. In this NIH Stage I behavioral intervention development trial, we will adapt and test an efficacious ACP intervention, SPIRIT (Sharing Patient's Illness Representation to Increase Trust), with people with mild dementia and their surrogates to promote open, honest discussions while such discussions about end-of-life care are possible. We will first adapt SPIRIT (in person) to target people with mild dementia and their surrogates through a process of modification-pretesting-refinement using stakeholders (persons with mild dementia, family caregivers, and clinicians) and experts, including adapting the delivery mode to interactive web-based videoconference format (SPIRIT-remote). Then in a 3-group RCT with 120 patient-surrogate dyads, we will evaluate the feasibility and acceptability of SPIRIT in-person and SPIRIT remote, and preliminary efficacy of SPIRIT compared to usual care on preparedness outcomes for end-of-life decision making (dyad congruence on goals of care, patient decisional conflict, and surrogate decision-making confidence) shortly after the intervention. This Stage I research of SPIRIT will generate valuable insights regarding how to improve ACP for people with mild dementia who will progress to an advanced stage of the disease in the foreseeable future., Trial Registration: ClinicalTrials.gov NCT03311711, Registered 10/12/2017., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Many informal caregivers of persons with dementia suffer adverse health consequences. Although established psychoeducation programs are known to benefit caregivers, attending in-person programs is challenging for them. To address this challenge, the Savvy Caregiver Program, an evidence-based psychoeducation program with demonstrated effectiveness for caregiving and disease-related outcomes, was transformed into an on-line program, Tele-Savvy. This article describes the rationale for and design of a prospective longitudinal randomized controlled trial (targeted N = 215), currently underway. The trial aims to establish Tele-Savvy's efficacy in (i) reducing the negative effects of caregiving on caregivers; (ii) promoting care recipients' quality of life; (iii) improving caregiver mastery; and to explore (iv) Tele-Savvy's efficacy among caregivers of different races/ethnicities. The mediating role of mastery will be assessed. Participants are randomized to the active condition (immediate Tele-Savvy participation), attention control, or usual care. Participants in the two latter conditions will complete Tele-Savvy 6 months post-baseline. Multilevel mixed effects models will be used to examine changes in outcomes and to model group by time (months since baseline) interactions. The exploratory aim will be addressed using analysis of covariance and qualitative analysis. This trial's results may be used by healthcare and community organizations to implement Tele-Savvy in dementia care, increasing caregivers' access to this evidence-based intervention., (© 2018 Wiley Periodicals, Inc.)

Dementia family caregivers display significant rates of psychological and physical symptoms. African Americans (AAs) are disproportionately affected by dementia. African American caregivers display unique patterns of symptomology and responses to interventions designed to promote caregiver well-being. This study analyzed qualitative focus group data from 32 AA caregivers to explore how issues of race and culture may be incorporated into a culturally sensitive intervention for AA dementia family caregivers. Caregivers were asked scripted questions about their caregiving experiences and to suggest alterations to an existing psychoeducation program. Analysis revealed 4 key themes: the tradition of family care, caregiving and caregiving issues, culturally appropriate care, and navigating without a map. Suggestions for an educational program included a focus on developing caregiver skills and knowledge for caregiving, promotion of self-care, and reflection on the AA family and community as resources for care., (© The Author(s) 2016.)

Purpose of the Study: To test fidelity and preliminary efficacy of Tele-Savvy, an internet-based version of the in-person, evidence-based psychoeducation Savvy Caregiver Program (SCP) for dementia caregivers. Tele-Savvy used synchronous (tele-conferences) and asynchronous components (video modules) to provide program access to caregivers in their homes., Design and Methods: SCP experts were surveyed to evaluate Tele-Savvy's fidelity to SCP. A convenience sample of 30 dementia caregivers from the Atlanta VA Medical Center enrolled in the Tele-Savvy clinical demonstration program. Twenty-two caregivers completed both pre- and postprogram evaluations, which included measures of caregiver stress and competence and behavioral and psychological symptoms of dementia (BPSD)., Results: Expert review confirmed Tele-Savvy's fidelity with and, in certain domains, improvement on the original. Participants demonstrated moderately high initial levels of burden, anxiety, and depressive symptoms all of which decreased significantly postprogram in an intention to treat analysis. Similar reductions were seen in care recipients' BPSD and caregivers' reactions to them. Marginally significant increases in caregiver competence were observed. Caregiver and expert panel evaluations of program quality were enthusiastic., Implications: An effective online caregiver psychoeducation program could provide greatly expanded access for caregivers who cannot attend in person for reasons of distance, transportation limitations, and caregiving responsibilities. Further testing in a controlled trial is needed to establish program efficacy., (Published by Oxford University Press on behalf of the Gerontological Society of America 2015.)

This study reports on the first phase of an investigation aimed at adapting The Savvy Caregiver program, a successful family caregiving curriculum developed in the United States, for application in South India. Thirty family members caring for a person with dementia were interviewed regarding their experiences as caregivers (CGs). Qualitative interviews were conducted with the family member at a geriatric clinic, while other diagnostic procedures were being carried out with the person with dementia. Findings from the study revealed that although family members understood the term CG, none could identify a word for CG in his or her language. There was little understanding of dementia as an illness. Family CGs reported feeling distressed, overwhelmed, and frustrated with caregiving. Caregivers were interested in an educational program, but many had unrealistic expectations for what they wanted to learn. The findings provide directions for adapting The Savvy Caregiver curriculum for Indian family CGs., (© The Author(s) 2015.)

The current study developed prognostic tools to identify dementia caregivers at-risk for clinically relevant burden or depressive symptoms following nursing home admission (NHA) of their family members. A retrospective, longitudinal design was used that included 1,610 dementia caregivers who provided data prior to and up to 6 months following nursing home admission. Response operant characteristic (ROC) curves were constructed to test and validate two prognostic tools: the NHA-Burden and NHA-Depression tools. An ROC curve yielded a sensitivity of 77% and a specificity of 62.5% at a cutoff score of 5.41 for the NHA-Burden Prognostic tool. A second ROC curve indicated a sensitivity of 75.4% and a specificity of 62.5% at a cutoff score of 7.45 for the NHA-Depression tool. Clinicians may wish to utilize cutpoints on the NHA-Burden and NHA-Depression tools to ensure that more persons who are at-risk for clinically significant burden or depression during NHA are identified., (© The Author(s) 2012.)

This article reports on the impact of the Savvy Caregiver Program (SCP) on English-speaking caregivers of Hispanic, Black/African American, and Asian/Pacific Islander descent. Caregivers completed a questionnaire prior to study enrollment, at 6 and 12 months postenrollment. Caregivers in all 3 ethnic groups showed more caregiver competence, reduced depression, greater tolerance for care recipients' memory problems, better management of their overall situation, and improved perception of that situation 6 months and 12 months post-enrollment. The study demonstrates that in the sample studied the SCP was as effective in helping ethnically diverse caregivers as it has shown to be with Caucasian caregivers.

This article presents findings of a 3-year Savvy Caregiver Program translational study designed with the RE-AIM framework to create a statewide sustainable infrastructure and improve dementia family caregiver outcomes in one rural state. The RE-AIM dimensions--reach, effectiveness, adoption, implementation and maintenance--were evaluated using mixed methods. The program reached 770 caregivers and 87.7% (n = 676) participated in the study with 60.5% (n = 409) residing in rural locations. Participants demonstrated improved confidence, fewer depressive symptoms, and better managed their situation. Trainer resources, partnerships, and adequate planning were essential for program adoption and sustainability. Implications for replication are discussed.

Purpose: The purpose of this study was to describe health literacy needs related to incontinence and skin care among family or friend caregivers of individuals with Alzheimer disease (AD) and develop supportive and educational materials that address these needs., Design: Descriptive., Subjects and Settings: The sample included 48 family/friend adult caregivers of individuals who had advanced dementia. Caregivers were spouses (44%), daughters (31%), or extended family members/friends (25%) recruited from community-based agencies, with a mean age of 64 ± 14 years (mean ± SD), and 75% were female. Nearly half (48%) had a racially or ethnically diverse background., Methods: Focus groups, interviews, and written surveys were conducted to assess health literacy needs of AD caregivers related to incontinence and skin care; verbal responses were audiotaped, transcribed, and summarized. To address these needs, a set of educational and supportive materials was developed, whose content was directed by caregiver responses and supported by a literature review of current evidence and consultation with clinical and research experts. Study procedures were guided by an advisory committee of AD caregivers., Results: Caregivers had numerous health literacy needs related to incontinence and skin care; areas of need were categorized into knowledge, skills, and attitudes. Caregivers expressed a need to validate the health literacy they possessed. Fourteen educational and supportive documents were developed to address these needs., Conclusion: Materials developed in this study are suitable to incorporate into interventions that support caregivers of persons with AD. They offer the potential to raise health literacy and care capacity of caregivers, increase communication with health care providers, and improve health outcomes of care recipients.

Communication between healthcare providers and patients/family caregivers about incontinence and associated skin damage is wanting, and information about healthcare providers perspectives on improving this communication is limited. A descriptive study was conducted using semi-structured, tape-recorded interviews with 11 healthcare providers with clinical expertise in geriatrics and dementia working in a large integrated healthcare system. The survey was developed by the authors based on a review of the relevant literature with guidance from a three-member Advisory Committee and consisted of nine open-ended questions related to communication with patients and families about incontinence and skin damage. Specifically, information was obtained about providers' perspectives on the timing of inquiring about these problems, how best to tailor language and approach the topic, barriers and facilitators to discussion of incontinence, and recommendations for educational and supportive resources. Responses were analyzed using a content analysis approach. Using a purposeful sampling technique, 11 experienced healthcare professionals agreed to participate in the study. Main themes observed included: 1) incontinence issues are not routinely or voluntarily addressed by all providers, 2) caregivers are receptive to discussion if the topic is broached by patient/caregiver, and 3) main barriers to providing information include limited clinician time and patient/family caregiver embarrassment. Participant clinicians expressed interest in readily available, single-topic, printed patient/caregiver-focused educational materials to enhance patient-provider communication and serve as a resource. These materials were subsequently developed. Further research is warranted to test the effectiveness of the recommendations and the materials developed as a result of the study.

Although dementia caregiver stress and burden can be ameliorated with intervention, such interventions typically occur in specific caregiving contexts and at specific points in the progression of the dementing illness. We explored the ongoing learning needs and preferences of previously trained caregivers. Descriptive analysis of caregiver survey responses (N = 168) informed follow-up focus group interviews conducted with 26 family caregivers. Content analysis of focus group data showed that caregivers enjoyed the interactive problem-solving of the group related to preparing for the future, shaping the troubling behavior of the care recipient, reshaping the resource team, and caring for themselves. These findings support the need for advanced training as caregivers move through the trajectory of caring for persons with dementia., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Although extensive research exists on informal long-term care, little work has examined the clinical significance of transitions in family caregiving due to a lack of established clinical cut-points on key measures. The objectives of this study were to determine whether clinically significant changes in symptoms of burden and depression occur among caregivers within 12 months of nursing home admission (NHA) of their relatives with dementia, and to identify key predictors of clinically persistent burden and depression in the first year after institutionalization., Methods: Secondary longitudinal analysis of dementia caregivers were recruited from eight catchment areas in the United States with 6- and 12-month post-placement follow-up data. The sample included data on 1,610 dementia caregivers with pre- and six-month post-placement data and 1,116 with pre-placement, six-month, and 12-month post-placement data. Burden was measured with a modified version of the Zarit Burden Inventory. Depressive symptoms were assessed with the Geriatric Depression Scale., Results: Chi-square analyses found significant (P < .05) reductions in the number of caregivers who reported clinically significant burden and depressive symptoms after NHA compared to pre-placement. Logistic regression models revealed that wives and daughters were most likely to experience clinically persistent burden and husbands were most likely to experience clinically significant depression after NHA., Conclusions: In addition to suggesting that clinically significant decreases in caregiver burden and depression are likely to occur following institutionalization, the results reveal particular subsets of caregivers who are at continued risk of distress. Such findings can facilitate development of screening processes to identify families at-risk following institutionalization.

This article is about the trial of a transportable psychoeducation program for family caregivers of older adults with Alzheimer's disease and other dementias that was based on a program developed and previously tested in an academic setting. Family caregivers were recruited by agencies in three states and invited to participate in a randomized trial of this six-session program. Questionnaires were administered prior to randomization and again 5 to 6 months later to assess program effect. A total of 52 caregivers completed both questionnaires (22 were in the wait-list control group). Experimental participants' scores on measures of mastery and distress were significantly better than control participants' scores at follow-up (Time 2 Results for this transported program showed benefits to caregivers com parable to those in the previous trials. The program demonstrated that it could be offered in a variety of settings and that it had benefit for caregivers.

This study examined the relationship between four framing categories of caregiving (Relational, Instrumental, Reactive, Role Acquiring), derived from interviews with spouse caregivers, and scores on standardized measures of responses to and outcomes of caregiving. Participants were 132 spouses recruited into a larger intervention study of family caregivers of community-dwelling persons with dementia. Qualitative data were analyzed using constant comparative method; quantitative data were analyzed using one-way analysis of variance (ANOVA). Findings demonstrated that relational spouses scored better than spouses in the other three categories, indicating greater positive well-being. Relational spouses also scored significantly lower than instrumental and reactive spouses on a composite caregiver distress measure (p = 0. 003). These results suggest that interventions may need to be tailored to spouses with different caregiving perspectives.

A method of constant comparative analysis was used to code open-ended interviews with 132 spouse caregivers regarding their experiences in caregiving. Results of this analysis yielded 69 qualitative code categories. We used these categories to compare the caregivers on several groupings that the literature has identified as providing meaningful ways to differentiate among caregivers. We used the qualitative responses to compare the caregivers by caregiver gender care-recipient dementia severity, and duration of caregiving. Results partly confirmed previous findings that wife caregivers are more distressed than husbands, but the results also indicated these caregivers were more similar than dissimilar The other analyses likewise indicated greater similarities than dissimilarities in the caregiving experience. We next continued the analysis and, using the coding categories as a springboard, identified four distinct patterns for construction of the meaning of the caregiving experience in the caregivers' discourse. These discourse-derived framing categories, applicable in about three-quarters of the caregivers, offered other ways to distinguish among caregivers. Further analysis of these robust groupings' showed important differences among the groups. These framing categories suggest ways to differentiate among caregivers, based on their perception of their role in the caregiving situation, ways that might point the way to intervention strategies for each of the groupings.

Objectives: Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving., Design: Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection., Setting: A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs., Participants: Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate., Measurements: Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs)., Results: Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007)., Conclusion: A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.

Family members, typically spouses, serve as the primary caregivers for individuals with dementia. While it is recognized that caregivers experience both positive and negative subjective responses to caregiving, relatively little research has been done on the relationship between these types of responses. The objectives of the study were to examine the relationships between and among spouse caregivers' positive and negative subjective responses to caregiving, and increase understanding of the experience of being a spouse caregiver for a person with dementia. Fifty spouse caregivers completed quantitative measures of positive subjective responses (Positive Aspects of Caregiving and Caregiver Competence) and negative subjective responses (Relational Deprivation, Role Captivity, and Loss of Self). Additionally, participants were interviewed concerning their caregiving experiences. Positive Aspects of Caregiving and Caregiving Competence were significantly related to each other (p < .01), as were the three measures of negative subjective responses (p < .01). No significant correlations were found between any measures of a positive and a negative subjective response, suggesting the two types of responses are independent. Duration of caregiving was significantly related to Positive Aspects of Caregiving (p < .05), Caregiver Competence (p < .05), and Relational Deprivation (p < .01). Qualitative interview data revealed that participants simultaneously experienced caregiving as self-affirming, while also enduring losses and difficulties resulting from their caregiving role. Integrating the positive and negative aspects of the whole of caregiving is important to understand the caregiving experience and to design interventions to support caregivers.

This 3-year randomized clinical trial tested the effectiveness of an interdisciplinary psychoeducational family group intervention in decreasing the caregivers' perceptions of the frequency and severity of behavioral problems in persons with dementia and their reactions to those problems, and in decreasing caregiver burden and depression. The intervention consisted of seven weekly, 2-hour multimedia training sessions that included education, family support, and skills training for 94 primary caregivers and their families. Repeated measures ANOVA was used to test for significant differences between the intervention and waiting list control groups over a 5-month period. The intervention was successful in reducing caregivers' negative reactions to disruptive behaviors and in reducing caregiver burden over time.

The Family Stories Workshop (FSW) is a process through which family members and friends of persons with dementing disorders living in nursing homes develop stories of these residents' lives. The stories are meant to help staff members to develop a better, more deeply felt understanding of the lives of the residents, persons who can no longer tell their own stories. The workshop is product-oriented and is not meant as a support group and works best in organizations emphasizing individualized care. This article describes the process of the FSW as well as outcomes from preliminary implementation. It suggests ways of using elements of the process to more broadly accomplish the FSW purposes.

The extensive literature on dementia (primarily AD) suggests that informal caregiving will play a significant role in patient well-being, will have an impact of some kind on the caregiver, and will benefit from tailored intervention on the part of the clinician. It should be clear from the review of six disorders that dementing conditions emanate from many diseases, affect widely diverse age groups, produce very different symptoms sets, and are a primary or secondary patient management issue for the clinician. In particular, the review points out the need for a comprehensive caregiver assessment and training program. Caregiver assessment needs to consider physical, emotional, social, and financial domains. The assessment should determine the physical demands of caregiving and the exceptional and particular emotional issues of the situation; this should take into account the physical and emotional demands already placed on the caregiver by a pre-existing condition to which the present dementia might be secondary. The assessment should examine the nature and extent of the social isolation of the caregiver, again factoring in the unique isolating effects of concurrent disorders. The clinician should explore what financial resources are available for helping with caregiving and examine the degree to which legal and financial planning have occurred. The assessment should also determine the strengths of the caregiver (skills, personality, physical well-being) as well as his or her information and training needs. This detailed data base will assist the clinician in providing the kind of training and management support that the literature suggests can be most beneficial for sustaining the caregiving situation as well as the caregiver. Within the context of particular disorders, optimal support provides the caregiver with needed information, skill and problem-solving training, opportunity for emotional outlet, attention to the need for social support, acknowledgement of the caregiver's pivotal role, and clinical care as needed.