Improving caregiving competence, stress coping, and mental well-being in informal dementia carers

Table 1 Reitman Centre “Coaching, Advocacy, Respite, Education, Relationship, and Simulation” Program session outline

Session	Objective	Description
1	Building group cohesion and trust Education about dementia	Participants are introduced to the group process and encouraged to connect directly with the facilitators and other group members. They are also introduced to the SP, who will be more actively involved in the therapeutic process beginning in Session 5. In response to their specific questions, participants gain a better understanding of dementia: overview, symptoms and effects on the care-recipients, the carers, and the family.
2-4	Introduction and elucidation of Problem-solving techniques Objective analysis of individual caregiving problems, and identifying solutions	The key goal of these sessions is to teach the PST method and help carers adopt a problem focused approach rather than less-effective, emotion-focused coping. Facilitator weaves the understanding of emotions described by the carers into the discussions of the PST process to help carers recognize how their emotions may interfere with identifying problems and solving them objectively. Carers are encouraged to implement the solutions at home and report the outcomes of implementation.
5-9	Skills training Simulations	Through role playing with a SP, carers can practice approaching caregiving challenges differently, focusing in points of interactional conflict and communication.
10	Skills training, simulation Summing up and termination	Review and recognition of gains made, and acknowledgement of the transition into a new and different phase of supportive care. First maintenance group is scheduled during this session.

PST: Problem solving therapy; SP: Simulated patient.

Table 2 Psychometric details of outcome measures

Instrument	Descriptions	Ref.
15-item geriatric depression scale	Validated and widely applied in older populations in community, acute and long-term care settings.	[35,36]
	Fifteen questions from the Long Form GDS which had the highest correlation with depressive symptoms in validation studies were selected for the Short Form GDS.
	Scores of 0-4 are considered normal; 5-8 indicate mild depression; 9-11 indicate moderate depression; and 12-15 indicate severe depression.
Self-mastery scale	Self-mastery is a perception that reflects one’s personal mastery or control over life outcomes	[26]
	Seven items are scored on a 4-point (agree-disagree format) scale with two items recoded in the opposite direction to produce scores ranging from 7 to 28.
	In the current study, Mastery score was calculated using a negative-oriented scale (i.e., response to positively phrased questions were reverse-coded). Thus, lower scores indicate higher self-mastery.
Role captivity scale	Three-items scale assesses degree of entrapment which carers perceive in their caregiving role.	[26]
	A 4-point Likert scale is used to document the extent to which carers may feel constrained in their caregiving role during the past week.
	Scores may range from 3 to 12, with higher scores indicating more role captivity.
Role overload scale	Four-item scale that reflects how carers may be overwhelmed as their time and energy level are being exhausted by the demands of caregiving.	[26]
	A 4-point Likert scale reports extent to which carers may feel overloaded in the past week.
	Scores may range from 4 to 16, with higher scores indicating more overload.
Caregiving competence scale	Four-item scale measures carers’ self-perception of his/her ability to carry out carer role properly.	[26]
	A 4-point Likert scale reports the level of competence.
12-item zarit burden interview	Covers multiple domains: financial difficulties, social life, physical and psychological health, and the relationship between the persons with dementia and the carer.	[14]
	A 5-point Likert scale assesses level of burden experienced by carers
	Total burden scores range from 0 to 60, with higher scores reflecting greater caregiver burden.
Coping inventory for stressful situations	48-item measure describes the manner in which an individual responds to stressful situations. It measures three forms of coping style: emotion-focused, task-oriented, avoidance-oriented	[28,29]
	For each coping strategy, respondents rate the usage frequency on a 5-point Likert scale ranging from 1 (not at all) to 5 (very much).

GDS: Geriatric depression scale.

Table 3 t-Test comparison of outcome measures taken before and after participation in the“Coaching, Advocacy, Respite, Education, Relationship, and Simulation” program (mean ± SD)

		Mean scores pre- and post-intervention		Change from baseline
Measures	n	Baseline	Post	mean ± SD	Pvalue
CISS A (-)1	68	40.59 ± 9.70	40.49 ± 10.26	-1.03 ± 5.97	0.887
CISS E (-)	68	39.65 ± 11.21	37.28 ± 10.49	-2.37 ± 6.73	0.005
CISS T (+)	68	57.72 ± 9.02	56.76 ± 8.94	-0.96 ± 7.99	0.327
Competence (+)	70	12.14 ± 2.12	13.40 ± 2.07	1.26 ± 1.92	< 0.0001
Geriatric depression scale	64	4.70 ± 3.89	4.03 ± 3.70	-0.67 ± 2.63	0.045
Mastery (-)2	70	14.76 ± 3.69	14.51 ± 3.32	-0.24 ± 2.54	0.426
Overload (-)	67	9.93 ± 2.67	9.37 ± 2.71	-0.55 ± 2.07	0.032
Role captivity (-)	69	7.42 ± 2.68	7.29 ± 3.23	-0.13 ± 2.20	0.623
Zarit burden (-)	67	19.87 ± 10.61	19.04 ± 9.54	-0.82 ± 6.87	0.332

¹The plus or minus sign following each measure indicates the direction of change sought through the intervention. For example, a decrease in Emotion-focused coping style or an increase in the Competence score would indicate good outcomes;

²Mastery score was calculated using a negative-oriented scale (i.e., response to positively phrased questions were reverse-coded). Thus, a decrease in Mastery score indicates improvement. CISS A: Coping inventory of stressful situations (Avoidance-Oriented); CISS E: Coping inventory of stressful situations (Emotion-Oriented); CISS T: Coping inventory of stressful situations (Task-Oriented); Competence: Pearlin’s competence scale; GDS: Geriatric depression scale (GDS-15); Mastery: Pearlin’s mastery scale; Overload: Pearlin’s overload scale; Role Captivity: Pearlin’s role captivity scale.

Table 4 Participants with more compromised baseline scores may experience more significant improvement in some outcome measures upon completion of the 10-wk “Coaching, Advocacy, Respite, Education, Relationship, and Simulation”intervention

				Clinical effect (Cohen’s D)
	n	Standard/arbitrary cut-off	P value	More “Compromised” baseline;(mean score; Cohen’s D)	Less “Compromised” baseline;(mean score; Cohen’s D)
Measures with standard cut-off
Geriatric depression scale	64	5[37]	0.074	9.00 ± 2.42; D = -0.58	2.14 ± 1.60; D = -0.022
zarit burden	67	15[38]	0.015	27.00 ± 6.93; D = -0.34	14.30 ± 1.10; D = 0.42
Measures with arbitrary cut-off
CISS A	68	40	0.40	49.74 ± 5.95; D = -0.15	33.00 ± 4.55; D = 0.077
CISS E	68	40	0.003	50.26 ± 5.10; D = -0.74	31.55 ± 6.58; D = -0.045
CISS T	68	55	0.004	48.52 ± 5.83; D = 0.38	63.38 ± 6.37; D = -0.47
Competence	70	12	0.012	10.82 ± 1.40; D = 1.06	14.30 ± 1.10; D = 0.33
Mastery (negative-oriented scale)	70	15	0.022	18.10 ± 2.30; D = -0.62	12.21 ± 2.23; D = 0.34
Overload	67	10	0.011	12.59 ± 1.35; D = -0.69	7.98 ± 1.20; D = -0.058
Role captivity	69	7	0.332	9.74 ± 1.48; D = -0.22	5.32 ± 1.42; D = 0.10

Cohen’s D values of each intervention effect stratified by baseline scores of respective outcome measure were also shown. CISS A: Coping inventory of stressful situations (Avoidance-Oriented); CISS E: Coping inventory of stressful situations (Emotion-Oriented); CISS T: Coping inventory of stressful situations (Task-Oriented); Competence: Pearlin’s competence scale; Mastery: Pearlin’s mastery scale; Overload: Pearlin’s overload scale; Role Captivity: Pearlin’s role captivity scale.