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A Family Intervention to Delay Nursing Home Placement of Patients With Alzheimer Disease A Randomized Controlled Trial

Mary S. Mittelman, DrPH; Steven H. Ferris, PhD; Emma Shulman, CSW; Gertrude Steinberg, MS; Bruce Levin, PhD
JAMA. 1996;276(21):1725-1731. doi:10.1001/jama.1996.03540210033030.
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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 31/2-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.


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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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