Skip to main content

Meeting Our Obligation to Caregivers - the REACH VA Study


I’m tired of innovative health care interventions targeted at those caring for the more than 5 million individuals living with dementia. It’s not that I don’t think they are important. Rather, I find it rather pointless work if these interventions can’t be translated into real world applications. Today, though, the Archives of Internal Medicine is publishing an important study that adapts and implements a multicomponent caregiver intervention into one of the largest health care organizations in the US - the Veterans Health Administration (VHA).

The study, authored by Olivia Nichols and colleagues, translates the Resources for Enhancing Alzheimer's Caregivers Health (REACH II) intervention into the VHA system. The initial REACH II randomized control trial showed significant improvement in caregiver burden, depression, health/self-care, social support, and management of patient behaviors. Caregivers also got something that is worth its weight in gold - one extra hour per day not spent in caregiving tasks.

The current prospective translational study, put into practice a modified REACH II intervention into 24 VA Home Based Primary Care programs in 15 different states.  The modified intervention (REACH VA) basically consisted of 9 one-hour individual home sessions and three half-an-hour telephone sessions, and five one-hour monthly telephone support group sessions. The focus of the sessions was on education, support, and skills training to address 5 caregiving risk areas: “safety, social support, problem behaviors, depression, and caregiver health.” All of the sessions were conducted by VA staff trained in the intervention, most of whom were social workers, psychologists, or nurses at their respective facilities.

To be eligible for the study, selected patients must have had dementia with at least one activities of daily living limitation or two or more instrumental activities of daily living limitations. To meet inclusion criteria, they also must have had a co-resident family caregiver that provided greater than 4 hours of care per day for at least 6 months. Caregivers also had to endorse two caregiving stress behaviors (i.e being overwhelmed, often needing to cry, angry or frustrated, etc).

The results revealed that the REACH II study can be implemented in a real world setting, and showed significant reductions at 6 months in caregiver frustration, burden, depression, and the number of troubling dementia related behaviors. The vast majority (96%) of caregivers felt the program should be provided by VA to caregivers

So what is the next step? In the Archives commentary that I wrote with Ken Covinsky on this study, we argue that “if health systems are going to increasingly rely on family caregivers to deliver complex care, then they have they have an obligations to aid caregivers in this task and reduce the personal costs associated with it”. The VA is taking the lead in this regard. The question remains – will others follow?

by: Eric Widera

Comments

Carol Levine said…
Thanks to Eric Widera and Ken Covinsky for their splendid commentary in support of family caregivers. Although there has been a greater recognition of the importance of family caregivers since I published the essay in NEJM cited in the article, these unpaid partners are still often invisible in health care settings or considered annoyances or intruders. At the United Hospital Fund we are nearing the end of a 15-month Transitions in Care-Quality Improvement Collaborative (TC-QuIC), which has focused on developing better ways to include family caregivers in developing and implementing effective transition plans. The 28 hospital, rehab, home care, and hospice teams are using the free guides for family caregivers (in four languages) and for health care professionals from the Next Step in Care website (www.nextstepincare.org. One guide of particular interest for Alzheimer's patients and caregivers is the provider guide to reducing the http://www.nextstepincare.org/uploads/File/Guides/Provider/Provider_Dementia.pdfstress of hospitalization

There are many ways to support caregivers; acknowledging their imiportance and helping them articulate their own needs are good first steps.
Carol Levine
clevine@uhfnyc.org
Jack said…
The AlgaeCal Bone Health Program is a natural <a href="http://www.algaecal.com/osteoporosis-treatment.html>osteoporosis treatment</a> that combines all of the above advice.This natural osteoporosis treatment consists of AlgaeCal Plus, Strontium Boost and weight bearing exercise.

AlgaeCal Plus is the world's only plant source calcium and It also includes magnesium, trace minerals, vitamin D3 and vitamin k2. Strontium Boost is a supplement consisting of strontium citrate, learn more about strontium, a powerful bone building mineral.

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Does “compassionate deception” have a place in palliative care?

by: Olivia Gamboa (@Liv_g_g)

There is broad consensus in the medical community that lying to patients is unethical.  However, in the care of patients with dementia, the moral clarity of this approach blurs.  In her recent New Yorker article, “The Memory House,”  Larissa MacFarquhar provides an excellent portrait of the common devices of artifice, omission and outright deception that are frequently deployed in the care of patients with dementia.  She furthermore explores the historical and ethical underpinnings of the various approaches used in disclosing (or not) information to patients living with dementia.

Ms. MacFarquhar introduces the idea of “compassionate deception,” or the concept that withholding truths, or even promoting outright falsehoods, is a reasonable and even ethical choice for those caring for patients with dementia.  To the extent that it helps a person with dementia feel happier and calmer, allowing them to believe in a gentler reality (one in which, say, their spo…