Review

American Journal of Alzheimer’s

Disease & Other Dementias®
Reducing Burden for Caregivers of Older 2018, Vol. 33(7) 401-414
ª The Author(s) 2018
Article reuse guidelines:
Adults With Mild Cognitive Impairment: sagepub.com/journals-permissions
DOI: 10.1177/1533317518788151
A Systematic Review journals.sagepub.com/home/aja

Nélia Sofia Domingues, BA1,2, Phylicia Verreault, BSc1,2,

and Carol Hudon, PhD1,2

Abstract
Background/Rationale: This systematic review aims to evaluate the efficacy of the nonpharmacological interventions reducing
burden, psychological symptoms, and improving quality of life of caregivers of individuals with mild cognitive impairment (MCI).
Method: Databases reviewed included Medline, Cochrane Library, Embase, PsycNet, AgeLine, and ProQuest Dissertations and
Theses. Studies using an experimental/quasi-experimental design including nonpharmacological intervention were included. Four
studies were included, and no meta-analysis was conducted. Results: Calendar training and note-taking (cognitive intervention)
significantly decreased caregiver’s depressive symptoms and prevented worsening of subjective burden 6 months posttreatment.
Daily engagement of meaningful activity combined with problem-solving therapy and educational material reduced depressive
symptoms 3 months posttreatment. Moreover, educational intervention and social conversation phone calls decreased caregiver
burden 3 months posttreatment. Conclusion: Studies suggest that nonpharmacological interventions can support caregivers of
older adults with MCI, but the few published articles present some bias and are inconclusive. Randomized-controlled trials
targeting specifically caregivers are needed to determine the most efficient type of interventions for those individuals.

Keywords
caregivers, burden, psychological symptoms, quality of life, mild cognitive impairment, nonpharmacological interventions,
cognitive interventions, psychological interventions, physical exercises, nutrition, systematic review

Introduction consequences. The concept of burden includes 2 dimensions:

Mild cognitive impairment (MCI) is characterized by deficits
in cognitive functioning in different domains (ie, controlled
attention, executive functioning, learning and memory, lan-
guage, sensorimotor functions, and social cognition). Reduced
cognitive functioning in MCI cannot be simply attributed to
aging, and cognitive decline does not have a significant impact
on everyday life.1 When the domain of learning and memory is
affected, more specifically when episodic memory is impacted,
MCI can be considered as a probable prodromal phase of Alz-
heimer’s disease (AD). Although individuals with MCI are still
able to function independently in most activities of daily living,
they frequently require some level of assistance and support
from family members, named caregivers.2 Caregiver is defined
as any family member or friend providing instrumental or psy-
chological support to another individual, without receiving any
financial compensation.3
The relationship between an individual with MCI and his or
her caregiver can sometimes be difficult, especially for the
person providing assistance. Indeed, 36% of caregivers of
people with MCI report a clinically significant burden.4 This
burden implies emotional, physical, social, and financial
(1) objective burden refers to concrete problems resulting from
daily care (eg, time per day) directed to the individual receiving
care or the impossibility for the caregiver to devote time for
himself or herself and (2) subjective burden refers to the care-
giver’s perception of caregiving, attitudes, and feelings (eg.,
depression, anxiety, and guilt).5 Objectively, caregivers of indi-
viduals with MCI assume new responsibilities such as financial
planning and grocery shopping, and they entrust a binding life-
style.2 Subjectively, caregivers suffer when they witness their
significant other having memory deficits6; caregivers report
increased psychological distress (ie, depressive and anxiety
symptoms)6 and a diminished quality of life (QoL).7
Caregivers express a need to be supported when providing
care and support to individuals with MCI.8 As a result, different
1
CERVO Brain Research Centre, Quebec, Canada
2
École de psychologie, Université Laval, Quebec, Canada
Corresponding Author:
Carol Hudon, PhD, CERVO Brain Research Centre, 2601, de la Canardière
(F-2400), Quebec G1J 2G3, Canada.
Email: carol.hudon@psy.ulaval.ca
402
areas of intervention emerged to help caregivers reduce their
burden and improve their QoL. Recently, cognitive, psycholo-
gical, and multidimensional interventions have successfully
reduced the burden of MCI caregivers.9-11 However, the major-
ity of these interventions target the individual with MCI
directly, and the impact of treatment on the caregiver is subse-
quently measured. Cognitive interventions include cognitive
training, cognitive remediation, and cognitive rehabilitation.12
The rationale of these types of interventions in the context of
this systematic review is that the impaired functioning of
elderly people with MCI predicts subjective burden of care-
givers.13 Therefore, it is plausible that improved functional
abilities of people with MCI reduce the burden of their care-
givers. Indeed, Greenaway and colleagues9 trained individuals
with MCI to use a calendar and to take notes (cognitive reme-
diation). The impacts of this type of intervention were mea-
sured; the intervention successfully increased caregivers’ mood
and had a protective effect against the caregiver’s subjective
burden at 6-month follow-up. Psychological interventions
include psychological support interventions, psychoeducation,
psychotherapy, and respite care.14 For example, a study using
problem-solving therapy (psychotherapy) significantly reduced
caregivers’ depressive and anxiety symptoms.10 Finally, other
researchers studied the effect of multidimensional interventions
for individuals with MCI and their caregivers. In particular, a
study using cognitive–behavioral therapy (CBT) combined with
certain components of cognitive rehabilitation and psychoeduca-
tion has shown to improve caregivers’ feelings of self-efficacy 6
to 8 months postintervention.15 In addition, a cognitive interven-
tion combined with psychoeducational activities reduced the
burden of caregivers for which individuals with MCI responded
positively to the intervention.16
Up to now, no systematic review of the literature regarding
the effect of nonpharmacological interventions on MCI care-
givers’ burden was done. Due to an increasing number of stud-
ies on the topic, a review of the literature is warranted to
identify those interventions that show the most promise. This
systematic review will clarify the efficacy of nonpharmacolo-
gical interventions available to date. It also suggests clinical
recommendations to improve support for caregivers of individ-
uals with MCI, and it proposes avenues for future research on
the topic.
Accordingly, the overarching objective of this systematic
review is to examine the efficacy of nonpharmacological inter-
ventions (ie, cognitive, psychological, physical exercise, and
nutritional interventions) on burden, psychological symptoms,
and QoL of MCI caregivers. To our knowledge, there does not
appear to be a previous study measuring the direct or indirect
impact of nutritional or physical exercise programs on care-
givers, but these 2 types of interventions were nevertheless
included in the present systematic review for exploratory
reasons. Since these interventions may improve cognition of
individuals with MCI, they may in turn positively impact care-
givers’ burden. Overall, we hypothesized that nonpharmacolo-
gical interventions directly administered to the caregiver or to
American Journal of Alzheimer’s Disease & Other Dementias® 33(7)
the individual with MCI significantly reduce caregivers’ bur-
den and psychological symptoms as well as improve their QoL.
Method
Literature Review and Articles Selection
The articles were obtained using MedLine, Cochrane, Embase,
PsycNet, AgeLine, and ProQuest Dissertations and Theses
databases. Since the year 1999 is the year of the first publica-
tion including MCI diagnostic criteria, articles were retrieved
for the period between January 1999 and September 2017.17
The literature search using key words was conducted. The key
words were combined and included (1) caregiver (or equivalent
words: carer, dyad, family, friend, significant other, care-
partner, partner, spouse); and (2) MCI (or equivalent words:
cognitive decline, cognitive disorder, cognitive deficit, cogni-
tive impairment, memory disorder, memory loss, memory
problem, pre-Alzheimer, preclinical AD, preclinical Alzhei-
mer, predementia state, prodromal, prodromal Alzheimer, pro-
gressive cognitive decline); and (3) nonpharmacological
intervention (or equivalent words: intervention, nonpharmaco-
logical therapy, nonpharmacological treatment); or (4) cogni-
tive intervention (or equivalent words: cognitive learning,
cognitive rehabilitation, cognitive stimulation, cognitive train-
ing, memory rehabilitation, memory stimulation, memory
training, neuropsychological intervention, neuropsychological
stimulation, neuropsychological therapy); or (5) psychotherapy
(or equivalent words: behavior intervention, behavior therapy,
behavior treatment, cognitive therapy, cognitive behavior
intervention, cognitive behavior therapy, psychodynamic psy-
chotherapy) or mind-body therapy (or equivalent words: medita-
tion, mindfulness, relaxation) or counselling or psychoeducation
or respite or support; or (6) physical activity (or equivalent
words: aerobic, balance, cycling, exercise, flexibility, gym,
motor activity, physical endurance, physical performance, phys-
ical program, physical therapy, physical training, run, strength,
swim, tai chi, walk, yoga); or (g) nutrition (or equivalent words:
calcium, diet, plant extract, plant oil, regimen, vitamins); and
(7) burden, caregiver health or quality of life: (or equivalent
words: anxiety, depression, caregiver distress, caregiver out-
come, CES-D, mood, neuropsychiatric inventory, psychiatric
status rating scale, RAND 36-Item Health Survey (RAND-36),
Revised Memory and Behavior Problems Checklist (RMBPC),
self-care, sense of competence questionnaire, severity of illness
index, stress, well-being); and (8) randomized trial (or equivalent
words: controlled clinical trial, controlled study, experimental
study, randomized clinical, randomized control) or quasi-
experimental study or longitudinal study or pilot project or
preliminary study or pre intervention (or equivalent words:
pretest–posttest, pre and postintervention, pre and posttreatment,
pretreatment). To complete the search, references in systematic
reviews and meta-analyses on nonpharmacological interventions
for individuals with MCI or caregivers were also considered.
The literature search was completed with the help of a
librarian (specialized in psychological literature searches) on
Domingues et al 403

September 24, 2017, and 4342 articles were initially retrieved.

The first author (NSD) examined titles and abstracts to exclude Step 1 : Literature search
Medline (n= 636)
any articles that could not be included, leading to the selection Cochrane (n= 1 043)
of 193 articles. Then, the first 2 authors (NSD and PV) inde- Embase (n= 1 944)
PsycNet (n= 625)
pendently verified the admissibility of each selected article AgeLine (n= 78)
ProQuest Dissertations and theses (n= 16)
according to predetermined inclusion and exclusion criteria. Total (n = 4 342)

Inclusion and Exclusion Criteria Number of articles after removal of the

doubled (4342 – 748 duplicated)
To define the inclusion and exclusion criteria, authors used the
(n = 3 594)
PICOS search strategy as recommended by the statement.18 Exclusion (n = 3 401)
This method focuses on generating criteria according to 5 cate- Reasons:
- other population (n = 3 124)
gories: P, participant; I, intervention; C, comparators (ie, con- Step 2 : Preliminary selection - MCI with comorbidity (n = 31)
trol group); O,: outcome; and S, study design. No criteria for (Titles and abstracts evaluated) - no treatment (n = 146)
- other treatment (n = 32)
comparators category were used to promote the inclusion of - biomarkers and imagery (n = 32)
- other literature review (n = 35)
relevant studies. Studies with or without control group were - book chapter (n = 1)
included. All the articles included in the systematic review had Retained articles
(n = 193)
to satisfy the following criteria.

Participants. The target population included individuals with Bibliographic search

MCI (amnestic or not) and/or their caregiver. Individuals (n = 0)
Exclusion (n = 189)
with MCI were identified according to published diagnostic Reasons:

criteria.1,17,19-23 All articles including participants with MCI Step 3 : Double-blind independent
- other language (n =4)
- other population (n = 78)
- MCI with comorbidity (n = 2)
for whom the cognitive deficits may be due to a psychiatric reading - different diagnosis criteria (n = 8)
(Inclusion/exclusion criteria) - MCI and AD combined (n = 14)
or a medical condition were excluded. Articles including - other treatment (n = 1)
participants with MCI and AD were included only if the - other measure (n = 42)
- protocol (n = 25)
results for each group were separately reported; the articles Included articles
- duplicated (n = 8)
- no response from the authors (n = 4)
were excluded otherwise. (n = 4) - missing information (n = 3)

Interventions. Participants with MCI or their caregivers

needed to receive a nonpharmacological intervention,
defined as a cognitive, psychological, nutritional, or physi-
cal exercise program. Interventions could be administered
individually to the participant or in groups. The duration of
the treatment and the time of each session were not speci-
fied as exclusion criteria.
Cognitive interventions had to include a cognitive training,
remediation, or rehabilitation intervention defined according to
the criteria of Clare and colleagues.12 Psychological interven-
tions had to include support intervention, psychoeducation,
psychotherapy, or respite care as defined by Sorensen and col-
leagues.14 Studies including meditation and relaxation inter-
ventions were additionally included. Physical exercise
interventions had to include a physical training program, a
physical rehabilitation program, or recreational activities incor-
porating resistance, cardiovascular, balance, or stretching ele-
ments as defined by Orgeta and colleagues24 and by van
Uffelen and colleagues.25 Finally, nutritional interventions had
to incorporate any change regarding alimentation such as sup-
plements and diets. All interventions could be administered
solely or in combination (eg, cognitive intervention including
psychotherapy elements).
Outcomes. Only articles reporting quantitative data regarding
the efficacy of the intervention directly measured on caregivers
were included. These measures included burden, psychological
Figure 1. Articles selection flow diagram.
symptoms (ie, psychological health), and/or QoL. Burden con-
struct had to be evaluated with tools or scales measuring objec-
tive and/or subjective burden. Results had to be reported in
terms of a significant difference between the experimental
group and the control group or in terms of a significant differ-
ence between pre–post measures or follow-up.
Study design. Articles had to use an experimental design (ie,
randomized groups) or quasi-experimental (ie, pre–post mea-
sures with control group, post measures only with control
group, or pre–post measures without control group) and needed
to be written in French, English, Spanish, or Portuguese.
Article selection was compared between the first 2 authors
as they performed the task independently. When discrepancy
occurred, the authors discussed the results until consensus. A
total of 4 articles were finally included in this systematic
review (for selection process, see Figure 1). One article was
excluded due to intervention type: researchers used a Reiki
intervention, which is a laying hand technique administered
by a peer.26 Finally, 4 authors did not reply to e-mails request-
ing additional information to evaluate whether their respective
articles met the inclusion criteria of the present systematic
review and, consequently, their articles were excluded.
404
Data Extraction and Risk of Bias
The following information was extracted for every article
included in the systematic review: (1) study (design, number
of groups, and type of control group), (2) participants (type of
participants, sample size, mean age and standard deviation, sex,
education, nature of the relation between individuals with MCI
and their caregiver), (3) intervention (type of intervention,
number and duration of sessions, follow-up measures, and type
of control intervention), (4) instruments or questionnaires
(name of questionnaire), and (5) quantitative results (means,
standard deviations, and effect sizes).
Additionally, each included study underwent an evaluation
of the quality of its methodology. An evaluation of the risk of
bias was performed using The Cochrane Collaboration’s tool
for assessing risk of bias27 for randomized studies, and the
evaluation of nonrandomized studies was performed using the
Checklist for the assessment of the methodological quality both
of randomized and nonrandomized studies of health-care inter-
ventions proposed by Downs and Black.28 This checklist
includes most critical domains for the evaluation of bias and
its use is recommended for systematic reviews.29
The first 2 authors performed data extraction and evaluation
of bias independently. Again, all diverging results were dis-
cussed until consensus.
Data Analysis
The articles were retained for this systematic review regardless
of the results of the study. Effect sizes were calculated for all
significant results when possible. Cohen d effect size with a
95% confidence interval was used to compare standardized
mean scores small effect: d ¼ 0.20 à 0.49; moderate effect:
d ¼ 0.50 à 0.79; large effect: d ¼ 0.80 à 1.00; very large effect:
d ¼ 1.01 and more.30
No quantitative meta-analysis of the results was performed
due to the methodological heterogeneity of the selected articles.
Results
Three randomized9,31,32 and 1 nonrandomized11 control trials,
for a total of 223 caregivers, satisfied the inclusion criteria of
this systematic review. Characteristics of these 4 studies are
detailed in Table 1. Measures are presented in Table 2 and
obtained results are presented in Table 3.
Cognitive Interventions
The impact of cognitive interventions was evaluated only in a
single study by Greenaway and colleagues. 9 This study
included 40 older adults with MCI along with their 40 care-
givers. There were no exclusion criteria to be considered for a
caregiver except to be in contact at least twice a week with their
program partner. A total of 67.5% caregivers were spouses, and
the relationship was not specified for 32.5% of caregivers.
The authors focused on the efficacy of a calendar and note-
taking rehabilitation intervention compared to a control group
American Journal of Alzheimer’s Disease & Other Dementias® 33(7)
receiving a calendar without any specific instructions. The cal-
endar included 3 sections (1) appointments, (2) “to-do” list, and
(3) taking notes concerning important daily events and activities
that could include a phone call received, thoughts, information
concerning family members, and so on. Intervention group
dyads received a total of twelve 60-minute training sessions over
6 weeks, with homework routinely assigned to encourage
practice.
The Greenaway and colleagues’ study measured the efficacy
of the cognitive intervention on subjective burden, depressive
and anxiety symptoms, and QoL of MCI caregivers.9 Change in
mood (ie, depressive symptoms as measured by CES-D) was
better in caregivers in the intervention group compared to the
caregivers in the control group. The effect was significant at 8
weeks (medium effect size; d ¼ 0.75) and 6 months (extra-large
effect size; d ¼ 1.03) postintervention. Compared to baseline,
caregivers of the intervention group reported a decrease in
depressive symptoms 6 months following the intervention (total
score at CES-D; small effect size; d ¼ 0.39), which was not
reported for caregivers in the control group. Moreover, care-
givers’ mood in the control group tended to get worse at 6
months postintervention (nonsignificant result; P ¼ .06).
The intervention did not significantly impact the
subjective burden (as measured by the Zarit Burden Interview),
QoL (as measured by the QoL-AD), and anxiety (instrument
not reported) of caregivers. However, a small effect size
(d ¼ 0.32) was reported; caregivers’ subjective burden wor-
sened in the control group 6 months post-intervention.
Multidimensional Interventions
The 3 other studies tested the efficacy of multidimensional
interventions.11,31,32 Banningh et al11 evaluated the efficacy
of CBT combined with cognitive rehabilitation and psychoe-
ducation components. The study included 88 caregivers (55%
women; mean age ¼ 68.2 years old), and no exclusion or
inclusion criteria were specified for these participants. In the
sample, 90.2% of them were spouses, 8.0% were relatives
(ie, brothers, sisters, or children), and 1.8% of caregivers had
an unspecified relation with the care recipient.
This intervention focused on acquisition of new strategies to
cope with MCI symptoms and consequences, learning to recog-
nize memory problems in everyday life, communication with
caregivers, and self-regulation skills. The following themes
were covered during the meetings: memory function, MCI as
a clinical label, available resources and interventions, strategies
to enhance memory, ways to recognize strain, learning to relax,
the importance of undertaking pleasant everyday activities, and
coping with social conflicts and worries. Participants were
invited to recognize and cognitively restructure dysfunctional
self-evaluations and negative social and unduly anxious cogni-
tions. The intervention consisted of 10 weekly 120-minute
group sessions. The control group consisted of a waiting list.
Overall, results demonstrated that CBT combined with cogni-
tive rehabilitation and psychoeducation components did not
significantly reduce caregivers’ subjective burden (as
 Table 1. Articles’ Characteristics.

Authors Exp. Gr. Ctrl. Gr. Interventions Duration/Frequency

Cognitive interventions
Greenaway et al, 20139a MCI MCI Exp. Gr. Twelve group dyads training sessions
n ¼ 20 n ¼ 20 Calendar training and note-taking. (60 minutes) per week for 6 weeks.
40% \; 60% _ 38% \; 62% _ The training includes 3 sections:
Mean age (SD): 72.7 (6.9) Mean age (SD): 72.3 (7.9) (1) appointments, (2) « to-do » items,
Ed.: 16.4 years Ed.: 16.4 years and (3) journaling section.
Caregiver Caregiver Ctrl. Gr.
n ¼ 20 n ¼ 20 No treatment. No calendar instructions.
Spouses: 60.0% Spouses: 75.0%
Others: 40.0% Others: 25.0%
Multidimensional interventions
Joosten-Weyn Banningh et al, 201311 Caregiver Caregiver Exp. Gr. One group session (120 min)/wk for
n ¼ 58 n ¼ 30 Cognitive-behavioural therapy combined 10 weeks.
38% \; 62% _ 52% \; 48% _ to psychoeducation and memory
Mean age (SD): 69.4 (8.2) Mean age (SD): 67.0 (8.2) rehabilitation elements.
Ed.b: level 4.9 Ed.: level 5.1 Ctrl. Gr.
Spouses: 91.4% Spouses: 88.9% Waiting-list.
Children/sisters–brothers: 8.6% Children/sisters–brothers: 7.4%
Others: 3.7%
Lu et al, 201632a MCI MCI Exp. Gr. Exp. Gr.
n ¼ 20 n ¼ 20 Daily engagement of meaningful activity Two sessions (average: 46.6 min)/wk for
60% \; 40% _ 55% \; 45% _ combined with problem-solving therapy 6 weeks over 3 months.
Mean age (SD): 71.2 (6.8) Mean age (SD): 76.5 (7.1) and educational material. Ctrl. Gr.
Ed.: 16.8 years Ed.: 16.2 years Ctrl. Gr. Two sessions (average: 31.2 min)/wk for
Caregiver Caregiver Information support attention with 6 weeks over 3 months.
n ¼ 20 n ¼ 20 (1) educational brochure; and (2) social
25% \; 75% _ 35% \; 65% _ conversation phone calls.
Mean age (SD): 65.3 (7.2) Mean age (SD): 70.5 (12)
Ed.: 15.4 years Ed.: 15.9 years
Spouses: 75% Spouses: 80%
Friends/others: 25% Friends/others: 20%
Schmitter-Edgecombe et al, 201431a MCI MCI Exp. Gr. Open discussion
n ¼ 27 n ¼ 28 Memory rehabilitation combined to Two sessions
30.4% \; 69.6% _ 52.2% \; 47.8% _ psychoeducation and support elements. Biopsychosocial workshop
Mean age (SD): 73.0 (7.1) Mean age (SD): 73.4 (7.9) It had 3 steps: (1) open discussions, Half-day
Ed.: 14.5 years Ed.: 15.8 years (2) biopsychosocial workshop, and Strategy training and problem-solving
Caregiver Caregiver (3) strategy training and problem-solving. Two group sessions (120 min)/wk for
n ¼ 27 n ¼ 28 Ctrl. Gr. 10 weeks.
30.4% \; 69.6% _ 30.4% \; 69.9% _ Standard care for person with MCI
Mean age (SD): 65.4 (9.8) Mean age (SD): 66.3 (9.3) including: (1) routine medical visits,
Ed.: 15.5 years Ed.: 15.7 years (2) monitoring of disease progression,
Spouses: 61.0% Children: 17.0% Spouses: 74.0% Children: 13.0% (3) maintenance of an active lifestyle, and
Friends: 22.0% Friends: 13.0% (4) AChE inhibitor or memantine.

Abbreviations: AChE, acetylcholinesterase; Ctrl. Gr., control group; Ed., education; Exp. Gr., experimental group; MCI, mild cognitive impairment; SD, standard deviation; \, men; _, women.
a
Randomized controlled trials.
b

405
Education level was rated using 7 categories in accordance with the Dutch educational system; level 1: less than primary school, that is, less than 6 years of education, up to level 7: university degree, that is, more than 14
years of education.
406 American Journal of Alzheimer’s Disease & Other Dementias® 33(7)

Table 2. Efficacy Measures Utilized in the Studies.

a
Measure Definition /4

Burden measures
BCOS-1533 Self-reported questionnaire of 15 items designed to measure caregiver perceptions of time and 1
difficulty associated with tasks performed in caring for their family member (eg, personal care,
assisting with medications, monitoring symptoms, managing the patient’s behaviors, dealing with
finances, and talking with health professionals). The time subscale items are rated on a 5-point scale
ranging from none to a great amount, and the difficulty subscale items are rated on a 5-point scale
ranging from not difficult to extremely difficult. Lower scores indicate negative life change.
CBS34 Self-reported questionnaire of 20 items measuring caregiver perceptions of their emotional or physical 1
health, social life, and financial status as a result of caring for their relative. Each item is answered on a
4-point Likert-type scale ranging from 1—not at all—to 4—extremely. Higher scores indicate higher
levels of burden.
ICQ35 Self-reported questionnaire of 18 items measuring cognitions about patient’s illness, including 3 1
dimensions: acceptance, helplessness, and perceived benefits. Each item is answered on a 4-point
Likert-type scale ranging from 1—not at all—to 4—completely. Total score ranges from 6 to 24.
MBPC or RMBPC36,37 Self-reported questionnaire of 22 or 24 (revised) items measuring caregiver’s subjective burden via 2
evaluation of the caregiver’s reaction to memory and behavioural problems (how much it bothered
you? 0: not at all, 1: a little, 2: moderately, 3: very much and 4: extremely). The 3 problem domains
are memory-related problems, affective distress, and disruptive behaviors.
SCQ38 Self-reported questionnaire of 27 items evaluating subjective burden through sense of competence 1
according to 3 dimensions: satisfaction with one’s own performance as a caregiver, satisfaction with
the MCI partner as the recipient of the support and implications of involvement in care for the
caregiver’s personal life. Each item is answer on 5-point Likert-type scales ranging from 1: totally
agree to 5: totally. The total score ranges from 27 to 135. Higher scores indicate weak sense of
competence.
Psychological symptoms measures
CES-D39 Self-reported questionnaire of 20 items evaluating depressive symptoms in the last week. The 1
frequency of symptoms is measured (0: never or rarely, 1: occasionally, 2: sometimes to 3:
frequently, all the time). The maximum score is 60. Higher scores indicate worse depressive
symptomatology.
GDS40 Self-reported questionnaire of 30 dichotomous (yes/no) items (or 15 items for the short version, GDS- 2
15) measuring depressive symptoms in older adults in the last week. When the results suggest the
presence of depression, the item is scored 1. The total score ranges between 0 and 30 (or 15 for the
short version). Higher scores indicate worse depressive symptomatology.
PHQ-941 Self-reported questionnaire of 9 items evaluating depressive symptoms in the last 2 weeks (how often 1
have you been bothered by these problems? 0: not at all, 1: several days, 2: more than half the days, 3:
nearly every day). Higher scores indicate worse depressive symptomatology. The instrument also
includes a functional health assessment. This asks the patient how emotional difficulties or problems
impact work, things at home or relationships with other people.
Quality of life measures
QoL-AD42 Self-reported questionnaire evaluating patient’s quality of life. The domains are physical condition, 2
mood, social interactions, and finances. This questionnaire includes 13 items answered on a 4-point
Likert-type (1: weak, 2: average, 3: good, 4: excellent). The total score ranges from 13 (weak QoL) to
52 (excellent QoL).
RAND-3643 Self-reported questionnaire of 36 items evaluating patient’s health condition and quality of life. It 1
included 8 domains: physical functioning, role limitations due to physical and emotional problems,
social functioning, pain, emotional well-being, energy/fatigue, and general health. The scoring is
performed in 2 steps; 1: each item is scored from 0 (poor health and QoL) to 100 (excellent health
and QoL), and 2: items in the same domain are averaged.
Abbreviations: BCOS-15, Bakas Caregiving Outcomes Scale; CBS, Caregiving Burden Scale; CES-D, Center for Epidemiological Studies- Depression; GDS,
Geriatric Depression Scale; ICQ, Illness Cognition Questionnaire; MBPC, Memory and Behaviour Problems checklist; PHQ-9, Patient Health Questionnaire-9;
QoL-AD, Quality of life-Alzheimer’s Disease; RAND-36, RAND 36-Item Health Survey; RMBPC, Revised Memory and Behavior Problems Checklist; SCQ: Sense
of Competence Questionnaire.
a
Number of studies including the questionnaire.

measured by the RMBPC—frequency and hindrance sub- measured by the RAND 36-Items Health Survey; RAND-
scales; the Illness Cognition Questionnaire, Sense of Compe- 36) 2 weeks postintervention.
tence Questionnaire), depressive symptoms (as measured by Lu and colleagues32 explored the benefits of the Daily
the Geriatric Depression Scale; GDS-15), or QoL (as Engagement of Meaningful Activities (DEMA) tool
Domingues et al 407

Table 3. Results.

Authors Questionnaire Results Effect Size d

Cognitive interventions
Greenaway et al, 20139 CES-D MC (pre-8 weeks) Exp. Gr. vs Ctrl. Gr. P < .05 0.75
MC (pre-6 months) Exp. Gr. vs Ctrl. Gr. P < .01 1.03
TS Exp. Gr. vs Ctrl. Gr. at 8 weeks NS NS
TS Exp. Gr. vs Ctrl. Gr. at 6 months NS NS
TS pre vs 8 weeks Exp. Gr. NS NS
TS pre vs 8 weeks Ctrl. Gr. NS NS
TS pre vs 6 months Exp. Gr. P < .05 0.39
TS pre vs 6 months Ctrl. Gr. NS NS
MC (pre-8 weeks) Exp. Gr. vs Ctrl. Gr. NS NS
MC (pre-6 months) Exp. Gr. vs Ctrl. Gr. NS NS
MBPC TS Exp. Gr. vs Ctrl. Gr. at 8 weeks NS NS
TS Exp. Gr. vs Ctrl. Gr. at 6 months NS NS
TS pre vs 8 weeks Exp. Gr. NS NS
TS pre vs 8 weeks Ctrl. Gr. NS NS
TS pre vs 6 months Exp. Gr. NS NS
TS pre vs 6 months Ctrl. Gr. P < .05 0.32
MC (pre-8 weeks) Exp. Gr. vs Ctrl. Gr. NS NS
QoL-AD MC (pre-6 months) Exp. Gr. vs Ctrl. Gr. NS NS
TS Exp. Gr. vs Ctrl. Gr. at 8 weeks NS NS
TS Exp. Gr. vs Ctrl. Gr. at 6 months NS NS
TS pre vs 8 weeks Exp. Gr. NS NS
TS pre vs 8 weeks Ctrl. Gr. NS NS
TS pre vs 6 months Exp. Gr. NS NS
TS pre vs 6 months Ctrl. Gr. NS NS
Anxiety (non-reported measure) MC (pre-8 weeks) Exp. Gr. vs Ctrl. Gr. NS NS
MC (pre-6 months) Exp. Gr. vs Ctrl. Gr. NS NS
TS Exp. Gr vs Ctrl. Gr. at 8 weeks NS NS
TS Exp. Gr. vs Ctrl. Gr. at 6 months NS NS
TS pre vs 8 weeks Exp. Gr. NS NS
TS pre vs 8 weeks Ctrl. Gr. NS NS
TS pre vs 6 months Exp. Gr. NS NS
TS pre vs 6 months Ctrl. Gr. NS NS
Multidimensional interventions
Joosten-Weyn Banningh et al., 201311 SCQ total MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
SCQ care recipient MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
SCQ own performance MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
SCQ personal life MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
GDS-15 MC (pre-post) Exp. Gr. vs Ctrl. Gr NS NS
RAND-36 MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
ICQ acceptance MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
ICQ hindrance MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
RMBPC reaction MC (pre-post) Exp. Gr. vs Ctrl. Gr. NS NS
Lu et al., 201632 Within and between-group effect sizes in total sample
PHQ-9 TS pre vs 2weeks in Exp. Gr. NS NS
TS pre vs 3months in Exp. Gr. 0.28
TS pre vs 2weeks in Ctrl. Gr. 0.34
TS pre vs 3months in Ctrl. Gr. 0.17
MC (pre-2weeks) Exp. Gr. vs Ctrl. Gr. 0.50
MC (pre-3 months) Exp. Gr. vs Ctrl. Gr NS NS
BCOS-15 TS pre vs 2weeks in Exp. Gr. NS NS
TS pre vs 3months in Exp. Gr. NS NS
TS pre vs 2weeks in Ctrl. Gr. NS NS
TS pre vs 3months in Ctrl. Gr. 0.41
MC (pre- 2weeks) Exp. Gr. vs Ctrl. Gr. NS NS
MC (pre-3 months) Exp. Gr. vs Ctrl. Gr. 0.46
(continued)
408
Table 3. (continued)
Authors Questionnaire
Within and between-group effect sizes in patients with PHQ-9 scores  5 at baseline only
PHQ-9
BCOS-15
Schmitter-Edgecombe et al., 201431 GDS-15
QoL-AD
Abbreviations: BCOS-15, Bakas Caregiving Outcomes Scale; CES-D, Center for Epidemiological Studies-Depression Scale; Ctrl. Gr., control group; Exp. Gr.,
experimental group; GDS-15, Geriatric Depression Scale; ICQ, Illness Cognition Questionnaire; MC, mean change; NS, nonsignificant; PHQ-9, Patient Health
Questionnaire-9; pre, pretreatment; post: posttreatment; QoL-AD, quality of life-Alzheimer’s disease; RAND-36, RAND 36-Item Health Survey; RMBPC, Revised
Memory and Behavior Problems Checklist; SCQ, Sense of Competence Questionnaire; TS, total score; vs, versus.
combined with problem-solving therapy that included some psy-
choeducation elements. This study included 40 patient–caregiver
dyads (caregiver: 70% women; mean age ¼ 67.9 years). In the
sample, 77.5% of caregivers were spouses, and 22.5% were
friends or others. The intervention included 2 main components:
(1) engagement in meaningful activities, autonomy support,
problem solving, goal achievement, and emotional needs articu-
lation and (2) self-management tool kit including educational
material to understand and deal with individuals with MCI. The
DEMA was tailored according to dyads’ awareness of congru-
ence in functional abilities, types and frequencies of meaningful
activity, and barriers to engage in these activities. This interven-
tion consisted of 6 biweekly sessions over 3 months. The aver-
age duration of each session was 47 minutes. The information
support (IS) attention control group received 2 face-to-face
meetings and obtained an Alzheimer’s Association MCI educa-
tional brochure, along with 4 biweekly follow-up conversation
phone calls to ask questions about this brochure. Measures were
administered at baseline (time 1), 2 weeks (time 2), and 3-
months after the intervention (time 3).
The IS intervention demonstrated a significant moderate
effect size (d ¼ 0.50) on depressive symptoms (measured
by Patient Health Questionnaire-9; PHQ-9) at time 2 and a
small effect size (d ¼ 0.46) on burden (measured by Bakas
Caregiving Outcomes Scale) at time 3 relative to DEMA. A
small effect size (d ¼ 0.28) was reported regarding the reduc-
tion in caregivers’ depression in DEMA group 3 months post-
intervention. Subset analyses were conducted for patients with
MCI and caregivers with depressive symptoms. Compared to
the IS group, DEMA did not significantly impact caregivers’
American Journal of Alzheimer’s Disease & Other Dementias® 33(7)
Results Effect Size d
TS pre vs 2weeks in Exp. Gr. NS NS
TS pre vs 3months in Exp. Gr. 1.55
TS pre vs 2weeks in Ctrl. Gr. 0.62
TS pre vs 3months in Ctrl. Gr. NS NS
MC (pre-2weeks) Exp. Gr. vs Ctrl. Gr. NS NS
MC (pre-3 months) Exp. Gr. vs Ctrl. Gr NS NS
TS pre vs 2weeks in Exp. Gr. NS NS
TS pre vs 3months in Exp. Gr. NS NS
TS pre vs 2weeks in Ctrl. Gr. NS NS
TS pre vs 3months in Ctrl. Gr. 0.66
MC (pre- 2weeks) Exp. Gr vs Ctrl. Gr. NS NS
MC (pre-3 months) Exp. Gr. vs Ctrl. Gr. 0.77
TS Exp. Gr. vs Ctrl. Gr. at post NS Ns
TS pre vs post in Exp. Gr. NS NS
TS pre vs post in Ctrl. Gr. NS NS
TS Exp. Gr. vs Ctrl. Gr. at post NS NS
TS pre vs post in Exp. Gr. NS NS
TS pre vs post in Ctrl. Gr. NS NS
depressive symptoms at time 3 or burden at time 2. The IS
group had more positive life changes (less burden) at time 3
(significant moderate effect size; d¼ 0.77). However, care-
givers in DEMA group did show a decrease in depressive
symptoms 3 months after the intervention compared to baseline
(significant very large effect size; d ¼ 1.55).
Schmitter-Edgecombe and Dyck31 included 55 older adults
with MCI and their respective caregivers. No inclusion or
exclusion criteria were predetermined for the caregivers. The
sample included 69.8% women, mean age was 65.9 years, and
mean education level was 15.6 years. Caregivers included
67.5% spouses, 15.0% children, and 17.5% friends. In this
study, authors measured the efficacy of a cognitive rehabilita-
tion focused on episodic memory combined with psychoeduca-
tion elements. Specific support intervention for older adults
with MCI and their family was also added to the intervention.
The intervention group was compared to a control group
receiving standard care. This multidimensional intervention
included 3 parts: (1) The first 2 sessions included open discus-
sions to develop complicity and obtain information about par-
ticipants’ competences and needs, (2) the next session involved
a half-day biopsychosocial workshop to acquire knowledge
about changes within the brain, memory deficits, and their
impact on daily functioning. This workshop also targeted par-
ticipants’ interest in learning new strategies to cope with mem-
ory deficits and to reduce distress and social isolation, and
(3) utilization of a 3-section notebook (ie, to-do list, monthly
calendar and personal notes), together with problem-solving
strategies acquisition and implementation of these strategies
in everyday life. This last part included 2 weekly 120-minute
Domingues et al
group meetings for 10 weeks. Standard care included routine
medical visits, monitoring of disease progression, maintenance
of an active lifestyle, and, in some cases, the administration of
acetylcholinesterase inhibitors or memantine.
The results of Schmitter-Edgecombe and Dyck31 revealed
that their cognitive/psychoeducation intervention did not sig-
nificantly impact caregivers’ depressive symptoms (as mea-
sured by the GDS-15) or QoL (as measured by the QoL-AD).
Moreover, caregivers in the intervention group did not show a
decrease in depressive symptoms or an increased QoL 2 weeks
after intervention compared to baseline.
Nutrition and Physical Exercise
No studies retained for this systematic review analyzed the
impact of nutritional or physical exercise interventions on care-
givers of older adults with MCI.
Risk of Bias
Risk of bias of randomized controlled trials and nonrando-
mized control trials is presented in Tables 4 and 5, respectively.
For the study of Greenaway et al,9 the risk of bias associated
with sequence generation and allocation sequence concealment
were judged uncertain as a result of the absence or improper
description of the methods. Due to the nature of the interven-
tion, blinding of participants to the allocated interventions was
impossible, and bias was judged high. The available informa-
tion regarding evaluator blinding was not sufficient, and bias
was therefore judged uncertain. Attrition rate and justification
of attrition were explained for both the groups, suggesting a
low risk of bias for incomplete outcome data. However, the
authors reported results for a measure of anxiety, which was not
mentioned in the method beforehand. Therefore, reporting bias
for selective outcome was judged to be high. Finally, 3 parti-
cipants in the intervention group developed AD before begin-
ning the program, leading to uneven groups at baseline.
In the study of Joosten-Weyn Banningh,11 the information
regarding blinding of evaluators was not sufficient, and the bias
risk was uncertain. Participants’ blinding was not possible, and
risk of bias was high. Duration variability across pre–post inter-
vention periods of the control group was not considered in the
analyses. All other possible sources of bias were judged low
(ie, participants’ recruitment, outcome measures, selective out-
come reporting, appropriate statistical analyses, confounding
variables, attrition, and compliance with the intervention).
Lu and colleagues32 described a nonrandomized component
in their sequence generation process (ie, a sequence generated
based on the patient’s PHQ-9 score and stage of MCI), result-
ing in a high bias associated with the sequence generation.
Evaluators were blind to the participant’s group assignments.
The attrition rate and justification of attrition were explained
for both the groups, suggesting a low risk of bias for incomplete
outcome data. Every initially planned outcome measure was
reported in the results. This study seemed free of any other
source of bias.
409
Finally, Schmitter-Edgecombe and Dyck31 described a non-
randomized component in their sequence generation process
(ie, a sequence generated by some rule based on the date and
location of admission), and bias was thus high. Evaluators were
blind to the study hypotheses, but the article did not report if
they were blind to group allocation. The risk for blinding of
outcome assessment was then judged uncertain. Per-protocol
analysis was used, thus excluding many participants. Bias asso-
ciated with incomplete outcome data was high. Finally, every
initially planned outcome measure was reported in the results.
This study seemed free of any other source of bias.
Discussion
Main Results
The goal of this systematic review was to determine whether
nonpharmacological interventions (ie, cognitive, psychologi-
cal, nutritional, and physical interventions) offered to people
with MCI or to their caregiver are efficient in reducing the
caregiver’s burden and psychological symptoms and/or to
improve the caregiver’s QoL. Four clinical trials focusing on
cognitive interventions and multidimensional interventions
(including elements from both cognitive and psychological
intervention) were included in the systematic review,9,11,31,32
3 of which were randomized control trials.9,31,32 Overall, the
nonpharmacological interventions included in this study did
not have an impact on burden, but 2 studies showed an effect
in reducing depressive symptoms of caregivers.
Cognitive Interventions
A single clinical trial using a cognitive intervention was
included.9 The study showed small to large effect-sizes in
reducing depressive symptoms of caregivers in the interven-
tion group, whereas caregiver’s mood tended to worsen after
6 months (nonsignificant results), and their subjective burden
became significantly worse. These results are important since
depressive symptoms may exacerbate burden of caregivers
and reduce their QoL. A reduction in depressive symptoms
reflects the caregiver’s more optimistic and hopeful feelings
with regard to their situation, and perhaps feel less tired and
irritable, which are all positive effects of this intervention.
However, the cognitive intervention did not have a significant
impact on caregivers’ other outcome measures. According to
the authors, a possible explanation for 3 results is the inclu-
sion of 3 of 18 participants with MCI who progressed to AD
(representing 16.7% of the participants in the intervention
group) by the time the authors began the intervention. Since
caregiver’s burden tends to increase in the progression from
MCI to AD, the data of these 3 caregivers may have contrib-
uted to the nonsignificant results. Additionally, considering
the weak compliance rate 6weeks after the program and 6
months after the intervention in the intervention group, the
omission of booster sessions may have contributed to non-
significant subjective burden results.
410
Table 4. Bias of Randomized Controlled Trials.

Allocation Participants Incomplete Selective Outcome

Authors Sequence Generation Concealment Blindinga Personnel Blinding Outcome Data Reporting Other Bias

Cognitive interventions
Greenaway et al, 20139 Uncertain Uncertain High Uncertain Low High High
No blinding Attrition with Anxiety measure not 3 MCI progressing
justifications specified in the method. to AD in Exp.
Analysis section little Gr. only
detailed
Multidimensional
interventions
Schmitter-Edgecombe High High High Uncertain High Low Low
et al, 2014 Allocation according to Possible allocation No blinding Protocol analysis Published reports include
admission location prediction all expected outcomes
and date
Lu et al, 2016 High High High Low Low Low Low
Allocation based on The statistician No blinding Masking participants’ Attrition with Published reports include
patient’s PHQ-9 scores randomized group assignments justifications all expected outcomes
and stage of MCI participants from the
evaluator
Abbreviations: AD, Alzheimer’s disease; Exp. Gr., experimental group; MCI, mild cognitive impairment; PHQ-9, Patient Health Questionnaire-9.
a
Due to the nature of the non-pharmacological interventions, participant’s allocation blinding is not possible.
Domingues et al 411

Table 5. Nonrandomized Control Trial Bias’s Risk. useless, but should be combined with other approaches in order
11 to alleviate caregivers’ burden or improve their QoL and well-
Multidimensional Intervention: Banning et al, 2013
being. Yet, these results are based on a single cognitive inter-
Authors vention, so generalizability cannot be made. Nevertheless, this
Bias Risk Evaluation Comments study had low risk of bias associated with incomplete outcome
data which strengthen the results.
Participant’s blindinga High No blinding
Evaluator’s blinding Uncertain
Selective outcome Low No unplanned subgroup Multidimensional Interventions
reporting analyses were reported
Analyses adjusted for High Different intervals between Three clinical trials evaluating the efficacy of multidimen-
different lengths of pretreatment–posttreatment sional interventions (eg, CBT combined with cognitive
follow-up of the Ctrl. Gr. (8-016 weeks) rehabilitation and psychoeducation elements,11 cognitive
not accounted for in the rehabilitation targeting episodic memory combined with
analyses
Suitable statistical tests Low The distribution of the date was
psychoeducation and support elements,31 and utilization of
not described, suggesting DEMA along with problem-solving therapy and educational
appropriate statistical analysis component32) were included in the present systematic review.
testing The results of the multidimensional interventions were mixed:
Compliance with the Low Attrition with justifications and 2 studies11,31 did not show significant results on any of the
intervention no contamination of the variables of interest, and 1 study32 reported significant changes
intervention 3 months after the intervention.
Outcome measures Low Measures clearly stated
accurate
According to Banningh and colleagues,11 the inefficacy of
Participant’s Low Same population and recruiting the cognitive–behavioral intervention combined with elements
recruitment period in both groups of cognitive rehabilitation may be explained by the measures
Adjustment for Low Confounding variables being collected at an early stage of MCI, hindering the quanti-
confounding in the accounted for in analyses (eg, fication of change regarding subjective burden, mood, and
analyses therapist effect, sex, cohort QoL. As the care recipients included in this study received the
effect) MCI diagnosis no longer than 16 weeks prior to starting the
Attrition Low Weak attrition rate (4/88
participants) limiting the
intervention, it is possible that their caregivers were positioned
effect on the results in an early adaptation phase. This phase is characterized by the
identification of stress factors, the elaboration of strategies to
Abbreviation: Ctrl. Gr., control group. adapt to the new situation, and the increase in distress and
a
Due to the nature of the nonpharmacological interventions, participant’s
allocation blinding is not possible.
anxiety.45 Accordingly, the participants may have been more
likely to report lower levels of burden and depressive symp-
toms. In fact, the baseline mean GDS-15 score for the care-
Three main observations can be reported as follows: givers was very low in the study of Banningh and colleagues.11
(1) calendar training and note-taking reduce depressive symp- Although the intervention addressed important issues, it was
toms of caregivers of people with MCI on the medium term somewhat unlikely to reduce depressive symptoms (or burden)
(6 months); (2) this type of intervention slows down the in persons who were not (or mildly) depressed preintervention.
worsening of caregivers’ subjective burden over the medium Moreover, the care partners included in this study reported
term (6 months); and (3) caregivers receiving this cognitive numerous examples illustrating adapted behaviors and apprai-
intervention differed from those in the control group on sals of stressors;11 caregivers were more alert to stress factors
subjective burden and depressive symptoms measures sev- and progressively adapted their behaviors to the problems they
eral months postintervention. Considering that 10% to 15% encountered. Finally, Banningh and colleagues11 proposed that
of people with MCI progress to dementia each year21 and the interval between the end of the intervention and the post-
that caregivers’ subjective burden is associated with the care treatment measures (ie, 2 weeks) was too short to detect a
recipient’s functional deficit,13 caregivers’ well-being may significant change in the psychosocial measures.
be more likely to worsen if no cognitive intervention is In the study of Schmitter-Edgecombe and Dyck,31 no sig-
offered to the care recipient. nificant results of the intervention were detected on objective
However, cognitive interventions may not be sufficient to and subjective burden, depressive symptoms, and QoL scales
help caregivers of patients with MCI in the short term, because for caregivers of older adults with MCI, regardless of an
these interventions do not target precisely caregivers’ needs for improvement in functional abilities among persons with MCI.
information about the disease, support, counselling, and respite This study utilized a cognitive rehabilitation method along with
care.2 Moreover, no significant results were observed previ- psychoeducation components. Perhaps, these results may be
ously on caregivers’ objective burden, depressive symptoms, explained, since this type of intervention does not specifically
and QoL, following a cognitive training intervention in patients target the psychological symptoms and the burden of the care-
with dementia.44 In brief, cognitive interventions are not givers. Moreover, although the memory abilities of the care
412
receiver improved, there was no significant improvement in
overall performance of activities of daily living by the care
receiver, which may perhaps translate into a similar perceived
burden and stable psychological symptoms by the caregivers.
The problem described in the previous paragraph regarding the
measurement of depression also arose in this study; it is possi-
ble that the absence of significant results in depressive mea-
sures was due to a floor effect at baseline mean GDS-15 score
of the groups ranging from 1.5 to 2.9;.11,31 Considering that the
presence of psychological symptoms was not an inclusion cri-
terion for caregivers, it is difficult to evaluate the short-term
effect of the multidimensional intervention on a sample with
very few or no psychological symptoms. Furthermore, it is
possible that teaching new skills to caregivers would be more
useful and efficient with the worsening of cognition of the care
recipient because caregivers in this situation need to apply their
skills more often. Consequently, the addition of follow-up mea-
sures in future studies may detail more accurately the utiliza-
tion frequency of the taught strategies and their efficacy
according to the evolution of cognitive functions among the
care recipients.
For the study of Lu and colleagues,32 DEMA’s caregiver
showed a significant reduction in depressive symptoms only
3 months after the intervention (no effect 2 weeks posttreat-
ment). The effect of this intervention appears to be delayed,
as one adapts to the new strategies learned in the interven-
tion and then applying them, emphasizing the important of
having follow-up measures. Moreover, compared to DEMA,
IS intervention seems more effective in reducing burden
3 months posttreatment.
Limitation
The absence of significant results of the interventions on care-
givers’ burden, psychological symptoms, and QoL may be
partly explained by methodological limitations that reduced the
possibility of detecting an effect. First, there were measurement
limitations that may explain the inconsistency in the results of
the previous studies. For example, 3 different questionnaires
were used to evaluate the construct of depressive symptoms of
caregivers in the 4 studies included in this review. Addition-
ally, the omission of clear inclusion and exclusion criteria for
the minimum level of burden or depression in the caregivers
(especially for studies without follow-up measures) may have
impeded the detection of significant intervention effects. There
is limited generalizability of the results of the 4 published
studies due to the fact that recruitment was performed in mem-
ory, neurology, or neuropsychology clinics.9,11,32 Another
important problem is the omission of long-term follow-up mea-
sures assessing the efficacy of the intervention to prevent the
worsening of the caregiver’s burden and psychological symp-
toms or QoL.11,31 Also, objective and subjective burdens were
not measured consistently in all clinical trials. Considering that
they are influenced by different factors and therapeutic ele-
ments,5 it is required to evaluate the effect of the intervention
on both measures independently. Finally, the cognitive
American Journal of Alzheimer’s Disease & Other Dementias® 33(7)
intervention developed by Greenaway and colleagues9 did not
respond to caregivers’ specific needs because it did not include
psychoeducation, support, or counseling elements.2
To summarize, it is important to remain cautious while
interpreting data about the efficacy of nonpharmacological
interventions to support caregivers of people with MCI. The
number of studies meeting the inclusion criteria of this sys-
tematic review was quite small, and due to the small sample
size of the previous studies as well as the clinical and
methodological variability between them, a meta-analysis
was not conducted.
Caregivers
Since this study found only 4 articles meeting the criteria, we
may infer that nonpharmacological interventions that success-
fully reduce burden in caregivers of older adults with dementia,
would perhaps be efficient in caregivers of people with MCI.
Meta-analyses previously conducted suggest that cognitive–
behavioral and respite care interventions have little success
in reducing burden of caregiver.46 Coping strategies interven-
tion has shown to reduce burden of caregivers of people with
dementia.47 Perhaps this type of intervention would also be
more successful in reducing burden of caregivers of people
with MCI; future studies should test this hypothesis. However,
we hypothesize that these effects would only be detected if
caregivers present with significant burden or depressive symp-
toms at baseline.
Recommendations
Regardless of the number of articles included, some recom-
mendations can be suggested for clinical practice. Particularly,
training using calendar and note-taking seems effective in
reducing caregivers’ depressive symptoms in the intermediate
term (6 months) and in delaying the worsening of their sub-
jective burden. It also appears that combining psychological
elements to a cognitive intervention can maximize success or
efficacy for caregivers of individuals with MCI. 14 Daily
engagement of meaningful activity combined with problem-
solving therapy and educational material reduce depressive
symptoms 3 months post-treatment. Moreover, educational
intervention and social conversation phone calls should be
offered to reduce caregiver burden.32 Finally, care must be
taken not to overload caregivers with the intervention.
The clinical practice guide named Guideline on supporting
people with dementia and their careers in health and social
care48 suggests developing programs that will include psychoe-
ducation interventions, support groups, problem-solving stra-
tegies, and information on available resources. These types of
programs are more efficient for prevention and alleviation of
burden among caregivers of patients with dementia. One could
hypothesize that these programs would also be relevant for
MCI caregivers, which Lu’s study supports.
Future research may benefit from a standardized definition
of the concepts of “caregiver” and “burden” in the context of
Domingues et al
MCI and suggest measures to quantify the efficacy of interven-
tions on caregivers. These definitions would standardize
clinical trials and increase the possibilities of achieving a
meta-analysis. Additionally, randomized control trials with
larger sample size are required to determine the most efficient
interventions. Future studies should focus on identifying the
therapeutic components of the interventions (and their combi-
nations) to maximize support for caregivers of older adults with
MCI. In addition, future nonpharmacological interventions
should specifically and directly target caregivers’ subjective
and/or objective burden. Finally, the systematic inclusion of
control groups and long-term follow-up measures are essential
to quantify the immediate and long-lasting benefits of the inter-
ventions. They should also be carried out while considering the
worsening of cognition of the care recipient with MCI.
Acknowledgments
The authors would like to thank Christine St-Pierre for her precious
advice concerning research methods, as well as Drs Linda Garand and
Birgitte Schoenmakers who provided additional information to verify
the inclusion of their article in the present systematic review.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: Carol Hudon
was supported by a salary award from the Fonds de recherche du
Que´bec – Sante´.
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