7.helping Caregivers of Persons With Dementia

International Psychogeriatrics (2006), 18:4, 577–595
C 2006 International Psychogeriatric Association

doi:10.1017/S1041610206003462 Printed in the United Kingdom
REVIEW
Helping caregivers of persons with dementia:

which interventions work and how large are
their effects?
..............................................................................................................................................................................................................................................................................
Martin Pinquart1 and Silvia Sörensen2

1
Department of Developmental Psychology and Center for Applied Developmental Science, Friedrich Schiller
University, Jena, Germany
2
Department of Psychiatry, University of Rochester, Rochester, NY, U.S.A.
ABSTRACT
Background: In recent years, many different forms of interventions for caregivers

of people with dementia have been developed. However, their results have
been, in part, inconclusive.
Methods: Meta-analysis was used to integrate the results of 127 intervention

studies with dementia caregivers published or presented between 1982 and
2005.
Results: Interventions had, on average, significant but small effects on bur-

den, depression, subjective well-being, ability/knowledge and symptoms of care
recipient. Only multicomponent interventions reduced the risk for institu-
tionalization. Psychoeducational interventions that require active participation
of caregivers had the broadest effects. Effects of cognitive-behavioral therapy,
support, counseling, daycare, training of care recipient, and multicomponent
interventions were domain specific. The effect sizes varied by study chara-
cteristics, such as caregiver gender and year of publication.
Conclusions: Because most interventions have domain-specific outcomes,

clinicians must tailor interventions according to the specific needs of the
individual caregivers. Although more recent interventions showed stronger
effects, there is room for further improvements in interventions.
Key words: family caregivers, dementia, interventions, outcomes, meta-analysis
Correspondence should be addressed to: Martin Pinquart, Department of Developmental Psychology and Center for Applied
Developmental Science, Friedrich Schiller University, Steiger3/1, D-07743 Jena, Germany. Phone: +49 3641 945210;
Fax: +49 3641 945202. Email: martin.pinquart@uni-jena.de. Received 26 Oct 2005; returned for revision 11 Jan 2006;
revised version received 22 Feb 2006; accepted 23 Feb 2006. First published online 11 May 2006.
577
578 M. Pinquart and S. Sörensen
Introduction
Providing care for a patient with dementia is stressful, and informal caregivers
of people with dementia show higher levels of psychological distress than carers
of physically frail elderly people and non-caregivers (Pinquart and Sörensen,
2003).
Several forms of interventions for dementia caregivers have been suggested,
such as practical assistance (e.g. respite), education, emotional support
provision, and multicomponent interventions. Although users report high levels
of satisfaction with these services, narrative reviews on objective outcome
measures, such as psychological health or institutionalization, have been
inconclusive. For example, based on six studies, Thompson and Spilsbury
(2004) conclude that there is little or no evidence for a quantifiable effect of
interventions with caregivers of patients with Alzheimer’s disease (AD), whereas
Cooke et al. (2001) report that 30% and 45% of studies they review have an
effect on caregiver burden and psychological health, respectively. Schulz et al.
(2002) report that 60% of their behavioral and pharmacological interventions
affected at least one aspect of caregivers’ quality of life. Cooke et al. (2001)
favor supportive interventions, whereas Pusey and Richards (2001) conclude
that problem and behavior management is most effective.
The inconsistency of these reports is due, first, to the small number of studies
reviewed (ranging from 6 to 43), so that conclusions are based on limited
empirical evidence. Second, most narrative reviews include both controlled
and uncontrolled studies, which are difficult to compare. For example, in
uncontrolled studies, stability of the mean level of care receivers’ (CRs)
symptoms and of caregiver outcomes is interpreted as a lack of success of the
intervention whereas it would be interpreted as success in controlled studies,
when deterioration of outcomes is found in the control group. Third, the
heterogeneity of results of narrative reviews is partly due to small sample
sizes in most available studies. For example, Cooke et al. (2001) report that
only 28% of their studies would have been able to detect medium-sized
effects.
Meta-analysis solves this problem because effect sizes from small samples are
pooled to create more reliable mean effects. Two meta-analyses on psychological
interventions with dementia caregivers have been published thus far. Acton
and Kang (2001) found no significant effects of 24 interventions on caregiver
burden. By contrast, in a meta-analysis of 30 studies, Brodaty et al. (2003)
report positive intervention effects on psychological morbidity (d = 0.31 standard
deviation units), caregiver knowledge (d = 0.51) and patient mood (d = 0.68),
although not on caregiver burden (d = 0.09). In addition, two meta-analyses
on interventions for caregivers of patients with dementia and of physically
Interventions with dementia caregivers 579
frail older adults have been published (Knight et al., 1993; Sörensen et al.,
2002). The latter study found smaller effects of 48 interventions with dementia
caregivers than with caregivers of physically frail older adults and mixed
samples.
The present paper extends our previous meta-analysis by including 127
studies with dementia caregivers. We ask, first, which average effects of
interventions are found on caregiver burden, depression, indicators of positive
subjective well-being (SWB), ability/knowledge of caregivers, symptoms of CRs,
and the risk of institutionalization. Second, we compare effects of different forms
of interventions, such as caregiver education, general support, and respite. Third,
we analyze the impact of study characteristics on the intervention effects, such
as group-based versus individualized interventions.
Forms of interventions
In the present meta-analysis, we compare forms of interventions that have
been evaluated in five or more controlled studies. Because many caregiver
interventions have more than one component, we categorize them according to
which is the dominant component. If no dominant component can be identified,
we use the category “multicomponent.”
P S Y C H O E D U C AT I O N A L I N T E RV E N T I O N S
These focus on the structured presentation of information about dementia and
caregiving-related issues and may include an active role of participants (e.g.
role playing, applying new knowledge to individual problems; Bourgeois et al.,
2002). Support may be part of a psychoeducational group, but is secondary to
the educational content.
C O G N I T I V E - B E H AV I O R A L T H E R A P Y
(CBT)
These approaches apply techniques from CBT to caregivers and focus on
identifying and modifying related beliefs, developing a new behavior repertoire
to deal with caregiving demands, and foster activities that may promote SWB
(e.g. McCurry et al., 1998).
COUNSELING/CASE MANAGEMENT
The goal is to resolve pre-existing personal problems that complicate caregiving,
to reduce conflicts between caregivers and CRs, and/or to improve family
functioning (e.g. Roberts et al., 1999).
G E N E R A L S U P P O RT
This is less structured than psychoeducational and therapeutic interventions.
Support groups provide the opportunity to share personal feelings and concerns,
and to overcome feelings of social isolation (e.g. Gonyea and Silverstein, 1991).
RESPITE
This is a planned, temporary relief for the caregiver through the provision of
substitute care. Respite may be delivered as a center-based daycare program that
offers congregate care for a certain number of weekly hours, in-home respite,
and institutional respite (vacation or emergency respite; Gottlieb and Johnson,
2000).
TRAINING OF THE CR
Because physical and cognitive decline and behavior problems of the CR are
associated with caregiver burden and depression (e.g. Schulz et al., 2002),
memory clinics and programs aimed at improving competence of the CR may
also have a positive effect on caregiver outcomes.
M U LT I C O M P O N E N T I N T E RV E N T I O N S
Some studies combine different forms of interventions, such as education,
support and respite (e.g. Newcomer et al., 1999).
M I S C E L L A N E O U S I N T E RV E N T I O N S
Forms of interventions that were evaluated only in one or two studies (e.g. life-
review) were combined into this category because sub-analyses could not be
computed.
Influences of study characteristics

Several characteristics of the sample and the intervention may influence the
efficacy of interventions.
GROUP SETTING V E R S U S INDIVIDUAL SETTING

Individualized interventions can be more easily adapted to the specific needs of
the caregivers and may therefore be more effective. However, interventions in
groups are more effective in increasing social support.
DOSAGE
Because many dementia-related problems are difficult to change, longer
interventions may be more effective (Brodaty et al., 2003).
Y E A R O F P U B L I C AT I O N
If researchers have learned from previous failures (Callahan, 1989), there may
be stronger effects in more recent studies. In fact, Brodaty et al. (2003) reported
a marginal increase of study quality over time.
CAREGIVER AGE
As caregiving-related stressors may vary by the age of the caregiver, we tested
whether intervention effects differed by caregiver age.
CAREGIVER GENDER
Because women provide, on average, more personal care than men and show
higher levels of caregiver burden and depression (Pinquart and Sörensen, 2006),
they may be more likely to benefit from interventions.
T Y P E O F R E L AT I O N S H I P W I T H T H E C R
Caregiving stressors may vary between spouses and adult children, for example,
because adult children are more likely to experience role conflicts between
caregiving and work. Thus, interventions may have different effects on spouse
and adult child caregivers as well.
S T U DY Q U A L I T Y
Several criteria of study quality have been suggested, such as randomization, use
of well-validated measures, sufficient statistical power, and low dropout rates
(Brodaty et al., 2003; Peacock and Forbes, 2003; Thompson and Spilsbury,
2004). Previous meta-analyses reported inconsistent findings as to whether the
study quality does (Acton and Kang, 2001) or does not (Brodaty et al., 2003)
influence intervention effects.
Methods
Literature search
A comprehensive sample of the available studies was identified by searching
electronic databases (Psycinfo, Medline, Ageline, Psyndex) using search terms
[dementia or Alzheimer’s disease] and [caregiver or carer or caregiving] and
[intervention or trial or support or training], and cross-referencing. Criteria for
inclusion of the studies in the meta-analysis were:
(1) the CR had dementia;

(2) an intervention condition was compared to a control condition that did
not receive the treatment;
(3) one of the following outcomes was reported: caregiver burden,

depression, SWB (e.g. life-satisfaction, happiness), knowledge and/or
coping abilities of the caregiver, CR symptoms, and institutionalization;
(4) statistics could be converted into effect sizes;
(5) studies were written in English or German, or in a language for which
we could get translation.
The 127 eligible studies are listed in the Appendix (available as supplemen-
tary material published online attached to this review at www.journals.
cambridge.org/jid_IPG). Ten studies were excluded because they provided
insufficient information to calculate effect sizes and 41 because they did not
include a no-treatment control group. Most studies were in English (119); six
German studies, one Dutch and one Spanish study were included as well. The
majority of articles were from The Gerontologist (11), the International Journal
of Geriatric Psychiatry (10), the Journal of the American Geriatrics Society (9),
and other journals (69). In addition, nine book chapters, 13 presentations at
conferences and six dissertations were included. If more than one paper was
published from the same study we omitted duplicate results from our files. The
studies were coded by two Ph.D.-level raters. Based on 20% of the studies, the
average observed interrater agreement (Cohen’s κ) was 0.91. Inconsistencies
between the raters were resolved by discussion.
Outcome measures
Caregiver burden was assessed using the Zarit Burden Interview (32 studies)
and other scales (53 studies). Depressive symptoms were most often measured
with the Center for Epidemiological Studies Depression Scale (23 studies), the
Beck Depression Inventory (17 studies), and other measures (22 studies). SWB
was assessed with perceived quality-of-life scales (eight studies), life-satisfaction
scales (four studies), and other scales (14 studies). Ability/knowledge was most
often assessed by questionnaires on coping abilities (16 studies), caregiving-
related self-efficacy (14 studies), and knowledge about dementia and available
services (11 studies). CR outcomes were assessed by measures of behavior
problems (11 studies), cognitive deficits (eight studies), negative affect (four
studies), and deficits in functional abilities (five studies). Institutionalization was
measured by the percentage of members of the experimental group and control
group who had been placed in a nursing home.
The study quality was assessed with five criteria, following Peacock and
Forbes (2003) and Thompson and Spilsbury (2004). We coded whether
participants were randomly assigned to intervention and control condition
(1 = yes, 0 = no/nor reported), whether the intervention and control group did
not differ by sample characteristics at T1 (1 = yes, 0 = no), whether both groups
had at least 10 participants (because studies with small sample sizes are more
error prone; 1 = yes, 0 = no), whether the attrition rate was < 10% (1 = yes,
0 = no), and whether well-validated outcome measures were used (1 = yes,
0 = no). A sum measure was computed, with higher values indicating a better
study quality.
Statistical integration of the findings

Calculations for the meta-analysis were performed in five steps, using random-
effects models (Lipsey and Wilson, 2001) that are recommended when there is
variability in effect sizes between studies beyond subject-level sampling error,
and when all sources of heterogeneity cannot be identified. Because a large
number of interventions have been applied to dementia caregivers, heterogeneity
of treatment effects is probable.
1. We computed effect sizes d for each study; d represents the difference

in the post-treatment measure between the treatment and control
conditions divided by the pooled standard deviation. The effect
sizes were adjusted for bias due to differences in pretests between
intervention and control condition and due to overestimation of the
effect size (common for small samples). When effects of more than one
intervention were evaluated separately, we computed separate effect
sizes for each intervention. Outliers that were more than two standard
deviations from the mean of the effect sizes were recoded to the value
of two standard deviations (Lipsey and Wilson, 2001).
2. Weighted mean effect sizes were computed.
3. The homogeneity of effect sizes was computed.
4. The significance of the mean was tested by dividing the weighted mean
effect size by the estimated standard deviation; confidence intervals that
include 95% of the effects were subsequently computed for each effect
size.
5. Weighted ordinary least squares regression analyses based on the
method of moments were conducted to identify predictors of outcome.
6. As a tool for interpreting the practical significance of the results, we
used the Binomial Effect Size Display (BESD; Rosenthal, 1991). If the
intervention and control groups are of equal size and caregivers with
above-average and below-average improvements are split at the median,
then the percentage of caregivers with above-average improvements in
the intervention group is computed by 0.5 + r/2, and the percentage
of above-average
√ improvement in the control group is 0.5 – r/2; with
r = d/ (d2 + 4).
To compare the risk of institutionalization in the intervention and control

group, we computed log odds ratio (OR) (Lipsey and Wilson, 2001). This
effect size statistic compares two groups in terms of the relative odds of being
institutionalized. The odds of institutionalization in both groups are computed
as the quotient of the probability of being institutionalized (p) and not being
institutionalized (1 – p). The OR for institutionalization is defined as the quotient
of the odds of institutionalization in the treatment condition and the odds of
institutionalization in the control group.
1. ORs were computed for each study.

2. Natural logarithms of the OR were computed; confidence intervals that
include 95% of the effects were subsequently computed for each logged
OR. The log OR and the confidence intervals were later reconverted to
their original metric.
3. The significance and homogeneity of the ORs were tested.
Results
Descriptive characteristics of the studies
Twenty-nine studies focused on caregivers of patients with AD, one study
on caregivers for presenile dementia, and the remaining 97 on caregivers
for dementia in general. With two exceptions, caregivers provided support
at home for the patients with dementia (Dziegielewski, 1989; Perkins and
Poynton, 1990). The number of intervention sessions ranged from one to 180
(median = 9). Follow-ups were conducted in 32 interventions after an average of
11 months (S.D. = 11.1). Group treatments were examined in 56% of the studies;
33% used individual treatments, and 11% combined group and individual
treatments.
The number of participants in the intervention condition ranged from four to
4151 (median = 23), and in the control group from four to 3944 (median = 22).
Mean age of the caregivers was 63.4 years (S.D. = 4.0). Two-thirds of the
caregivers were women, and 80% co-resided with the CR, 60% were spouses
and 39% were adult children. Only 17% reported their ethnicity as non-white.
The caregivers had been providing care for an average of 3.6 years (S.D. = 0.8)
and they provided 83 hours/week of care (S.D. = 20). For CRs the mean age was
77.6 years (S.D. = 2.4); 64% were female.
Effects of caregiver interventions

We computed average effects across all outcome variables. As shown in Table 1,
the interventions had statistically significant immediate effects on caregiver
burden, depressive symptoms, SWB, abilities/knowledge of the caregivers, and
symptoms of the CR. Follow-ups with an average time lapse of 11 months
showed a significant effect on burden, depressive symptoms, and ability/
Table 1. Intervention effects on caregiver burden, depression, SWB, abilities/

knowledge, symptoms of CR, and risk for institutionalization
VA R I A B L E k N ES 95% CI t Q
.............................................................................................................................................................................................................................................
Immediate effects (pre – post)

Burden 98 5930 −0.12 −0.17 to −0.07 −4.51∗∗∗ 74.13
Depression 74 4907 −0.24 −0.33 to −0.15 −5.06∗∗∗ 98.83∗
SWB 27 856 0.31 0.17 to 0.44 4.43∗∗∗ 24.74
Ability/knowledge 48 1813 0.46 0.28 to 0.63 5.20∗∗∗ 110.87∗∗∗
Symptoms of CR 80 2578 −0.17 −0.25 to −0.08 −4.01∗∗∗ 49.20
Institutionalization 29 1936 0.72 0.52 to 1.00 −1.94 70.28∗∗∗
Pretest – follow-up
Burden 27 1949 −0.14 −0.23 to −0.05 −3.03∗∗ 24.44
Depression 21 1917 −0.17 −0.26 to −0.08 −3.62∗∗∗ 9.73
SWB 6 298 0.10 −0.06 to 0.25 1.23 9.77
Ability/knowledge 12 385 0.42 0.20 to 0.65 3.77∗∗∗ 5.37
Symptoms of CR 20 564 −0.11 −0.29 to 0.06 −1.26 16.38
Institutionalization 14 4782 0.92 0.68 to 1.25 −0.55 25.51
k = number of interventions; N = number of treated caregivers; ES = effect size (for all measures except
institutionalization effects were measured as change in standard deviation units, for institutionalization,
effect size was measured in terms of odds ratio); 95% CI = 95% confidence interval of the effect size;
t = test of significance of the mean; Q = test for homogeneity of effect sizes (significant effects indicate
heterogeneity of the effect sizes); SWB = subjective well-being; CR = care receiver.
∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001.
knowledge. Improvements in ability/knowledge were significantly larger than

improvements in CR symptoms. No significant effect of interventions on the risk
of institutionalization appeared. We also tested whether the intervention effects
would become more homogeneous or heterogeneous over time. For depression
we observed a decline in between-study heterogeneity between post-test and
follow-up [F(83, 24) = 2.36, p < 0.01], whereas no change in heterogeneity
appeared for other outcomes.
To assess the practical significance of the results, we used Cohen’s criteria for
evaluating the size of effects and the BESD (Cohen, 1992); immediate effects
on ability/knowledge, depression, and SWB were small and improvements in
burden and CR symptoms were very small. According to the BESD, 53%
of the recipients of the intervention experienced above-average immediate
improvements in caregiver burden, as compared to 47% of the control group
members. Corresponding figures for depression are 56% (intervention) and
44% (controls), for SWB 57.7% (intervention) and 42.3% (controls), for
ability/knowledge 61.2% (intervention) and 38.8% (control), and for symptoms
of the CR 54.2% (intervention) and 45.8% (controls).
We also compared effect sizes for different kinds of interventions.
Because some studies have reported only immediate effects on the risk for
Table 2. Effects of different types of intervention on caregiver and CR outcomes

(pre – post)
.............................................................................................................................................................................................................................................
Psychoeducation
Burden 42 1670 −0.15 −0.25 to −0.04 −2.76∗∗ 22.28
Depression 32 1124 −0.27 −0.41 to −0.13 −3.88∗∗∗ 33.20
SWB 13 389 0.24 0.04 to 0.44 2.35∗ 8.40
Symptoms of CR 33 1131 −0.17 −0.29 to −0.04 −2.66∗∗ 14.48
Institutionalization 4 354 1.09 0.63 to 1.89 0.30 0.60
Psychoeducation – active participation of caregivers
Burden 28 1102 −0.20 −0.32 to −0.07 −3.01∗∗ 11.37
Depression 15 585 −0.36 −0.58 to −0.15 −3.29∗∗∗ 20.77
SWB 9 322 0.21 0.00 to 0.43 −1.98∗ 5.11
Symptoms of CR 18 690 −0.15 −0.31 to −0.00 −1.99∗ 9.57
Institutionalization 2 112 0.99 0.50 to 1.99 −0.01 0.34
Psychoeducation – information provision only
Burden 12 505 −0.03 −0.21 to 0.15 −0.32 7.99
Depression 12 412 −0.10 −0.30 to 0.11 −0.90 6.94
SWB 3 43 0.31 −0.33 to 0.95 0.94 2.80
Ability/knowledge 15 433 0.28 0.08 to 0.47 2.82∗∗ 9.72
Symptoms of CR 13 396 −0.20 −0.41 to 0.01 −1.89 4.64
Cognitive-behavioral therapy
Burden 9 144 −0.36 −0.73 to −0.01 −1.98∗∗ 5.19
Depression 11 230 −0.70 −1.10 to −0.30 −3.45∗∗ 15.42
SWB 1 19 0.37 −0.27 to 1.01 1.13 −
Ability/knowledge 3 70 1.12 −0.23 to 1.62 1.62 11.73∗∗∗
Symptoms of CR 10 182 −0.29 −0.62 to 0.05 −1.68 8.07
Institutionalization 1 19 1.20 −
Counseling/case management
Burden 4 137 −0.50 −0.86 to −0.14 −2.73∗∗∗ 3.18
Depression 3 94 −0.20 −0.63 to 0.23 −0.92 1.69
SWB 3 104 0.42 −0.01 to 0.85 1.93 3.32
Ability/knowledge 3 88 0.43 −0.01 to 0.86 1.94 2.79
Symptoms of CR 4 137 −0.33 −0.69 to 0.02 −1.82 2.61
Institutionalization 0
Support
Burden 4 138 0.01 −0.33 to 0.35 0.07 2.01
Depression 2 38 0.05 −0.68 to 0.78 0.13 0.28
SWB 1 26 2.03 1.36 to 2.70 5.95∗∗∗ −
Ability/knowledge 3 332 0.29 −0.03 to 0.61 1.77 3.16
Symptoms of CR 2 65 0.07 −0.44 to 0.58 0.26 0.02
Institutionalization 3 101 0.89 0.15 to 5.50 −0.12 8.20∗
Training of CR
Burden 6 88 −0.17 −0.60 to 0.27 −0.76 2.00
Depression 4 56 0.01 −0.56 to 0.58 0.03 2.50
SWB 3 41 0.42 −0.18 to 1.01 1.36 0.54
Table 2. Continued.
.............................................................................................................................................................................................................................................
Ability/knowledge 2 44 −0.12 −0.78 to 0.49 −0.37 0.15

Symptoms of CR 8 163 −0.35 −0.67 to −0.02 −2.08∗ 1.64
Institutionalization 0
Respite
Burden 12 781 −0.26 −0.39 to −0.12 −3.73∗∗∗ 10.12
Depression 10 577 −0.12 −0.24 to −0.00 −2.03∗∗ 10.27
SWB 5 251 0.27 0.03 to 0.51 2.19∗ 1.35
Ability/knowledge 2 213 −0.06 −0.58 to 0.46 −0.23 0.44
Symptoms of CR 5 218 −0.08 −0.34 to 0.18 −0.62 0.36
Institutionalization 10 786 0.76 0.44 to 1.32 −0.98 29.78∗∗∗
Multicomponent interventions
Burden 10 2619 −0.03 −0.11 to 0.05 −0.74 6.47
Depression 8 2841 −0.10 −0.26 to 0.06 −1.19 10.69
SWB 2 36 −0.13 −0.68 to 0.41 −0.48 0.29
Ability/knowledge 2 36 0.55 −0.55 to 1.55 0.93 7.55∗
Symptoms of CR 9 381 −0.11 −0.35 to 0.13 −0.90 6.92
Institutionalization 15 5119 0.65 0.44 to 0.98 −2.06∗ 46.59∗∗∗
Multicomponent – structured approaches
Burden 7 257 −0.18 −0.44 to 0.07 −1.40 2.86
Depression 5 253 −0.17 −0.42 to 0.08 −1.31 5.82
Symptoms of CR 8 363 −0.17 −0.41 to 0.08 −1.33 6.89
Institutionalization 12 839 0.51 0.30 to 0.88 −2.42∗ 29.89∗∗
Multicomponent – unstructured approaches
Burden 3 2329 −0.01 −0.10 to 0.07 −0.33 0.79
Depression 3 2329 −0.02 −0.11 to 0.06 −0.56 1.51
Symptoms of CR 1 18 −0.20 −0.67 to 0.27 −0.82 −
Miscellaneous interventions
Burden 11 322 −0.20 −0.42 to 0.02 −1.76 9.85
Depression 6 229 0.12 −0.15 to 0.38 0.86 0.96
SWB 1 19 0.37 −0.09 to 0.83 1.58 −
Ability/knowledge 1 20 0.35 −0.13 to 0.82 0.82 −
Symptoms of CR 8 211 −0.21 −0.48 to 0.06 −1.51 4.01
Institutionalization 1 36 1.81
k = number of interventions; N = number of treated caregivers; ES = effect size (for all measures except
institutionalization effects were measured as change in standard deviation units, for institutionalization,
effect size was measured in terms of odds ratio); 95% CI = 95% confidence interval of the effect size;
t = test of significance of the mean; Q = test for homogeneity of effect sizes (significant effects indicate
heterogeneity of the effect sizes); SWB = subjective well-being; CR = care receiver.
∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001.
institutionalization and others only follow-up effects, we computed average

effects to maximize the number of included studies for this analysis.
As shown in Table 2, psychoeducational interventions had significant effects
on all outcomes except institutionalization. Because Kennet et al. (2000) and
Peacock and Forbes (2003) have suggested that only caregiver education
that involves active participation of the participants would have an effect,
we compared educational interventions with pure information provision to
interventions that included a more active role of caregivers (e.g. role playing).
Only the latter interventions had a significant effect on burden, depression, SWB
and symptoms of the CR, but both groups of interventions caused an increase
in caregiver knowledge.
CBT improved caregiver burden and depression. The effect on depression
was large and the effect on burden small to moderate. The lack of effects on
SWB and ability/knowledge should be interpreted with caution because only
one and three studies, respectively, were available for these variables.
Counseling had significant and moderately sized effects on burden.
Supportive interventions improved SWB, although this effect was only based
on one study. Training of the CR had statistically significant and small effects
only on CR symptoms.
The effects of respite interventions on burden, depression, and SWB were
significant and small. Multicomponent interventions did not show significant
effects on most of the outcomes, but they were significantly related to
delayed institutionalization. The multicomponent category included highly
structured interventions with components shown to be effective in previous
studies and also less structured interventions. Therefore, we further compared
these two subcategories of multicomponent interventions. An effect on the
delay of institutionalization emerged only for the structured multicomponent
interventions. Because only few studies had collected follow-up data, we were
not able to compare the long-term effects of all interventions on all outcome
measures.
Impact of study characteristics

With regard to our final question, we analyzed whether intervention effects would
vary between individual and group settings, and by length of the intervention,
year of publication, caregiver age, caregiver gender, percentage of spousal
caregivers, and study quality. Using weighted multiple linear regression analyses,
we found that longer interventions were more likely to improve depression and
to decrease the risk of institutionalization of the CR (Table 3). Samples with
a higher percentage of women showed more improvements in depression and
knowledge/abilities, a greater delay of institutionalization, but less improvement
in SWB. A greater delay of institutionalization was also found in studies with
a higher percentage of spouses. Improvements in caregiver burden were larger
in more recent studies. Furthermore, higher study quality was associated with
less improvement in caregiver burden. An additional regression analysis with
the individual criteria of the study quality revealed that non-randomized studies
Table 3. Inﬂuence of moderator variables on positive intervention effects (weighted multiple linear regression analysis)
DECREASE OF
IM PROVEM ENT INCREASE INCREASE IM PROVEM ENT RISK FOR
IM PROVEM ENT IN IN IN ABILITY/ IN SYMPTOMS INSTITUTIO-
IN BURDEN DEPRESSION WELL-BEING KNOWLEDGE OF CR N A L I Z AT I O N
VA R I A B L E B β B β B β B β B β B β
.......................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Individual intervention −0.02 −0.04 −0.09 −0.13 −0.34 −0.35 −0.13 −0.10 0.00 0.00 0.10 0.05
(1 = yes, 0 = no)
Number of sessions 0.00 0.04 0.00∗∗ 0.33 0.00 0.16 −0.00 −0.16 −0.00 −0.16 0.01∗∗∗ 0.44
Caregiver age (sample −0.01 −0.18 0.00 0.00 −0.01 −0.26 0.02 0.20 0.01 0.24 −0.02 −0.10
mean)
Percentage female 0.00 0.07 0.01∗∗∗ 0.58 −0.03∗∗ −0.75 0.02∗∗∗ 0.49 0.00 0.16 0.03∗ 0.39
caregivers
Interventions with dementia caregivers

Percentage of spouses 0.00 0.06 0.00 0.05 −0.01 −0.41 −0.00 −0.11 −0.00 −0.12 0.03∗∗∗ 0.69
Year of publication 0.01∗ 0.26 0.01 0.16 0.00 0.06 −0.02 −0.21 0.01 0.08 0.02 0.12
Study quality (1 = yes, −0.12∗ −0.38 −0.04 −0.10 −0.02 −0.05 0.11 0.11 −0.11 −0.26 0.21 0.29
0 = no)
(Constant) −27.39 −24.86 5.63 46.72 −10.65 41.93∗∗∗
R2 0.25 0.32 0.42 0.29 0.11 0.39
CR = care receiver; B/β = unstandardized (standardized) regression coefficient; R2 = explained variance. Positive regression coefficients indicate that high levels
of the independent variable increase positive intervention effects.
∗ p < 0.05, ∗∗ p < 0.01, ∗∗∗ p < 0.001.
589
(B = 0.23, p < 0.05), studies with small sample size (B = 0.25, p < 0.05), and
with higher dropout rates (B = 0.20, p < 0.05) had larger effect sizes. We also
found that more recent studies indeed had a higher quality (r = 0.20, p < 0.05).
Discussion
Caregiver interventions have positive immediate effects on dementia caregivers’
burden, depression, SWB, ability/knowledge and CR symptoms, but only
structured multicomponent analyses decrease the risk for institutionalization.
However, the effect-sizes are usually small and fewer significant effects appear
at follow-up. Psychoeducational interventions have the broadest effects, but
only if they call for active participation. Effects of other interventions are
mostly domain specific. We found moderator effects of study characteristics and
sample characteristics. Our discussion was organized according to the research
questions.
Statistical efficacy and practical importance of interventions

Our meta-analysis replicates the results of Brodaty et al. (2003) on small-to-
medium effect size for caregiver knowledge/abilities and psychological health of
caregivers with a larger sample. However, contrary to Acton and Kang (2001)
and Brodaty et al. (2003), we found a significant, albeit small, effect on caregiver
burden. In our meta-analysis more recent studies have stronger effects on burden.
Thus, the positive average effect on burden is probably due to the inclusion of
recent and improved studies.
Because even the smallest effects are significant in very large samples, we
must evaluate the practical and clinical significance of our results. Schulz et al.
(2002) have suggested four criteria of practical significance: (1) effects on
symptomatology and (2) quality of life of caregivers/CRs, (3) social significance,
and (4) acceptability to clients (social validity). Because high levels of caregiver
satisfaction have been found for otherwise ineffective interventions (e.g. Haley
et al., 1987), we did not analyze client satisfaction. However, according to the
BESD, 56–58% of the participants of the intervention showed above-average
improvement in caregiver depression and SWB, as compared to 42–44% of
control group members. Thus the results are meaningful in practice, although
greater improvements are desirable.
Because of the high costs of long-term care facilities, a prevention or delay of
institutionalization has high social significance (Kinosian et al., 2000). However,
only one type of intervention has such an effect – structured multicomponent
interventions. These interventions are more intense and provide a larger variety
of services to caregivers. Reasons for the lack of effects on the risk for
institutionalization for other intervention types may include the facts that:
(1) some interventions prepare the caregivers for institutionalizing the CR
(placement planning is a subject of many respite programs), (2) the dose of
many interventions is too low, and (3) even the best intervention has only a
limited effect on some stressors, such as the progression of AD.
Another important criterion of practical significance is the maintenance of
effects after the end of the intervention. We found that effects on caregiver
burden, depression and ability/knowledge persisted for about 11 months whereas
effects on SWB and symptoms of the CR did not. The lack of long-term
effects on SWB may be due to the small number of studies focusing on this
variable, or to the fact that aspects of SWB, such as positive affect, show large
situational variability. Intervention effects on symptoms of the CR may not
last very long because the increasing deterioration of patients with dementia
counteracts intervention-related gains over time.
Comparisons of different interventions revealed that caregiver education had
an effect on most outcome variables. However, in order to be effective in reducing
caregiver burden and depression, these interventions require active participation
of the caregivers, such as role playing or applying the attained knowledge and
abilities during homework. Merely providing information in a classroom format
and very limited time for discussion is insufficient for reducing stressors and
influencing caregiver burden and depression.
With regard to other interventions, our results indicate that one approach does
not fit all outcomes. For example, the effects of CBT were specific to burden
and depression, and training of the CR led to improvement in their symptoms.
Thus, interventions need to be tailored to the specific goals of the program.
Although the effects of psychoeducational interventions were domain unspecific,
the observed heterogeneity of effects on depression and on ability/knowledge
indicates that some of these interventions were more effective than others.
However, we cannot rule out an alternative interpretation, namely that the
heterogeneity of results may reflect differences in the pretest level of the variables;
if few caregivers report depressive symptoms at T1 , floor effects preclude much
intervention-based improvement.
Impact of caregiver and study characteristics

We observed that in studies with a higher proportion of women,
intervention effects on depressive symptoms and ability/knowledge and delay
of institutionalization were stronger, but effects on SWB were weaker. Female
caregivers are more depressed than male caregivers whereas gender differences
in positive SWB are small (Pinquart and Sörensen, 2006). Men are less likely to
show a decline in depression probably because, regardless of the intervention,
they are less likely to admit negative feelings. It has been suggested that male
caregivers would be more willing to seek social support and to relinquish the
caregiver role (Stoller, 1990). Thus, they may be more likely to respond to the
intervention with positive feelings, rather than guilt, and they may be more likely
to use interventions as assistance in the decision to institutionalize the CR. The
greater improvement in ability/knowledge in female caregivers may be explained
by the fact that male caregivers are, on average, more knowledgeable on the
subject of dementia (Graham et al., 1997), and therefore need less additional
information. Because spouse caregivers are often frail themselves, use of services
has a larger effect on their ability to delay institutionalization of their CRs.
Finally, we found an effect of age on improvement in ability/knowledge. This
may indicate that older caregivers have less access to information about dementia
and dementia care in their daily lives, possibly because they have less access to
the internet.
Consistent with previous studies (e.g. Brodaty et al., 2003), we found stronger
effects for longer interventions. Lasting changes in the lives of the caregivers were
more likely to prevent or delay institutionalization.
The effect of study quality on change in caregiver burden indicates that non-
randomized studies may overestimate intervention effects, probably because
highly distressed caregivers are more likely to be assigned to the intervention
condition. Greater improvements in burden in studies with high dropout rates
indicate that caregivers who perceive no intervention effect often do not complete
the study. Finally, the smaller effect of interventions with small samples is due
to the application of a statistical correction for overestimation of effects in small
samples (Lipsey and Wilson, 2001).
Finally, similar to Brodaty et al. (2003), we found empirical evidence for
greater improvements in caregiver burden in more recent studies. Thus, recent
interventions probably used more efficacious strategies, such as ensuring active
participation of the caregivers. Nonetheless, the increase in effect sizes over time
should not be overinterpreted, given that the year of publication explained less
than 5% of the variance in improvement in caregiver burden and no similar
effects were observed on the other outcomes.
Conclusions
We conclude from the present study, first, that interventions with caregivers
for patients with dementia have, on average, small but meaningful effects on
reducing burden and depressive symptoms, and increasing ability/knowledge and
SWB, and, for a subset of interventions, reducing the risk for institutionalization.
Given the small magnitude of change, however, there is continued need for
improvement in the quality of interventions. As it is clear that more structured
and more intensive interventions, especially ones that require active participation
of the caregiver, are more effective than less structured interventions, one
approach to improving interventions might be to promote more active
participation of caregivers in applying theoretical knowledge. Furthermore, we
recommend that clinicians decide in advance whether specific or broad outcomes
are desired because each goal may require different intervention techniques.
Second, because multicomponent interventions had only few effects, future
research is needed regarding how the complexity of interventions relates to
treatment effects and which combination would have the largest effects. For
example, it would be useful to test whether a combination of effective individual
interventions, such as education or CBT with respite, would produce an
effective multicomponent intervention or whether simpler interventions with
fewer components are better received and therefore more effective. Third, in
order to assess long-term consequences of interventions, we need follow-ups over
longer time intervals. Fourth, more long-term follow-up measures are needed on
positive aspects and outcomes of caregiving, for example on SWB and finding
benefits in the caregiving role. Because positive aspects of caregiving may buffer
the stressors (Mausbach et al., 2004), there needs to be a stronger focus on
understanding these factors in future longitudinal analyses. Furthermore, the
short- and long-term effects of interventions on ethnic minority caregivers have
received very little attention and are recommended for future studies. Fifth,
studies are recommended about individual differences in caregivers’ response to
particular intervention strategies, for example depending on specific stressors,
resources, expectations, or personality traits. Finally, studies on mediators of
intervention effects are needed. For example, do observed effects result from a
change in caregivers’ beliefs, particular coping strategies, or a reduction in the
amount of care provision?
Conﬂict of interest declaration

None.
Description of author’s roles

M.P. conducted the literature search and the statistical computations. Both M.P.
and S.S. coded the studies and wrote the paper.
Acknowledgments
S.S. has received support through a career development award (K01 AG022072)
from the National Institute of Aging.
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International Psychogeriatrics (2006), 18:4, 577–595

C 2006 International Psychogeriatric Association

Helping caregivers of persons with dementia:

Martin Pinquart1 and Silvia Sörensen2

Background: In recent years, many different forms of interventions for caregivers

Methods: Meta-analysis was used to integrate the results of 127 intervention

Results: Interventions had, on average, significant but small effects on bur-

Conclusions: Because most interventions have domain-specific outcomes,

Key words: family caregivers, dementia, interventions, outcomes, meta-analysis

Influences of study characteristics

GROUP SETTING V E R S U S INDIVIDUAL SETTING

(1) the CR had dementia;

(3) one of the following outcomes was reported: caregiver burden,

Statistical integration of the findings

1. We computed effect sizes d for each study; d represents the difference

To compare the risk of institutionalization in the intervention and control

1. ORs were computed for each study.

Effects of caregiver interventions

Table 1. Intervention effects on caregiver burden, depression, SWB, abilities/

Immediate effects (pre – post)

knowledge. Improvements in ability/knowledge were significantly larger than

Table 2. Effects of different types of intervention on caregiver and CR outcomes

Ability/knowledge 2 44 −0.12 −0.78 to 0.49 −0.37 0.15

institutionalization and others only follow-up effects, we computed average

Impact of study characteristics

Interventions with dementia caregivers

Statistical efficacy and practical importance of interventions

Impact of caregiver and study characteristics

Conﬂict of interest declaration

Description of author’s roles

Pinquart, M. and Sörensen, S. (2006). Gender differences in caregiver experiences: an

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