Evaluation of Technology-Based Interventions for Informal Caregivers of Patients With Dementia—A Meta-Analysis of Randomized Controlled Trials

Accepted Manuscript

Evaluation of technology-based interventions for informal caregivers of patients with dementia – A meta-analysis of randomized controlled trials Friederike Deeken M.Sc. , Anna Rezo M.Sc. , Matthias Hinz M.Sc. , Robert Discher B.Sc. , Michael A. Rapp M.D., Ph.D. PII: DOI: Reference:

S1064-7481(18)30587-6 https://doi.org/10.1016/j.jagp.2018.12.003 AMGP 1141

To appear in:

The American Journal of Geriatric Psychiatry

Received date: Revised date: Accepted date:

27 June 2018 14 November 2018 3 December 2018

Please cite this article as: Friederike Deeken M.Sc. , Anna Rezo M.Sc. , Matthias Hinz M.Sc. , Robert Discher B.Sc. , Michael A. Rapp M.D., Ph.D. , Evaluation of technology-based interventions for informal caregivers of patients with dementia – A meta-analysis of randomized controlled trials, The American Journal of Geriatric Psychiatry (2018), doi: https://doi.org/10.1016/j.jagp.2018.12.003

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Highlights

1) Effective and easily accessible interventions for caregivers of people with dementia (PWD)

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are needed. The aim of this meta-analysis is to evaluate the efficacy of technology-based interventions for informal caregivers of PWD for the two outcome domains depression and burden.

2) Technology-based interventions show a small but significant effect on the outcomes

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depression and burden in informal caregivers. The strongest effects were found for

interventions with a combination of telephone and computer or telephone and DVD/video. 3) Technology-based interventions have the potential to support caregivers of PWD. They are a

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promising alternative to traditional services.

Evaluation of technology-based interventions for informal caregivers of patients with dementia –

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A meta-analysis of randomized controlled trials

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Friederike Deeken1,2, M.Sc., Anna Rezo1,2, M.Sc., Matthias Hinz 1, M.Sc., Robert Discher1, B.Sc., Michael A. Rapp1, M.D., Ph.D. Social and Preventive Medicine, University of Potsdam, Potsdam, Germany

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National Graduate College “Optimization Strategies in Dementia”, Karl and Veronica Carstens-

Foundation, Essen, Germany

Corresponding author: Michael A. Rapp, MD, PhD 1

ACCEPTED MANUSCRIPT Social and Preventive Medicine University of Potsdam Am Neuen Palais 10 D-14469 Potsdam Germany

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Phone: +49 331 977 4185 Fax: +49 331 977

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Email: [email protected]

Key words: caregiver, dementia, technology, meta-analysis Conflict of interest: M.A. Rapp received a honorarium from Dr. Willmar Schwabe GmbH & Co. KG for

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scientific writing, and consultant fees from Lilly, Inc..

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Acknowledgments: This research work was funded by the Karl and Veronica Carstens-Foundation as

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part of the National Graduate Programme “Optimization strategies in Dementia – OptiDem”.

Disclosure: This work was performed in partial fulfillment of the requirements for obtaining the

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degree “Dr. phil.” for author FD at the Faculty of Human Sciences of the University of Potsdam.

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ACCEPTED MANUSCRIPT Abstract Objective: To estimate the efficacy of technology-based interventions for informal caregivers of people with dementia (PWD). Method: PubMed, PsycINFO, and Cochrane Library databases were searched with no restrictions in language or publication date in August 2018. Two independent reviewers identified 33 eligible

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randomized controlled trials (RCTs) conducting a technology-based intervention for informal carers of PWD. Meta-analyses for the outcome measures caregiver depression and caregiver burden were conducted with subgroup-analyses according to mode of delivery (telephone, computer/web-based, combined interventions). To assess methodological quality, the Cochrane “risk of bias”-assessment

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was rated.

Results: Meta-analyses revealed a small but significant post-intervention effect of technology-based interventions for caregiver depression as well as for caregiver burden. Combined interventions showed the strongest effects.

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Conclusions: Technology-based interventions have the potential to support informal caregivers of

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PWD. Due to advantages such as high flexibility and availability, technology-based interventions provide a promising alternative in comparison with “traditional services”, e.g. for people living in

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rural areas. More high quality RCTs for specific caregiver groups are needed.

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ACCEPTED MANUSCRIPT Introduction Relevance of the topic Beside the strong interest in interventions for people with dementia (PWD), treatments to maintain and improve the physical and mental health of caregivers of PWD have increasingly become a focus of attention.

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Caregivers of PWD are confronted with multiple challenges. As the disease progresses, PWD may need help for most activities of daily living, and to be monitored by the caregiver to ensure his or her safety (1). This leads to high responsibility and less free time for the caregiver to take care of him- or herself. A meta-review (2) of systematic reviews focusing on stress, coping, and interventions in

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dementia and dementia caregiving came to the conclusion that being a caregiver for a PWD is a risk factor for both psychological stress and poor physical health.

Depression and burden are the two most researched constructs in terms of caregiving outcomes and are widely used among studies on informal caregivers of PWD. According to Schulz et al. (3), these

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outcomes are meaningful indicators of caregiver distress. Depression shows multiple associations

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with potential adverse consequences for caregivers such as functional decline or mortality (4). Many studies investigated the association between being a caregiver of a PWD and symptoms of

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depression and found an increased risk for caregivers (5). Sallim et al. (6) found an aggregate prevalence of 43.6% for depression among caregivers of people with Alzheimer's disease. The

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outcome burden is associated with lower perceived health in family caregivers (7) and an increased

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risk of institutionalization of the PWD (8). The number of families affected by dementia will continuously increase and therefore the need for support for family caregivers is crucial, also in order to reduce burden to the health system. Institutionalization of a PWD is the largest component when it comes to costs of caring (9). There is an urgent need for effective and easily accessible interventions for caregivers of PWD, caused by the growing number of PWD, the rising costs of care, and the difficulties caregivers of PWD are confronted with. 4

ACCEPTED MANUSCRIPT Advantages of technology-based interventions over traditional interventions The use of technology-based interventions, including computers, smartphones with app-based technologies, web-based interventions, and telephones (cell phones as well as landline), is a rapidly growing field, for both young and elderly people. A report from the Pew Research Center in 2014 showed that in 2012, for the first time more than half of the older adults (defined as 65 years and

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older) in the survey were internet users and also the number of older adults using a cell phone was increasing to 77% (10). Besides using the internet for communication with friends and family,

entertainment or searching Internet web sites for information, a large part of the older internet users is searching for health and medical information online (11). Nevertheless, older adults are

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more likely to use those technologies that have been accessible for a longer time, e.g. telephone (12).

There are several potential advantages of technology-based interventions. Compared to face-to-face delivery interventions, an advantage of technology-based interventions is that they are always

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available and accessible, especially for people living in rural areas (13) or with limited access to

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“traditional services” like psychotherapy or self-help groups. In descriptive studies it was found that almost half of all caregivers living in rural communities do not receive assistance for reasons such as

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not being aware that specific programs exist or because services are too geographically distant to be helpful (14). Because of their flexibility, technology-based interventions have the potential to reach

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caregivers with limited temporal and financial resources who are especially prone to develop

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caregiver depression (15). In addition, technology-based interventions can combine different approaches such as psychoeducation, supportive approaches, and relaxation training in a costeffective way, which can be seen as an advantage given that multicomponent interventions have shown superior efficacy for the treatment of caregiver burden (16). Other advantages for computermediated communication are anonymity, the ability to personalize use, and the ease of connecting with other caregivers in similar situations (17). Previous reviews and meta-analyses 5

ACCEPTED MANUSCRIPT Up to now, several reviews have investigated the use of new technologies in caregiving contexts (e.g. (18, 19)). However, much of the research has been of qualitative nature and to our knowledge, there is no quantitative meta-analysis concerning this topic until now. A systematic review of the effect of telephone, internet, or combined support for carers of people living with Alzheimer's, vascular, or mixed dementia in the community from Jackson et al. (20) with 22 studies, including

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randomized controlled trials, non-randomized controlled trials, quasi-experimental, and pre-post studies, highlighted that combined interventions yielded more positive outcomes than telephone or internet interventions alone.

The importance of the topic corresponds to the rising number of published articles dealing with

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technology-based interventions for informal caregivers of PWD. A systematic review on computer and telephone delivered interventions for caregivers of PWD suggested that the number of publications increases by 13% each year (21). Aim of the article

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The main object of this article was to conduct a meta-analysis to evaluate the efficacy of technology-

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based interventions for informal caregivers of PWD living in the community related to two outcome domains separately (depression and burden). Subgroup analyses were conducted separately for the

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type of intervention, namely computer/web-based interventions, telephone interventions, and the combination of telephone and computer or DVD. Given that older adults in this cohort may be less

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conversant with the use of computer and internet, and more familiar with telephone use, or benefit

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more from personal contacts as provided via telephone, we expected different effects of the various modalities with telephone interventions showing larger effect sizes than computer/web-based interventions.

Following findings that combined interventions provide more favorable outcomes for caregivers of PWD, we expected this subgroup to have the largest effect sizes. Moreover, we analyzed mean baseline depression scores of the caregivers to explore whether degree of depressivity has an influence on the effectiveness of the intervention. Baseline values of 6

ACCEPTED MANUSCRIPT the depression scores could potentially confound intervention effects, in that caregivers with higher depression scores at baseline could show larger treatment gains compared to caregivers with lower depression scores at baseline. In their review, Zarit and Femia (22) proposed a potential set of moderators which can influence the effectiveness of interventions for caregivers of PWD. One explanation for small intervention effects was that treatments could only be successful in reducing

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symptoms (e.g. depression) in caregivers if they present with a sizeable symptom load in the first place. Therefore, we expected higher effect sizes in studies with higher mean depression baseline scores. Methods

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Inclusion and exclusion criteria

Studies included in the meta-analysis had to meet the following criteria: (1) Randomized controlled trial as study design.

(2) Participants were informal, un-paid caregivers of a PWD living in their own home.

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(3) The intervention had to be mainly directed to the caregiver; studies with an intervention

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solely aimed at the patient were excluded. (4) The intervention was technology-based, including web-based, telephone, DVD/video, and

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computer-mediated interventions. The intervention did not need to be exclusively technology-based but it should be the main part of the intervention.

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(5) The study had to use at least one quantitative measurement to estimate caregiver

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burden or depression. Studies examining the feasibility, user friendliness, or convenience of an intervention only were excluded. (6) Comparators could be usual care, a non-technology-based intervention, a second technology-based intervention, which was used as a comparison or any other type of control intervention. Search method

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ACCEPTED MANUSCRIPT PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] guidelines were followed (23) and the study protocol was registered at the International Prospective Register of Systematic Review, PROSPERO, on the December 12, 2016 (Registration: CRD42017053959). For the systematic literature search, the databases PubMed and PsycINFO were used. The database Cochrane Library was added as a third database after protocol for cross validation. The last search

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was conducted on August 7, 2018 (see document, SDC_1_Search Terms, where search terms are described in detail). As an additional search strategy, the reference lists of relevant articles were reviewed, including systematic reviews that we found. Study selection

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One author (FD) conducted the title and abstract scan. Full-texts were then reviewed by two

independent authors to examine if the studies fulfilled inclusion criteria (FD and MH). Discrepancies between the two reviewers were discussed and a third reviewer (MR) was asked. If different articles were based on the same study just showing different aspects of the same intervention, they were

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treated as one study. A preliminary narrative review of the data collected, detailing the selection

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process, has been submitted elsewhere (Deeken F, Rezo A, Hinz M, Discher R, Rapp MA: Evaluation von technologie-basierten Interventionen für pflegende Angehörige von Personen mit Demenz: Ein

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narratives Review, in Nicht-pharmakologische Präventions-, Therapie- und Versorgungsansätze bei Demenz – Ergebnisse der Übersichtsarbeiten des Graduiertenkollegs OptiDem. Edited by Gräßel E,

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Pendergrass A. Essen, KVC Verlag, submitted).

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Study characteristics

Study characteristics, such as participants, intervention, control group, and principal findings, were extracted from eligible studies (see Table 1).

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Risk of bias assessment 8

ACCEPTED MANUSCRIPT The risk of bias assessment was conducted by two independent reviewers (FD and RD) using the Cochrane Risk of Bias tool (24). In case of disagreements, a third author (MR) was consulted. Statistical analysis The first reviewer (FD) extracted the data from the studies needed for the RevMan 5.3 (25). If more than one follow-up occasion was available, we used the first time point after the intervention to

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examine the direct effect of the intervention. A second reviewer (AR) verified the data. Data then were entered into Review Manager 5.3 for analysis. Where data was not reported or could not be calculated from given data, studies were described narratively.

Meta-analyses were performed using the computer software program Review Manager 5.3. Random

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effects model was chosen to meet the expected heterogeneity due to differences in intervention, control group, and population (26). Effect sizes were calculated for standardized mean differences (SMD (Hedges` adjusted g) with 95% confidence intervals (CIs)) between intervention and control group due to the different measurements used across the trials. The standardized mean differences

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were coded so that negative values meant a greater improvement in the treatment group than in

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the control group.

Analyses were performed separately for the two outcome domains (depression and burden) as well

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as for differences in the type of intervention (telephone, web-based/computer, or combined). In the main meta-analysis, active control group studies were preferred over passive control groups. To

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examine whether this effect differs when only passive control group studies were taken into account

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a subgroup analysis was conducted. Heterogeneity

I² was used to describe the proportion of total variation in study estimates that is due to statistical heterogeneity (27). An I² estimate of 25% or less was interpreted as low (28). Correlational Analyses To test the influence of differences in baseline depression scores on the effectiveness of the interventions, correlations between baseline values (as percentage of the total score) and 9

ACCEPTED MANUSCRIPT standardized mean differences were calculated for all included studies and for studies with a baseline depression score over the clinical cut-off value for (mild) depression separately. Results Study selection The initial search resulted in a total of 603 articles, and a total of four studies was identified through

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other sources, specifically, manual searches in the lists of references from empirical studies, and systematic reviews (see Figure 1). After eliminating duplicates, 385 articles remained for title and abstract scan. 80 articles were identified as relevant or possibly relevant and were full text reviewed by two independent authors (FD and MH). The 210 articles found using the Cochrane Library led only

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to the inclusion of one additional study in the meta-analysis (29).

For four studies (30–33), the provided data could not be converted due to missing data (mean and standard deviation). For these reasons, these studies could be only described narratively but were

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not included in the quantitative meta-analysis.

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A total of 33 studies (34–39, 32, 31, 40–56, 33, 57–60, 29, 30, 61) with overall 3313 participants was included in the qualitative synthesis and 29 (54, 34–53, 55–61, 29) studies with full (pre-post) data

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sets of 2672 participants were included in the meta-analysis.

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Study Participants

The mean age of the participants was between 46 and 71 years, with an overall mean age of around 62 years. Age of the participants ranged between 18 and the mid-eighties, but not all studies reported age-ranges. Except for two studies (46, 53), the participants were predominantly female caregivers, and in four studies (40, 42, 56, 59), only female caregivers were included. In one study (46), the intervention was addressed to male caregivers only. The sample size ranged from eleven (32) to 299 (35). 10

ACCEPTED MANUSCRIPT Intervention characteristics The interventions in the trials were all technology based, comprising telephone, web-based interventions, DVD/video, or a combination of telephone and computer or DVD/video. Telephone interventions In eleven studies, a telephone intervention was conducted. In terms of delivery, in three studies

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telephone support groups were implemented (42, 47, 51). In two of these studies (42, 51), telephone group meetings of five to six caregivers headed by a trained social worker or group leader were conducted and topics like coping strategies and behavior management were discussed. In one study (47), four to five caregivers in a peer telephone network called each other in a rotating pattern

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for supportive conversations.

Five studies conducted individual sessions (34, 41, 43, 58, 61), with treatments of behavioral activation (e.g. pleasant event scheduling), psychoeducation, coping strategies, supportive approaches, or cognitive-behavioral therapy. Two studies consisting of group and individual sessions

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(33, 38) conducted a telephone-based cognitive behavioral therapy. One study (31) used a

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telephone-based collaborative care management program with multiple modules such as communication skills, stress management, and coping skills.

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Computer/web-based interventions

Eleven studies investigated a computer/web-based intervention. These studies were delivered via

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online platform (48), application (52), internet course (44), or web-based program (32, 35, 36, 39,

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53, 55, 29, 30). Different modules like psychoeducation, relaxation training, daily tasks, and communication skills were offered for caregivers. In eight studies (35, 36, 48, 52, 53, 55, 29, 30), the intervention was personalized for the user. In one study (44), caregivers received individualized feedback from a trained coach. In seven interventions, videos to specific topics were available for the caregiver (35, 36, 39, 44, 52, 30, 48). Contact to other caregivers through private mail and a forum (55), via Facebook and LinkedIn (48) or another social network section (52, 53) was implemented in four trials. 11

ACCEPTED MANUSCRIPT In one study, the conducted online training workshop was not described in detail (32), but it was mentioned that participants had workshops for gaining knowledge and skills and got information about the use of online resources. Combined interventions In ten studies, a combined intervention of telephone and computer (37, 45, 50), or telephone and

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DVD/video (40, 46, 49, 56, 57, 59, 60) was found. Two studies used a computer-telephone-integrated system for calls, conferences and information (37, 45) and in one study a computer-mediated automatic voice response system was implemented (50).

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In trials with telephone calls and video sessions the treatments supplemented each other by dealing with the same issue such as behavioral strategies (e.g. activation, management of disruptive behaviors, relaxation training) (40, 46, 59), psychoeducation (49, 57, 60), or sportive exercises (56). DVD/video

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One study used only DVDs as treatment (54).

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In most of the studies, additionally, a workbook or manual was provided for the participants. Treatment duration and control groups

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The duration of the interventions varied from 30 days (35) to twelve month (e.g. (55)). As control intervention, 17 trials (31, 33, 35–37, 42–44, 48, 50–53, 56, 58, 29, 61) used a passive

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control such as waiting list, usual care, no intervention, or the participants in the control group got

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printed or online information without any further intervention. 13 trials (54, 32, 34, 38–41, 46, 47, 49, 55, 30, 59) used an active control group such as educational information, face-to-face therapy, or a second technology-based intervention and three studies (45, 57, 60) had both a passive and an active control group. Outcomes Depressive symptoms were most often measured with the Center for Epidemiological Studies Depression Scale (CES-D) (62, 63) (studies (54, 32–35, 37–39, 41–45, 50–52, 55, 56, 29, 60, 61)), with 12

ACCEPTED MANUSCRIPT the Beck Depression Inventory (BDI) (64) in four studies (36, 40, 53, 57) (data were reported only in three studies), with the Geriatric Depression Scale (GDS) (65), the Patient Health Questionnaire (PHQ) (66), and the Brief Symptom Inventory (BSI) (67) in one study each (58, 30, 59). To asses caregiver burden, the Zarit Burden Interview (ZBI) (68) was used in twelve studies (32, 31, 36, 41, 42, 47, 49, 51, 53, 58, 29, 30) and the original or revised Memory and Behavior Problem Scale

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(RMBPC) (69) or subscales of this questionnaire were used in 17 studies (54, 31, 36–41, 44–47, 50, 51, 56, 58, 60), but in three studies the data of the RMBPC were not reported in the article. Other scales to measure burden were the Impact of caregiver scale (70) (study (55)), the Caregiver Strain Instrument (71) (study (35)), the subscale “subjective burden” of the Caregiver Appraisal Inventory

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(CAI) (72) (studies (33, 38, 59)), a visual analogue scale (ranging from 0 to 100) (61) and in one study burden was assessed with only one question (48). Efficacy of interventions

Meta-analysis was conducted for the outcome depression with 24 studies (54, 34–45, 50–52, 55–58)

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(29, 59–61) and burden with 22 studies (54, 35–42, 46–51, 53, 55, 56, 58, 29, 60, 61) separately.

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Depression

The pooled analysis for the 24 studies with 2453 participants showed a small effect in favor of the

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intervention on caregiver depression (SMD = -0.20; 95% confidence interval (CI) -0.31 to -0.10; I² = 36%; Figure 2). The highest effect size was shown for combined interventions (SMD = -0.31; 95%

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confidence interval (CI) -0.53 to -0.10; I² = 41%). A significant effect size was found also for

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telephone interventions (SMD = -0.24; 95% CI –0.40 to -0.08; I² = 26%). The effect size for the subgroup “DVD” (one study only) was not significant (SMD = -0.33; 95% CI -0.81 to 0.14; I² = not applicable). Computer/web-based interventions showed the smallest effect size (SMD = -0.06; 95% CI -0.24 to 0.13; I² = 38%). In the main meta-analysis with all included studies, we preferred active control groups over passive control groups. We then conducted a subgroup analysis for passive control groups only. 15 studies which provided data for a passive control group were included (29, 35–37, 42–45, 50–52, 56–58, 61). 13

ACCEPTED MANUSCRIPT The overall pooled effect was similar to the main meta-analysis (SMD = -0.20; 95% CI -0.32 to -0.07; I² = 69%). Burden 22 studies with 2101 participants were included in the pooled analysis on caregiver burden. A significant, albeit small effect could be shown (SMD = -0.13; 95% CI -0.24 to -0.02; I² = 32%; Figure 3).

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Similar to the results for the outcome depression, for the outcome caregiver burden, combined interventions showed the highest effect size (SMD = -0.20; 95% CI -0.48 to 0.09; I² = 52%), whereas computer/web-based interventions showed the smallest effect size (SMD = -0.03; 95% CI -0.21 to 0.14; I² = 21). Telephone interventions showed a small, but nonsignificant effect in favor of the

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intervention (SMD = -0.10; 95% CI -0.24 to 0.03; I² = 0%). One study was included in the subgroup “DVD/video” (SMD = -0.58; 95% CI -1.06 to -0.10; I² = not applicable).

For the outcome burden, twelve studies could be included in the subgroup analysis for passive control groups (29, 35–37, 48, 50, 51, 53, 42, 56, 58, 61). The effect did not reach statistical

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significance (SMD = -0.07; 95% confidence interval (CI) -0.22 to 0.08; I² = 37%).

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Risk of Bias of the included studies

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A summary of the risk of bias assessment is shown in Figure 4 (see Figure, SDC_2_ Risk of Bias, which offers a more detailed table of the risk of bias for each included study). A randomized allocation was conducted in all included studies, but only 14 studies described the specific randomization method, such as software or computerized random-number generators. The blinding of the participants was only described in two studies (34, 44) and the risk was rated as low. For six studies, a protocol was available and all relevant variables were named in the protocol. Overall, the risk of bias was not rated as high and no studies were excluded from the analyses based 14

ACCEPTED MANUSCRIPT on risk-of-bias assessments. However, it should be noted that there was a lack of clear reporting in many trials which makes it difficult to determine the overall quality of the studies.

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Correlational Analyses Referring to all studies that collected depression scores, no significant correlation could be found (r=-.23, ns) between depression baseline values and the standardized mean differences associated with the intervention. Including only studies with a baseline value over the defined cut-off for having

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at least mild depression (43, 44, 55, 45, 39, 51, 52, 40, 41, 61), a significant negative correlation was shown (r=-.89, p<0.05). Discussion

The current meta-analysis identified 33 randomized controlled trials reporting technology-based

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interventions for informal caregivers of PWD. We found significant but small effects on caregiver

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depression and caregiver burden for caregivers receiving a technology-based intervention. In the subgroup analyses concerning different delivery modes for the intervention, differences could be

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found. The highest effect sizes were evident for combined interventions and the smallest effect sizes for computer/web-based interventions.

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The results for the outcome depression indicate evidence that technology-based interventions can

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help to improve the mental health of caregivers of PWD. Our findings are comparable to a prior meta-analysis by Scott et al. (73) who found a small significant post-intervention effect of pure technology-based cognitive behavioral therapy interventions for depression equivalent to face-toface interventions. Similar to Jackson et al. (20), we found the strongest effect for combined interventions. The meta-analysis concerning caregiver burden showed a significant, albeit small effect for the 22 included trials. Findings regarding caregiver burden are not consistent in the literature. As in this 15

ACCEPTED MANUSCRIPT meta-analysis, Pinquart and Sörensen (74) found a significant small effect for caregiver burden. On the contrary, Acton and Kang (75) found no overall effect for burden in their meta-analysis concerning interventions for reducing the burden of caregivers of PWD. They argued that a possible explanation for this result might be that burden is a global and multidimensional concept, showing a lack of conceptual clarity with both subjective and objective qualities. Instruments measuring

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burden often not differ clearly between objective burden and subjective feelings about the impact of caregiving and this could lead to conflicting or unclear results. The studies included in this metaanalysis used different instruments to measure caregiver burden. The ZBI and the (R)MBPC were the most frequently used instruments. The ZBI was developed to measure subjective burden whereas

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the (R)MBPC measures the impact of problematic behaviors in dementia on the caregiver. Seng et al. (76) showed that the ZBI and the (R)MBPC are strongly correlated. Similarly to a Cochrane review concerning telephone counselling for informal carers of PWD (77), we subsumed the (R)MBPC under the outcome burden. However, other authors have classified the (R)MBPC as problematic behavior

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(78).

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An explanation for the very small effect that we found is that dementia is a progressively deteriorating and ultimately terminal disease. Feelings of grief, loss, and burden in caregivers may

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not be altered much even though interventions are perceived as helpful. Influence of baseline depression scores

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In the correlational analysis of all included studies, no significant correlation could be found.

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However, when we analyzed only studies with depression baseline values over the defined cut-off for at least mild depression, the correlation between baseline values of depression and the standardized mean differences was significantly negative. This result suggests that studies with higher mean caregiver depression baseline scores show smaller effect sizes. Despite this general finding, no conclusions with respect to individual differences in caregiver depression can be drawn. In contrast, in some of the included studies, the authors discussed lower baseline scores as a reason

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ACCEPTED MANUSCRIPT for smaller effects sizes, leaving an inconclusive pattern with respect to the influence of baseline depression on treatment outcomes. Gallagher-Thompson et al. (54) discuss low baseline CES-D scores as an explanation for the absence of a significant decrease in depressive symptoms in the intervention group. Furthermore, Mahoney et al. (50) stated in their discussion that because of the low baseline values they experienced floor

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effects and a meaningful decline of the values would be very unlikely. Future trials should consider baseline status of caregivers by developing interventions adapted to the needs of caregivers with more or less severe depression. Reasons for small effects

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In the subgroup analyses of computer/web-based interventions, we found the smallest effect for both outcomes, depression and burden, compared to the other subgroups. It is possible that the attitude of the caregiver toward the delivery medium influences its effectiveness or that caregivers benefit more from personal contact as provided in phone-based interventions. Until now, in terms of

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communication technologies, telephone communication is the most commonly adopted method

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among older adults (79). When it comes to the use of personal computers, middle-aged and older adults have been shown to have lower self-efficacy and increased anxiety compared to younger

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adults, which may affect the likelihood of the general use of this technology (80). However, also among older adults, differences in various age cohorts can be shown. With increasing age, the use

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and therefore the experience with the internet and smart phones is decreasing (10), which could

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make it more difficult to implement technology-based interventions in these cohorts. For subsequent generations, the use of computer, smartphones, and tablets will be more integrated in everyday life. Especially computer and web-based interventions offer practical assistance for caregivers of PWD because of their independence of time and location. Future research Mahoney et al. (50) argued in their discussion that they did not find a significant main effect in the intervention for reducing burden or depression scores, however, for caregivers with lower mastery 17

ACCEPTED MANUSCRIPT at baseline and for caregivers who were wives, results showed a significant effect. Differences in the characteristics of the subgroups may have influenced who most benefits from the intervention. Christancho-Lacroix et al. (36) found that specific subgroups of caregivers benefited more from the program and discussed the different needs of caregivers. Further research with a focus on the specific characteristics of caregivers is therefore suggested to better understand the needs of

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specific subgroups. This finding is in line with the review of Zarit and Femia (22) who stated that family caregivers are a heterogeneous population and interventions should be “tailored” or

“adaptive” for varying profiles of risk and protective factors. Other methodological issues for

developing effective caregiver interventions are that the treatment mechanisms need to have a

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functional link to the measured outcomes and that treatments need sufficient dosage to be

effective. Additionally, especially in non-face-to-face interventions, it can be difficult to assure that the treatment is delivered as planned. These points need to be taken into account for developing and testing future interventions.

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Moreover, in this meta-analysis, we focused only on the direct effect of the intervention. For

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examining if effects are sustainable, future studies should also assess the long-term effects of technology-based interventions.

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Limitations

One limitation of this meta-analysis is the heterogeneity of the interventions in terms of

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implementation, content, dose, and study population. This affects the generalizability of the findings

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and it is not clear which part of the intervention specifically lead to the observed effect. We conducted subgroup analyses for different types of interventions, but we did not conduct other potential sub-analyses based on intervention dose or study population due to the small number of available studies. Meaningful subgroup analyses for gender could not be conducted since most study participants were female. Moreover, the division into subgroups e.g. according to dosage of delivery can be difficult. The aim of this article was to give an overview of the existing randomized control

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ACCEPTED MANUSCRIPT trials in the field of technology-based interventions for informal caregivers of PWD and to provide an insight of the efficacy despite the apparent difficulties. While most included studies had comparatively small sample sizes, which may be seen as limitation in this research field, the meta-analysis of pooled data revealed significant effect sizes. Furthermore, we focused only on two main outcomes, depression and burden. Other possible

additional information about the effectiveness of interventions.

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outcomes like anxiety, well-being or more specific outcomes such as goal attainment could provide

In a review of Cheng (81), the author showed that various neuropsychiatric symptoms of the care recipient are predictive of caregiver burden and depression. In addition to caregiver-focused

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interventions, patient-focused interventions that improve the management of such symptoms could complement effects to improve caregiver outcomes and should attract attention in further research. Conclusion

In conclusion, this meta-analysis provides evidence for a small positive effect of technology-based

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interventions on depression and caregiver burden in informal caregivers of PWD. The strongest

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effects were recorded for combined interventions. Overall, the estimated effect sizes were small. At the same time, even small and subthreshold improvements in levels of depressivity and burden have

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been associated with a reduction of unfavorable outcomes in caregivers (7) and a decreased risk for institutionalization in PWD (8), and hence together with the fact that many caregivers can be

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reached by technology-based interventions these effect sizes may be relevant from a public health

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perspective. More high quality RCTs and effectiveness trials are needed to examine specific components or combinations of components of interventions in order to enhance comparability between studies and allow subgroup analyses.

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ACCEPTED MANUSCRIPT Author and article information From the Department of Social- and Preventive medicine, University of Potsdam, Potsdam, Germany. Address correspondence to M. A. Rapp ([email protected]). F. Deeken and M. A. Rapp conceived the idea for the meta-analysis, designed the study and wrote the study protocol. F. Deeken conducted the structured literature search, abstract scan, full-text

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scan and managed data analyses. As secondary reviewer M. Hinz conducted the full-text scan, A. Rezo verified the data and was involved in the analyses and R. Discher assessed the study quality of the included studies.

F. Deeken wrote the first version of the manuscript together with M. A. Rapp. All authors revised the

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manuscript for intellectual content. The final manuscript was read and approved by all authors. The study protocol of this meta-analysis is registered at PROSPERO (International Prospective Register of Systematic Reviews) (Registration: CRD42017053959).

Supported by the Karl und Veronica Carstens-Foundation. The Carstens-Foundation provided a

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partial schorlarship to F. Deeken and A. Rezo as part of the National Graduate College “Optimization

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strategies in Dementia - OptiDem”. The funder had no role in study design, data collection, data analysis, data interpretation, or preparation of the manuscript.

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The authors report no financial relationships with commercial interests.

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65. Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, Leirer VO: Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research 1983; (17):37–49 66. Kroenke K, Spitzer RL: The phq-9: a new derpession diagnostic and severity measure. Psychiatric Annals 2002; (32):509–521 67. Derogatis LR: The Brief Symptom Inventory (BSI) Administration, Scoring & Procedures ManualII. Clinical Psychometric Research 1992

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ACCEPTED MANUSCRIPT 78. Pendergrass A, Becker C, Hautzinger M, Pfeiffer K: Dementia Caregiver Interventions: A Systematic Review of Caregiver Outcomes and Instruments in Randomized Controlled Trials. International Journal of Emergency Mental Health and Human Resilience 2015:459–468 79. Yuan S, Hussain SA, Hales KD, Cotten SR: What do they like?: Communication preferences and patterns of older adults in the United States: The role of technology. Educational Gerontology 2015; 42(3):163–174

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80. Czaja SJ, Charness N, Fisk AD, Hertzog C, Nair SN, Rogers WA, Sharit J: Factors predicting the use of technology: findings from the Center for Research and Education on Aging and Technology Enhancement (CREATE). Psychology and aging 2006; 21(2):333–352

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Figures

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Figure 1: Flow diagram of study selection process.

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Figure 2: Forest plot of comparison: technology-based vs. control group for the outcome depression.

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Figure 3: Forest plot of comparison: technology-based vs. control group for the outcome burden.

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Figure 4: Risk of Bias.

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Tables Table 1: Characteristics of included studies

Au, 2014

Participants/ Sample Size/ Mean age (years)/ Female (%) Caregivers of people with dementia N=60

Intervention

Control group

Telephone-assisted pleasant event scheduling (TAPES) 3 components: behavioral activation, 6 subsequent phone calls, active coping

passive CG: Treatment as usual (TAU)

Psychoeducation with behavioral activation (PsyED-BA) group, 4 weeks psychoeducation + 8 biweekly sessions of BA practice focused on pleasant event scheduling and improving communications

active CG: Psychoeducation only (PsyED Only) group, 4 weeks psychoeducation + 8 biweekly sessions of general discussion of psychoeducation and related information via telephone.

Web-based multimedia intervention: Caregiver´s friend: Dealing with dementia Provides text material and videos. Individualized tailoring Multiple components (knowledge, cognitive and behavioral skills)

passive CG: Usual care waitlist control group with no attention-placebo (free to view Caregivers friend after T2)

Internet course Mastery over Dementia (MoD) Information (text material and

passive CG: e-bulletins (digital newsletter) sent by e-mail

Informal family caregiver of a person with dementia Beauchamp, 2005

N=299 Mean age = 46.90 Female = 73.00%

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Blom,

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Family caregivers of people with dementia

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N=96 Mean age = 56.23 Female = 80.00%

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Au, 2015

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Mean age = 56.60 female = 77.00% Informal family caregiver for a care recipient diagnosed with Alzheimer’s disease

Outcome measure

Duration/ Intensity

Results/ Principal findings

CES-D

6 telephone calls (20 min) 4 weeks

The TAPES group had significantly lower levels of depressive symptoms than the TAU group post-intervention.

CES-D (20 item)

PsyED: 4 weeks/30min BA: 4 month/8 biweekly calls

Significant decrease of depressive symptoms in PsyED-BA group postintervention.

CES-D (9 item)

30 days access

Participants in the intervention group reported significantly greater reductions in caregiver strain und depressive symptomatology.

8 lessons + 1 booster session (over 5-6

Caregiver in the experimental group showed significantly lower symptoms of depression post

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Study (first author)/ Year

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Caregiver Strain Instrument (three subscales) CES-D (20 item)

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2015

N=251

Brennan, 1995

Mean age = 61.20 Female = 69,40% Caregivers of persons with Alzheimer`s disease

videos), exercises, homework (electronic feedback), evaluation One booster session ComputerLink group 3 functions: information, decision support, communication

active CG: Placebo training

Christancho -Lacroix, 2015

Informal caregivers of persons with Alzheimer´s disease N=49 Mean age = 61.65 Female= 65.50% Primary caregivers for a spouse with dementia

Connell, 2009

N=157 Mean age= 66.80 Female = 100.00%

Brief Symptom Inventory (BIS): depression subscale

Diapason program: free passwordprotected website 12 thematic sessions (theoretical and practical information, video of health professionals, practice guide) + additional sections e.g. relaxation training, forum…

passive CG: Usual care: information about the illness

Health First: 14 telephone calls 1) Health First video 2) exercise videos 3) booklet 4)workbook 5) two “motivational” newsletters

passive CG: No intervention Written materials about physical activity at the end of the study

CES-D (11 item)

Technology-based multi-component psychosocial intervention

Active CG: Attention only Same format as in the intervention

CES-D (10 item)

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Caregivers of persons with dementia

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Czaja, 2013

intervention after adjustment for baseline differences.

12 month

Experimental group showed improvement in the depression score post-intervention.

8 weeks

Significant main effect in depression over time for intervention group. No significant differences in caregiver burden between groups

3 month, weekly session lasting 15 to 30 minutes

No significant mean differences in depression and burden for IG and CG.

14 telephone calls over 6 month

Significant greater average decline in depressive symptoms in the IG.

Caregiver Appraisal tool: burden subscale

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Mean age = 66.50 Female = 100.00%

active CG: Attention only weekly calls

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N=65

Cognitive behavioral intervention Nurseline video-assisted modeling program (NVAMP) 1) videotapes demonstrating assisted modeling behavior 2) Nurseline support program (weekly Nurseline telephone calls)

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Family caregivers of persons with dementia

month)

CES- D (20-item)

Mean age = n/a Female = 67.00%

Chang, 1999

Impact of caregiver scale

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N=102

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BDI II ZBI (French Version, 22 items) RMBPC

RMBPC

Participation in IG did not affect subjective caregiver burden postintervention.

RMBPC

5 month

Caregivers in the intervention group reported a decrease in burden.

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Mean age = 60.90 Female = 81.00%

two in-home sessions and four sessions delivered via a CISCO IP 7900 videophone: education and skills training five videophone support group sessions

Passive CG: Information only Packet of educational material and one “check-in call”

caregiver notebook

Eisdorfer, 2003

American and Cuban American family caregivers of a patient with AD and related disorders

group (2 in-home sessions, 4 videophone sessions, 5 videophone support group sessions) Content: nutrition and healthy eating

Computer-telephone-integrated system (CTIS) (calls, conferences, reminders) and Structural Ecosystems Therapy (SET) course of 12 month

N=150

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CBT Skill Training DVD Workbook (home practice exercise)

N=76 Mean age = 58.78 Female = 87.14% Male family dementia caregivers

Primarily behavioral strategies training: Videos (10 sessions)/ workbook/ telephone coaching (12 weekly phone calls)

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N=32

CES-D (20 item) RMBPC

passive CG: Information-only Basic educational material, 2 brief (<15min) telephone check-in calls

CES-D (10 item)

active CG: Education DVD Written educational material

CES-D (20 item)

12 month (weekly session for the first 4 month, biweekly the next 3 month, monthly the last 6 month)

Caregiver in the IG showed a significant reduction in the depression scores after 6 month. After 18 month, mean CES-D scores decreased in the IG. Results for the RMBPC not reported.

6 month, 12 sessions with the CTIS system

Caregivers in the IG reported a significant decrease in burden postintervention. Caregiver with a high depression score at baseline experienced a significant decline in depression. The intervention not led to a significant decline in depressive symptomatology.

RMBPC

12 week program

RMBPC For the RMBPC the mean reaction clearly decreased in the IG.

active CG: Education (booklet Basic dementia care guide)/ check-in-call (7 biweekly phone calls)

RMBPC

10 videos, 12 weekly calls

In both the IG and the CG a significant effect for postintervention improvement in the RMBPC was found.

Mean age = 71.60

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Gant, 2007

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GallagherThompson, 2010

N=46 Mean age = 64.60 Female = 67.60% Chinese American dementia caregivers

Computer-Telephone Integration system (CTIS): screen phone (calls, messages, information, conferences)

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Finkel, 2007

Passive CG: telephone based minimal support condition (active listening and empathic comments)/ generic educational material active CG SET course of 12 month

Mean age= 68.48 Female = 75.00% Family caregiver of people with dementia

No significant effect for depression.

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N=110

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Female = 0.00%

N=36

Cognitive Behavioral (CB) intervention program with multiple components: e.g. relaxation training, pleasant daily activities, problem-solving skills 12 weekly sessions (7 telephonebased group and 5 individual)

passive CG: Routine education and support (ES) Written educational materials

Telephone based cognitivebehavioral therapy 12, 1hour weekly sessions (7 group and 5 individual sessions) Guidebook, information about local dementia resources, The 36 Hour Day (copy)

active CG: Face-to-face cognitive behavioral therapy 12, 1hour weekly sessions (7 group and 5 individual sessions) Guidebook, information about local dementia resources, The 36 Hour Day (copy)

CES-D (20 item)

Mean age = 58.09 Female = 90.00%

Goodman, 1990

Caregivers of Alzheimer`s patients N= 66

Hattink, 2015

Mean age = 64.52 Female = 80.00% Informal caregivers of person with dementia N=46 Mean age = 53.88 Female = 71.50%

Hicken, 2016

Caregivers of rural veterans with dementia

AC

There was a trend in the direction of reduced caregiver burden in the IG, but pre-posttest differences did not reach statistical significance.

12 weeks, 1 hour weekly

Caregiver reported significant improvements in subjective burden and depression from pre- to posttreatment in IG and CG. No statistically significant effect could be found for group or interaction effects.

12 weeks

No change over time occurred for caregiver burden. No significant group x time effects were found neither for the MBPC nor for the ZBI.

RMBPC (17 items)

Subjective burden subscale of the CAI ZBI (23 item)

CB group reported a decline in depressive symptoms from pre to posttreatment, but this reduction was statistically not significant.

active CG: 12 telephone-accessed taped lectures about Alzheimer`s disease

STAR platform: online course, 8 modules (text, videos, interactive exercises, knowledge tests, references to other websites), personalized learning path through the modules

passive CG: Waiting list control group

Burden (1 item)

4 month, at least 4 modules

For informal caregiver in both groups, IG and CG, the burden score decreased from pre- to posttreatment but the effect was not statistically significant.

Electronic intervention (via internet or telehealth technology) 1) video vignettes (dementia progression/caregiving skills) 2) written information (health topics/caregiving skills)

active CG: Telephone support Monthly telephone call from the care manager Printed educational material DVD (content identical to the

ZBI (12 items)

4 – 6 month

No significant differences in change scores of burden or depression

CE

N=231 Mean age = 70.16 Female = 90.00%

CES-D (20 item)

12 weekly sessions; Group sessions: 45 min. Individual sessions: 60 minutes

Telephone support program Peer telephone network of 4-5 caregivers One call and one received call weekly (~15 min) supportive conversation over a 12-week period

ED

N=14

PT

Glueckauf, 2012

M

Mean age = 60.46 Female = 72.22% African American dementia caregiver with depression

Subjective burden subscale of the CAI

AN US

Glueckauf, 2007

Family caregivers of care recipients with progressive dementia in rural Panhandle area of Florida

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ACCEPTED MANUSCRIPT

MBPC

Patient Health Questionnaire (depression symptoms)

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Dementia family caregivers Kales, 2018

N=57 Mean age = 65.90 Female = 75.00%

family caregivers of persons with dementia

Kwok, 2013

WeCareAdvisor tool 1) guided DICE (describe, investigate, create and evaluate non-cognitive behavioral and psychological symptoms of the person with dementia) approach + strategies 2) Caregiver survival guide 3) daily messaging feature

N=11 Mean age = n/a Female = n/a

AC

CE

N=100 Mean age = 62.00 Female = 80,00%

Computer-mediated automatic interactive voice response (IVR) Integrated telephone network system IVR computer network system 4 modules (weekly caregiver`s conversation/personal Mailbox/Bulletin Board/ActivityRespite Conversation)

PT

Mahoney, 2003

Family caregivers of persons with Alzheimer`s disease

active CG: Educational DVD

Online group 7-week training workshop through a website

CES-D (20 item)

3 month

No significant pre- posttreatment changes were found for the RMBPC and the CES-D and the group x time interaction was not statistically significant, too.

1 month

No significant pre-posttreatment changes in depression and burden for intervention and control group.

ZBI (Chinese version, 22 items)

12 sessions (appr. ~30min), one session per week 12 weeks

Statistically significant reduction in caregiver burden in the IG compared to the CG.

CES-D (Chinese version)

7 weeks

No significant difference was found in the IG pre- and postintervention. Participants in the CG had significantly lower depression scores after the workshop.

12 month access to the IVR-mediated system

Overall, there was no significant main effect of the intervention in reducing RMBPC scores and CES-D scores, but there was a significant intervention effect for RMBPC and CES-D for participants with lower mastery at baseline.

RMBPC

CES-D (20 item) ZBI (12 item)

active CG: Onsite group 7-week workshop with face-to-face sessions

ED

Family caregivers of people with dementia

Passive CG: Waitlist control group

Educational DVD 12-session psychoeducation program over the telephone

N=42 Mean age = n/a Female = 71.10%

Lai, 2013

active CG: Education/information (EOC) Website, video-taped information, booklet

AN US

N=150 Mean age = 56.14 Female = 85.00%

electronic formats)

M

Dementia family caregivers Kajiyama, 2013

3) assessments (caregiver health/well-being) iCare (ICC): web-based program with 6 modules (e.g. information, communication skills, behavioral activation) workbook

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ZBI (Chinese version) passive CG: Reference booklet

CES-D (20 item) RMBPC

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User`s manual

Caregivers of veterans with dementia Mavandadi, 2017

N=75 Mean age = 70.01 Female = 97.30%

Informal caregivers of people with dementia NúñezNaveira, 2016

N=77 Mean age = n/a Female = 63.90%

Dementia family caregivers Steffen, 2000

N=24

AC

ZBI (12 item) RMBPC

passive CG: Usual care, mailed general material

RMBPC (subscales)

ZBI (12 items)

The UnderstAID Application Learning section (text, videos, images), daily task section, social network section, personalized through interactive customization questionnaire

passive CG: No use of the application, maintained their usual lifestyle

8 psychoeducational video series Workbook (reading material and worksheets) Weekly phone calls (review progress on homework and problem solving of difficulties)

passive CG: Waitlist control group

CE

Mean age = 64.06 Female = 75.80%

Care management program 1) individualized dementia care management (min. 3 contacts (calls/visits) over 3 month) 2) Telehealth Education Program (TEP): manualized group-based telephonic education and psychosocial program modified for use with individual caregiver, individualized program: up to seven modules TEP workbook

CES-D (10 item)

AN US

Mean age = 66.00 Female = 83.70%

passive CG: Print materials Telephone numbers for local resources

M

N=154

ED

MartindaleAdams, 2013

Telephone support groups (5 or 6 caregivers), Multicomponent intervention: Education/coping skills/support (based on REACH II intervention)

PT

Family dementia caregivers

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ACCEPTED MANUSCRIPT

CES-D (20 item)

12 month (2 month biweekly, than monthly), 14 meetings / 1hour

No significant treatment effect differences in the outcomes between IG and CG.

1. component: min. 3 contacts over 3 month 2. component: up to 7 modules

No significant group differences in reported global caregiver burden. Caregiver in the intervention arm reported greater reductions in their negative reaction to dementiarelated behavioral symptoms compared to caregiver in the CG over time.

3 month access

Caregiver in the IG had a significantly decrease in their depression scores pre- to postintervention. In the CG no significant difference for the depressive symptomatology was found.

active CG: Class-based viewing of the angermanagement video series (90min/week)

BDI (13 item)

8 week; weekly video segment (30 minutes); weekly phone calls (averaged 20 minutes)

Mean posttreatment BDI for the IG was significantly different than the passive CG (waitlist); The comparison between active and passive CG was not significant.

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Family caregivers of people with dementia Torkmani, 2014

N=60 Mean age = 60.69 Female = 45.00%

Tremont, 2008

Dementia caregiver N=33 Mean age = 63.79 Female = n/a

Tremont, 2015

Distressed, family dementia caregivers N=250

passive CG: No intervention

Telephone-Tracking Dementia (FITTD) Multicomponent intervention: Orientation and psychoeducation, supportive approaches and active strategies

Telephone-Tracking Caregiver (FITTC) Orientation and psychoeducation/support/coping strategies

CE

Mean age = 62.72 Female= 78.00%

Computerized platform (ALADDIN) 4 key features “Aladdin TV”: educational material “Social networking”: communication with other caregivers “My tasks”: distant monitoring of the caregiver “Contact us”: communication between caregiver and health professional

AC

Family caregivers of

Tele.TAnDem Intervention

RMBPC

BDI II

BDI (21 item)

AN US

Mean age = 60.30 Female = 100.00%

10 videos (30 minutes), 12 calls (30 to 50 minutes) (14 weeks)

Post-intervention BDI and RMBPC scores were statistically lower in the IG compared to the CG.

6 month access

On average, the reported burden of caring decreased more in the IG than in the CG, but did not reach statistical significance.

ZBI (22 item)

passive CG: Standard care

M

N=74

active CG: Basic education (booklet Basic dementia care guide) and support (7 phone calls) “treatment as usual”

ED

Steffen, 2016

Behavioral Coaching condition: 10 video segments, workbook, 10 weekly telephone calls, 2 maintenance calls, telephone coaching in behavioral management, pleasant events scheduling, and relaxation

PT

Female family caregiver for a family member

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active CG: Telephone support (16 contacts) Empathic and reflective listening, provide non-directive support

GDS ZBI

RMBPC

CES-D ZBI RMBPC

passive CG:

CES-D (German

Results for depression scores were not reported due to missing data.

23 telephone calls over 12 month, approx. 12 hours of contact

Post-intervention caregiver in the IG showed significantly lower scores in the ZBI and the RMBPC than caregiver in the CG. Caregiver in the IG showed fewer depressive symptoms post-intervention than caregiver in the CG, but this difference did not reach statistical significance

6 month, 16 telephone contacts, length of calls: mean = 36,69 minutes

Caregiver in the IG improved significantly in depressive symptoms after 6 month compared to caregiver in the CG. There was no significant group differences for ZBI scores as well as for the reaction score of the RMBPC.

6 month

Post-intervention, symptoms of

37

Wilz, 2018

persons with dementia N=273

twelve 50-min sessions of individual cognitive-behavioral therapy delivered via telephone

usual care

N=103 Mean age = 66.60 Female = 100.00%

AN US

Winter, 2007

Telesupport groups (telephonebased): group of 5 caregivers for one hour per week Conducted by trained social workers

version)

depression decreased for participants of the intervention group compared with the control group. Post-Intervention, participants of the intervention group experienced a burden of care similar to that of participants in the control group.

Burden (visual analogue scale 1-100)

Mean age = 64.19 Female = 80.60%

Female family caregivers of dementia patients (Alzheimer's disease or related disorder)

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ACCEPTED MANUSCRIPT

passive CG: No intervention

CES-D (20 items)

ZBI (22 items)

6 month (26 possible sessions)

No statistically significant differences between caregiver in the IG and CG at 6 months on depression and burden.

M

N= sample size; CG= control group; IG = intervention group; CES-D= Center for Epidemiology Studies Depression Scale; (R)MBPC= (Revised) Memory and Behavior Problem Checklist; ZBI= Zarit Burden Interview; BDI= Beck Depression Inventory; CAI=Caregiver Appraisal Inventory; AD=Alzheimer's disease,

ED

ALADDIN=Assisted living of Dementia elDerly INdividuals and their carers’; CBT=cognitive behavioral therapy; STAR=European Skills Training and Reskilling;

AC

CE

PT

n/a = not available

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CR IP T

ACCEPTED MANUSCRIPT

List of Supplemental Digital Content

AN US

SDC_1_Search Terms.docx

AC

CE

PT

ED

M

SDC_2_ Risk of Bias.tif

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