Dementia affects over 7% of veterans age 65 and above seeking care through the Veteran's Health Administration (VHA), amounting to one out of every eleven veterans in some VISNs. The unique functional and behavioral impairments associated with Alzheimer's or a related dementia (ADRD) contribute substantially to psychological and physical morbidity of family caregivers and high rates of nursing home placement, with 60% of ADRD caregivers rating the emotional stress of caregiving as high or very high, and over one third reporting depressive symptoms. Although numerous evidence-based interventions have been developed to reduce caregiver burden and improve mental health and functional outcomes of the person with dementia, a recent systematic review noted almost none of these interventions make it off of the shelf to be readily available in clinical settings. Care Consultation (CC) has emerged as a rare exception. CC is an evidence-based telephone intervention delivering psychoeducation, care coordination, and resource referrals in diverse areas such as safety and mental and behavioral health support. Yet CC's focus on coaching and support is inadequate for dyads experiencing high levels of distress. A stepped- intervention approach would address the VA's efficiency needs while allowing the flexibility for more resource-intensive additional counseling beyond the established CC framework when warranted by high dyad distress. This CDA-2 proposal would move such a dyadic intervention forward. Objectives: 1) Manualize the integration of care consultation and counseling components (i.e., the CC+C intervention). CC+C is guided by a rehabilitation recovery-based conceptual model to address the most common high distress targets (e.g., relationship distress, veteran or caregiver depression, anxiety, or pain) using patient-centered approaches. 2) Evaluate preliminary effectiveness and feasibility of the CC+C Intervention in a randomized controlled pilot study of distressed dyads to compare: a) the established CC intervention, to b) the CC+C intervention on veteran and caregiver outcomes. 3) Conduct exploratory analyses of the CC+C intervention on veteran long-term care placement at six and 12 months and examine two key treatment moderators (behavioral symptoms and spousal relationship status) that may impact intervention engagement and response to treatment. Methods: Ten modules combining successful elements from existing manualized therapies and exercises developed by the investigative team during the CDA-1 period will be integrated with CC into a draft CC+C intervention manual. The manual will be finalized with input from the mentoring team and an Expert Advisory Panel for completeness, feasibility, and safety and risk considerations. Next 68 distressed veterans with dementia and their family caregivers will be recruited and randomized to either the CC+C intervention group or the CC comparison group. Patient, caregiver, and relationship outcomes (e.g., burden, depressive symptoms, anxiety, quality of life, relationship distress) will be measured at baseline, 6 months, and 12 months. Treatment implementation and feasibility data will be collected. Anticipated Impacts: The goal of this career development proposal is to acquire the knowledge, skills and experience necessary to successfully compete for an RR&D Merit Review Award evaluating a randomized controlled trial powered to establish efficacy and test effectiveness of the CC+C intervention. Rehabilitation- focused interventions that maximize functioning are essential for successful non-institutional VA dementia care in the future. Work completed during the CDA-2 period will serve as a foundation for a career committed to this goal. The impact of this work will be realized when an efficacious and highly-accessible rehabilitation intervention, such as the telephone-based dyadic intervention being piloted, becomes available for aging veterans and their families.
More individuals with dementia will seek services from the VA over the next 10 years than at any point in our nations' history. Yet critical gaps remain in the Veteran's Health Administration' (VHA) dementia care plans. Research is needed on the best way to get rehabilitation-focused, sustained, evidence-based care to community-dwelling aging veterans and their families. Remote delivery of care via telehealth is one answer that ensures resources are available for those with diminished access to specialty health care resources due to disease burden or transportation barriers. This application describes two important contributions: 1) the manual development and an initial randomized controlled pilot study of a telephone-based counseling and care consultation intervention for veterans with dementia and their family caregivers; and 2) the training plan that will prepare Michelle Hilgeman, Ph.D., for a career devoted to developing and translating dyadic interventions that optimize recovery-focused outcomes for veterans with dementia and their caregivers.
