Memory Strategy Training Can Enhance Psychoeducation Outcomes for Dementia Family Caregivers: A Randomized Controlled Trial

Abstract

This study investigated caregiver outcomes when a psychoeducation program for older people with dementia and caregivers is modified to extend practice in memory strategies. Moderation effects of increased memory strategy use were also explored. Fifty-six care dyads participated in the multicenter, randomized controlled trial comparing psychoeducation (active control) with psychoeducation and memory strategy practice (intervention). Primary outcome was memory strategy use; secondary outcome was caregiver emotional reactivity (burden, depression, and anxiety). Results showed memory strategy use significantly increased following psychoeducation for both groups. However, psychoeducation combined with memory strategy practice resulted in a significant reduction in depression for caregivers reporting at least mild baseline symptoms. Greater use of memory strategies moderated the relationship between burden and depression following intervention. Psychoeducation programs that incorporate practical memory strategy training may offer more substantial outcomes.

Keywords

dementia caregiving psychoeducation intervention memory strategy training caregiver outcomes

Background

Dementia caregiving can be an intensely stressful experience due to a complex interplay of factors relating to both the person with dementia and their family caregiver (van der Lee et al., 2014). Memory and cognitive deficits associated with increased functional dependency are challenging for both the care recipient and the caregiver, contributing to caregiver burden (Chiao et al., 2015). Meta-analyses indicate that dementia caregivers report significantly higher levels of burden compared to nondementia caregivers (Pinquart & Sörensen, 2003) and are at significantly increased risk of developing symptoms of depression and anxiety (Sallim et al., 2015), even in the early stage of the disease (Välimäki et al., 2009). Subsequently, caregivers who report high levels of burden are more likely to turn to residential aged care for the person with dementia (Gaugler et al., 2011; Toot et al., 2017).

In the context of these findings, there is a clear need for early interventions that support dementia caregivers in their caregiving role and protect their psychological well-being (World Health Organization [WHO], 2015). The literature on dementia caregiver interventions is substantial, with the types of interventions studied as diverse as the range of outcomes targeted. Systematic reviews and meta-analyses of caregiver interventions indicate that psychoeducation may have positive effects on caregiver burden and depression (Elvish et al., 2013; Gallagher-Thompson & Coon, 2007; Pinquart & Sörensen, 2006; Walter & Pinquart, 2019), although the evidence continues to be mixed, with some observing an effect for either burden or depression but not for both (see Kishita et al., 2018, for a recent systematic review of randomized trials). Psychoeducation programs that combine education with an active skill-building component have been shown to achieve the greatest effects (Clare & Woods, 2004; Kishita et al., 2018; Parker et al., 2008; Pinquart & Sörensen, 2006); although, the psychological mechanism underlying this finding is unclear, with few intervention studies underpinned by an explicit theoretical framework that can both guide more effective interventions and account for moderating variables.

Dynamic models of caregiving such as the stress process model proposed by Pearlin et al. (1990) suggest that stress (burden) can lead to outcomes such as depression or anxiety, but that the effect of burden on these outcomes may also be impacted by secondary variables. One such moderator is personal mastery, or the sense of control individuals feel they have over forces affecting their lives (Pearlin et al., 1990). Support for the intermediary role of mastery in the caregiver burden–depression relationship has been demonstrated, especially for spouse caregivers (McAuliffe et al., 2018 ). Therefore, it could be argued that psychoeducation interventions that incorporate skill building elements work by increasing caregivers’ feelings of control over their situation, thereby promoting caregiver well-being.

Training in the use of compensatory memory strategies provided to caregivers (so that they can use these with the person with dementia to support and optimize residual memory) is an example of skill building that has the potential to boost caregivers’ sense of control over their life circumstances. Smith et al. (2011) used a knowledge translation framework drawing on the best available evidence to develop a set of facilitative memory strategies for caregivers to use with people with dementia. Referred to by the pneumonic RECAPS (Reminders, Environment, Consistent routines, Attention, Practice, and Simple steps), the strategies were trialed with both professional and family caregivers and found to have a positive effect on caregiver knowledge and experience (Broughton et al., 2011; Liddle et al., 2012). Evidence for the utility of memory strategies in early dementia also comes from a recent randomized controlled trial of goal-oriented cognitive rehabilitation (including methods such as environmental adaptations and prompts, and compensatory strategies and memory aids) versus treatment as usual, which demonstrated large, positive effects for goal attainment corroborated by informant ratings (Clare et al., 2019).

As memory impairment often presents in the earliest stages of dementia, it is an ideal target for early intervention, with research suggesting that the earlier a strategy is introduced to the care dyad the more likely it will be used effectively in everyday life (Clare et al., 2011). Secondly, memory impairment affects daily life in numerous ways; for example, difficulty with preparing meals, forgetting appointments, or misplacing items (e.g., glasses or keys) around the house. Such difficulties can lead to early dependency and disability in the person with dementia and are frustrating for both the care recipient and caregiver (Clare & Woods, 2004; Smith et al., 2011). Yet relative preservation of procedural memory in many cases of dementia (van Halteren-van Tilborg et al., 2007) suggests using memory strategies to help relieve such difficulties is possible. Several randomized controlled trials have shown that teaching memory strategies to people with memory loss and their caregivers is achievable (Clare et al., 2011, 2019; Kinsella et al., 2009); however, whether doing so actually impacts, or moderates, the emotional and physical health of the caregiver has yet to be determined.

Aims

Psychoeducation programs that include direct training in memory strategies provided to caregivers in order to support the person with dementia may present an opportunity to enhance efficacy on caregiver outcomes (Smith et al., 2011). Using a theoretical stress process model that emphasizes the role of moderators, increasing caregiver strategy use may also indirectly affect caregiver emotional reactivity by buffering, or moderating, the effect of caregiver burden on depression or anxiety (Pearlin et al., 1990). Therefore, the aim of the current study was to investigate the relationship between memory strategy use, self-perceived burden, and emotional reactivity (depression and anxiety) in caregivers of people with dementia following a psychoeducational intervention.

By comparing a standard psychoeducational program to a similar program including direct training in memory strategies delivered to caregivers, it was hypothesized that caregiver memory strategy use would increase following intervention, especially if the intervention provided direct training in strategy use (Clare et al., 2019). It was also hypothesized that caregiver burden and emotional reactivity (depression and anxiety) would decrease following intervention (Walter & Pinquart, 2019). Finally, we investigated as an exploratory hypothesis whether memory strategy use by caregivers moderated the expected relationship between caregiver burden and depression/anxiety (Pearlin et al., 1990).

Method

Design

This study was a multicenter randomized trial involving an active control condition (standard psychoeducation program) and an intervention condition (psychoeducation and direct memory strategy training). Assessments occurred at baseline, 6 weeks (posttest), and 10 weeks (follow-up) and were completed in participants’ homes. Outcome selection was guided by the stress process model (Pearlin et al., 1990) whereby the assessment of perceived burden and its relationship with caregiver depression/anxiety included the impact of a potential moderating variable (personal mastery in the form of memory strategy use).

Participants

Participants (care dyads) were recruited from three Dementia Australia (Vic) centers across metropolitan and regional Victoria, Australia. Study inclusion criteria were (a) care recipient was a community-dwelling older adult (aged ≥65 years) with a medical diagnosis of dementia, considered to be mild (Mini Mental State Examination Score = 21–24; Folstein et al., 1975); (b) caregiver identified as the primary support person for the person with dementia; and (c) caregiver had sufficient English literacy for completing written surveys. Exclusion criteria applied to the care dyad were: (a) history of additional neurological disorder; (b) previous participation in a memory training intervention; and (c) recent commencement of mood or memory enhancing medications (within 2 months).

Measures

Demographic characteristics of the dyad were recorded, along with measures of the care recipient’s impairment in (a) cognition (Informant Questionnaire on Cognitive Decline in the Elderly [IQCODE short form], Jorm, 2004); (b) functional activity (the Katz Activities of Daily Living Scale [ADL], Katz et al., 1963); and (c) behavior (the Revised Memory and Behavior Problems Checklist [RMBPC], Teri et al., 1992).

Caregiver memory strategy use was measured using the Memory Strategy Use (MSU) questionnaire (see Supplemental Material). Developed specifically for this study to ensure the strategies corresponded to those featured in the intervention, the questionnaire consisted of 28 items relating to memory strategies frequently cited in research as supportive of memory performance in dementia (e.g., Clare & Woods, 2004; Smith et al., 2011). Caregivers indicated how often (0 = never to 4 = nearly always) they had used each of the memory strategies to support the person living with dementia over the previous 4 weeks, with scores summed to produce a total score (range 0–112). Cronbach’s α for the MSU questionnaire was α = .89, indicating good reliability of the scale.

Caregiver burden was measured using the short form of the Zarit Burden Interview (ZBI-12; Bédard et al., 2001), which has been found to produce results comparable to the full version (Bédard et al., 2001). Caregiver perceptions regarding the degree to which caregiving responsibilities have adversely impacted on various aspects of their life (e.g., health, personal life, and relationships) were rated (from 0 = never to 4 = nearly always) with item scores summed to produce an overall burden score (range 0–48). Previously reported Cronbach’s α for this abridged version of the scale is .88 (Bédard et al., 2001), with α = .89 in the current study.

Caregiver anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983), which can be used in the community setting (Snaith, 2003) and is useful for older adults as it eliminates symptoms of physical disorder that may overlap with other medical conditions (e.g., fatigue; Quinn et al., 2014). The scale contains 14 items scored on a four-point Likert scale (from 0 = not at all to 3 = often indeed), with some items reverse scored. Subtotals are scored for anxiety and depression, with scores classified as normal (0–7), borderline abnormal (8–10), or abnormal (11–21). Reported Cronbach’s α ranges from .68 to .93 (anxiety) and from .67 to .90 (depression; Bjelland et al., 2002). In this study, Cronbach’s α for the anxiety subscale (seven items) and depression subscale (six items) were .77 and .68, respectively.

Measures of caregiver physiological stress (cortisol and immunoglobulin A) were also obtained but will be reported elsewhere.

Active Control and Modified Intervention Conditions

Living with Memory Loss Program (Active Control Condition)

The Living with Memory Loss (LwML) program is a group psychoeducation program that offers education and support for people with early-stage dementia who are experiencing memory loss and their family caregiver (Dementia Australia,). The program is delivered as six, weekly 2 hr sessions with a 1-month follow-up, and runs in metropolitan and regional areas. Dementia Australia counselors facilitate the program and group discussion, with part of each session also split into separate facilitated group discussions for care recipients and caregivers. Counselors follow a manualized approach and sessions focus on a different topic each week: experiences and reactions to the diagnosis; understanding the diagnosis and impact of brain changes; how memory works; communicating more effectively; impact of dementia on daily life and managing change; and planning for the future. The program provides general information about memory aids and strategies (through the provision of tip sheets) but does not involve in-group training and practice of memory strategies. An early evaluation of the program was favorable, with caregivers reporting high satisfaction and a significant decline in stress caused by changed behaviors in the person with dementia (Bird et al., 2005).

Living with Memory Loss Program - Strategy (Modified Intervention Condition)

The LwML program was modified to incorporate direct training in memory strategies provided to caregivers in order to support and optimize residual memory in the person with dementia (LwML-S). The modification did not involve additional program time but a memory strategy module (RECAPS) was delivered during the time reserved for separate caregiver discussion.

RECAPS: Memory in Dementia is a memory strategy training DVD module that was developed to assist knowledge and practice of practical strategies for everyday use by family (and professional) caregivers (Smith et al., 2011). Each letter of RECAPS represents a compensatory strategy (Table 1).

Table 1

The RECAPS Memory Strategies.

R: Reminders	Spoken prompts Written word and picture reminders
E: Environment	Have a permanent place for objects Don’t change surroundings
C: Consistent routines	Keep up familiar routines Make routines
A: Attention	Avoid distractions Focus attention
P: Practice	Maintain skills through use Practice new skills
S: Simple Steps	Break into simple steps Allow extra time

Source. From Smith et al. (2011).

The DVD includes an interactive, participatory element in the form of “trigger” video interactions, which depict either the use or nonuse of the recommended strategies (Smith et al., 2011). Several studies have been published on the development and testing of the RECAPS training (see Broughton et al., 2011; Liddle et al., 2012; Smith et al., 2011) and the DVD content is accessible online (UQDementiaCare, 2012; 2012a; 2012b).

The RECAPS DVD and related discussion was delivered by a trained neuropsychologist during Week 3. The neuropsychologist assisted caregivers to identify relevant and meaningful goals on which to focus memory strategy use at home with the person with dementia. This was important to ensure that the intervention was the best “fit” for each care dyad in terms of matching their needs and preferences (Van’t Leven et al., 2019). Caregivers were provided with the RECAPS DVD and booklet summarizing the strategies for guided practice at home. During Weeks 4–5, the neuropsychologist telephoned caregivers in the intervention group in order to refine or modify goals, encourage use of the memory strategies, and to answer any questions from participants.

Procedure

A flow chart of the study procedure is presented in Figure 1. Assessments were completed in participants’ homes in the fortnight prior to program commencement (pretest), at program completion 6 weeks later (posttest), and 1 month following program completion (follow-up).

Figure 1

Outline of study procedure including recruitment, randomization, intervention delivery, and assessments.

A computer algorithm was used to randomize LwML groups (1:1 ratio) to the active control condition (standard psychoeducation program) or direct training intervention condition (psychoeducation and memory strategy training), stratified by geographical location (metropolitan vs. regional center). Randomization occurred at the group (rather than individual) level as randomization of care dyads within groups would have risked potential “contamination” between groups (Puffer et al., 2005). The researcher was blind to group allocation.

Research was conducted in keeping with the conditions of approval as granted by the institutional ethics committee and written consent was obtained from caregivers and care recipients. All active control participants were sent the RECAPS DVD and booklet at the end of the study.

Data Analysis

Analyses were performed using the statistical software package IBM SPSS (version 25). Given the low incidence of missing responses from within scales (less than 5%), missing items were replaced with individual participants’ mean responses across the remaining items to calculate subscale scores (Shrive et al., 2006). Differences between the groups in terms of sample characteristics including baseline performance on outcome measures were analyzed using independent t tests or Mann–Whitney U for continuous data and Chi square test for categorical data.

A two (group) x two (time) multiple analysis of variance (MANOVA) was conducted to assess the impact of the two different versions of the psychoeducation program (LwML, LwML-S) on caregivers’ scores on memory strategy use, self-perceived burden, and emotional reactivity (depression and anxiety) across time points.

As an individual could change up to seven units on the HADS subscale across time and be categorized as “no depression” (e.g., 0: no depression to 7: no depression), only those participants who scored at least mild levels of depression or anxiety (i.e., HADS subscale score ≥8) at baseline were included in the remaining statistical analyses.

The association between key variables (memory strategy use, burden, depression, and anxiety) was assessed with Pearson correlation, irrespective of group allocation. The stress process model was investigated with the PROCESS macro (Hayes, 2013) which assessed if memory strategy use moderated (buffered) the relationship between burden and depression, or burden and anxiety, after controlling for caregiver relationship. Relationship of the caregiver to the person with dementia was included as a covariate given the known variation in caregiving experience (McAuliffe et al., 2018 ) and caregiver emotional reactivity due to this variable (Iwata & Horiguchi, 2016). The Johnson–Neyman technique (Bauer & Curran, 2005) was used to identify boundary values of the regions of significance.

Assumptions of normality, homogeneity of variance, sphericity, and multicollinearity were assessed using Shapiro-Wilk, Levene’s test, and Mauchly’s tolerance statistic, respectively. Due to the small sample size, α remained at .05 without Bonferroni adjustment, with the size of the effect used to assist interpretation. Effect sizes were calculated using partial eta squared (η_p ² ) and were interpreted according to Cohen (1988): .01 = small effect, .06 = moderate effect, and .14 = large effect.

Results

Sample Characteristics

A total of 56 care dyads participated in this study across metropolitan and regional areas of Victoria, Australia. Characteristics of study participants are presented in Table 2.

Table 2

Sample Characteristics at Baseline.

Characteristic	All participants(N = 56 dyads)	LwML(active control)(N = 31 dyads)	LwML-S(modified intervention)(N = 25 dyads)	Statistical comparison between control and intervention groups
Caregivers
Age—years	Mdn = 70.50; IQR = 17	Mdn = 70.00; IQR = 15	Mdn = 71.00; IQR = 26	z = -.272^a; p = .786
Gender—female	43 (77%)	25 (81%)	18 (72%)	χ² (1) = .20^b; p = .657
Education—years	M = 12.84; SD = 2.59	M = 12.94; SD = 2.63	M = 12.71; SD = 2.80	p = .821^c
Country of birth—Australia	43 (77%)	24 (77%)	19 (76%)	χ² (1) < .00^b; p > .100
Relationship to care recipient
Spouse/partner	42 (75%)	25 (81%)	17 (68%)	χ² (1) = .602^b; p = .438
Other	14 (26%)	6 (20%)	8 (32%)	χ² (1) = 2.20^b; p = .138
Coresident—yes	48 (86%)	29 (94%)	19 (76%)
Duration of care
1–11 months	24 (44%)	11 (36%)	13 (55%)	χ² (2) = 3.23^b; p = .199
1–2 years	28 (51%)	19 (61%)	9 (38%)
3 + years	3 (5%)	1 (3%)	2 (8%)
Direct care per week
0–20 hr	25 (51%)	13 (45%)	12 (60%)	χ² (2) = 1.64^b; p = .440
21–40 hr	4 (8%)	2 (7%)	2 (10%)
41 + hr	20 (41%)	14 (48%)	6 (30%)
No. services/supports	M = 2.20; SD = 1.41	M = 2.26; SD = 1.26	M = 2.13; SD = 1.60	p = .386^c
Relationship quality rating	M = 3.73; SD = 1.10	M = 3.57; SD = 1.07	M = 3.92; SD = 1.12	p = .575^c
Self-reported health rating	M = 3.32; SD = 0.83	M = 3.26; SD = 0.93	M = 3.40; SD = 0.71	p = .478^c
Reaction to disruptive behaviors (RMBPC)	M = 3.29; SD = 2.04	M = 3.15; SD = 2.25	M = 3.50; SD = 1.74	p = .648^c
Care recipients
Age—years	M = 77.54; SD = 6.02	M = 76.77; SD = 5.90	M = 78.50; SD = 6.17	p = .931^c
Diagnosis
Alzheimer’s disease	42 (76%)	24 (77%)	18 (75%)	χ² (3) = .982^b; p = .806
Vascular dementia	4 (7%)	2 (6%)	2 (8%)
Mixed	3 (6%)	1 (3%)	2 (8%)
Other/unknown	6 (11%)	4 (13%)	2 (8%)
Cognitive status (IQCODE)	M = 4.33; SD = 0.55	M = 4.30; SD = 0.56	M = 4.36; SD = 0.54	p = .910^c
Functional status (ADL)	M = 5.62; SD = 0.69	M = 5.67; SD = 0.48	M = 5.57; SD = 0.90	p = .093^c
Frequency of disruptive behaviors (RMBPC)	M = 1.18; SD = 1.34	M = 1.29; SD = 1.51	M = 1.04; SD = 1.10	p = .361^c

Note. LwML = living with memory loss program; LwML-S = living with memory loss program—strategy intensive; RMBPC = Revised Memory and Behavior Problems Checklist; IQCODE = Informant Questionnaire on Cognitive Decline in the Elderly (short form); ADL = activities of daily living.

*p≤.05

a = Mann–Whitney U

b = Pearson’s Chi square

c = Independent groups t test

Median age of caregivers was 70 years (IQR = 17), and mean age of care recipients was 77 years (SD = 6.02). The majority of caregivers were female (77%); spouse/partner of the care recipient (75%); coresided with the care recipient (86%); and had begun caregiving in the past 1–2 years (95%). Caregivers were reasonably well educated, with an average of 13 years of schooling. Care recipients typically had a diagnosis of Alzheimer’s disease (76%) and had moderate levels of cognitive and functional impairment as indicated by proxy measures (IQCODE: M = 4.33, SD = 0.55; ADL: M = 5.62, SD = 0.69). There were no statistically significant differences (p > .05) at baseline between groups for any of the demographic measures (including cognitive and functional status) or for any of the outcome measures (MSU questionnaire, ZB1-12, and HADS—depression and anxiety).

The CONSORT flow diagram for the study trial is presented in Figure 2. Of the 56 participants recruited to the study, 25 were allocated to the modified intervention group (LwML-S) and 31 to the active control group (LwML). Due to participant death in the intervention group (n = 1) and participant withdrawal from the control LwML program (n = 1), the total number of participants who received the modified intervention and active control conditions were 24 and 30, respectively. Posttest and follow-up assessments were collected for 23 intervention group participants and 28 control group participants. Removal of cases with missing data led to a further reduction in N. In order to preserve statistical power, and in line with our aim of capturing enduring changes of the interventions, the decision was made to include only pretest and follow-up data in the analyses (i.e., immediate posttest data were removed).

Figure 2

CONSORT flow diagram of study.

Memory Strategy Use, Burden, and Emotional Reactivity Between Groups and Across Time

A two (group) x two (time) MANOVA was conducted to assess the impact of the two different versions of the psychoeducation program (LwML, LwML-S) on caregiver reported memory strategy use, burden, and emotional reactivity (depression and anxiety) across two time-points (pretest and 1-month follow-up). There was a moderate but nonsignificant interaction between group and time, Wilks’s lambda = .92, F (4, 35) =.73, p = .58, η_p ² =.08, and a moderate but nonsignificant main effect comparing the two groups, Wilks’s lambda = .87, F (4, 35) = 1.29, p = .29, η_p ² =.13, indicating no significant differences in outcome between the two versions of the psychoeducation program. By contrast, there was a large and significant main effect for time, Wilks’s lambda = .49, F (4, 35) = 8.95, p < .001, η_p ² =.51, with univariate analyses showing an increase in caregiver reported memory strategy use for both psychoeducation groups over the course of the study, F (1, 38) = 34.10, p < .001, η_p ² =.47 (Table 3).

Table 3

Memory Strategy Use, Burden and Emotional Reactivity (Depression and Anxiety) Scores Across Two Time Points (Pre-Test and Follow-Up).

Outcome measure	N	Pretest M (SD)	Follow-up M (SD)	Time effect η ²	Interaction effect η ²
Memory strategy use
LwML	23	55.17 (16.78)	65.13 (21.78)
LwML-S	17	48.71 (17.23)	60.88 (19.39)
Total	40	52.43 (17.06)	63.33 (20.65)	.473*	0.009
Burden
LwML	23	16.52 (8.11)	18.13 (8.23)
LwML-S	17	16.06 (8.49)	15.06 (8.42)
Total	40	16.33 (8.17)	16.83 (8.34)	0.003	0.057
Depression
LwML	23	5.17 (2.46)	5.70 (3.36)
LwML-S	17	5.76 (3.70)	5.76 (4.51)
Total	40	5.43 (3.02)	5.73 (3.84)	0.009	0.009
Anxiety
LwML	23	7.57 (4.03)	8.00 (4.10)
LwML-S	17	6.35 (3.81)	6.14 (3.34)
Total	40	7.05 (3.15)	7.19 (3.86)	0.008	0.016

Note. LwML = living with memory loss program; LwML-S = living with memory loss program—strategy intensive. *p ≤ .001.

Memory Strategy Use, Burden and Emotional Reactivity Between Targeted Groups and Across Time

A two × two MANOVA was repeated in the targeted sample of caregivers (n = 28) who reported at least mild levels of depression or anxiety at pretest. Of the 12 caregivers removed (eight female), six were from LwML and six were from LwML-S. A comparison of the removed caregivers with those remaining revealed no age, gender, education, or memory strategy usage (pre, post, or prepost change) differences (all p > .05).

The difference between intervention phases persisted, Wilks’s lambda = .66, F (4, 23) = .2.91, p = .044, η_p ² =.34, again driven by significant improvements in memory strategy use, F (1, 26) = 9.18, p = .005, η_p ² =.26. Additionally, there was an interaction effect for depression, F (1, 26) = 4.154, p ≤ .05, η_p ² =.14, with depression scores decreasing over time for participants in the modified intervention group (LwML-S; Table 4).

Table 4

Memory Strategy Use, Burden and Emotional Reactivity (Depression and Anxiety) Scores Across Two Time Points (Pre-Test and Follow-Up) in Those Caregivers with at Least Mild Depression or Anxiety at Pre-Test.

Outcome measure	N	Pretest M (SD)	Follow-up M (SD)	Time effect η ²	Interaction effect η ²
Memory strategy use
LwML	16	59.00 (21.27)	65.19 (23.30)
LwML-S	12	54.25 (20.72)	61.50 (23.07)
Total	28	56.96 (20.79)	63.61 (22.85)	.261**	0.002
Burden
LwML	16	22.88 (8.52)	24.81 (7.95)
LwML-S	12	19.33 (7.61)	19.00 (7.51)
Total	28	21.36 (8.19)	22.32 (8.17)	0.014	0.027
Depression
LwML	16	6.44 (2.39)	7.75 (2.77)
LwML-S	12	7.83 (2.33)	7.17 (3.66)
Total	28	7.04 (2.43)	7.50 (3.13)	0.017	.138*
Anxiety
LwML	16	10.06 (2.77)	10.44 (3.24)
LwML-S	12	8.50 (2.50)	7.50 (2.71)
Total	28	9.39 (2.73)	9.18 (3.32)	0.013	0.058

Note. LwML = living with memory loss program; LwML-S = living with memory loss program—strategy intensive. *p ≤ .05, **p ≤ .01.

Moderation Model: Impact of Memory Strategy Use on Burden and Emotional Reactivity in the Targeted Sample

Next, we assessed the impact of caregiver reported changes in memory strategy use on caregiver burden and emotional reactivity (depression and anxiety) in the targeted sample, irrespective of group allocation. Memory strategy use and burden (r = .069), depression (r = .082), and anxiety (r = .267) were not associated. Significant positive relationships were however found between changes in burden and anxiety (r = .470, p ≤ .05) and burden and depression (r = .624, p ≤ .01), such that as burden decreased across the course of the study so too did anxiety and depression.

We assessed if improved memory strategy use reported by caregivers moderated the association of decreased caregiver burden with decreased caregiver anxiety or depression, after controlling for caregivers’ relationship with the care recipient. Changes in caregiver reported memory strategy use did not moderate the association between decreases in burden and decreases in anxiety, b = 0.003, p = .584; however, changes in memory strategy use did moderate the relationship between decreased burden and decreased depression, b = 0.010, p = .038. Applying the Johnson–Neyman technique, greater decline in burden across the study predicted greater decline in depression, but only for those who had larger gains (top 75%) in memory strategy use (Figure 3).

Figure 3

Change scores for caregiver depression and burden according to low/high memory strategy use.

Discussion

This study found that participation in a psychoeducation program resulted in greater use of memory strategies by caregivers of people with early-stage dementia. This occurred not only for those caregivers who participated in the modified intervention program (direct training in memory strategies) but also for those caregivers who participated in the standard version of the program (which involved the provision of memory strategy information sheets but not additional direct training). The generality of the positive response to information (indirect or direct) about memory strategies is promising and supports related research (e.g., Clare et al., 2011; Kinsella et al., 2009). Teaching memory strategies at this early stage has the potential to enable strategies to become securely integrated into the everyday lives of the care dyad and support the care recipient to maintain at least some functional independence (e.g., engaging with the familiar routines of preparing lunch) as cognitive impairment worsens. This may help to lessen some of the impacts of dementia on both care recipient and caregiver and by doing so enable caregiving in the home to continue for longer than might otherwise be possible (Nelis et al., 2007; Smith et al., 2011).

A possible reason for the observed lack of a specific group effect may be the strength or “dosage” of the direct training intervention provided to caregivers (Conn & Chan, 2016). The study attempted to integrate an evidence-based intervention into a real-world setting (i.e., working within the structure of an established psychoeducation program, LwML) and the modified intervention involved only one focused face-to-face session between caregivers and the neuropsychologist during which the RECAPS DVD was presented. In their meta-analysis of psychosocial interventions for caregivers of people with dementia, Brodaty and colleagues found that higher dosage was generally associated with better outcomes for brief interventions (Brodaty et al., 2003); therefore, additional face-to-face sessions with the neuropsychologist (i.e., increasing the intensity of strategy training) may have resulted in a larger effect.

That the comparison group in this study was an active control—with caregivers in this group receiving tip sheets of memory strategies—may also have contributed to the lack of a group effect and reflects the methodological challenges in research with active controls (Street & Luoma, 2002). While advantageous over passive controls (e.g., no treatment and waitlist), which can be ethically problematic and are known to overestimate the effect of an intervention, active controls tend to produce relatively smaller effect sizes of interventions (Mohr et al., 2014), especially when structurally matched (e.g., number of sessions, length of sessions, and format; Baskin et al., 2003), as was the case in this study. There may have been too many “common factors” (Wampold, 2015) shared by the control and intervention conditions to show a significant group effect. As group facilitators were not blind to the aims of the study, it is also possible that they may have inadvertently emphasized memory strategies within the active control groups during the study period, furthering the commonalities across conditions and impacting the study outcome. Blinding poses a particular challenge in intervention studies such as this (Page & Persch, 2013) where a degree of compromise to internal validity is required in order to deliver a pragmatic study.

It has been observed that intervention effects tend to be larger for increasing general caregiving skills than decreasing caregiver burden or depression (Schulz & Martire, 2004). That was the case in this study, with the discrete skills involved in using memory strategies found to significantly increase, whereas there was limited change observed in the emotional reactivity measures when the entire sample was considered. The potential inadequacy, or limitations, of commonly used standardized outcome tools to detect psychological benefits in intervention research has been identified within a large study that found positive qualitative reports by caregivers and yet lack of change in standard psychological tests (Clare et al., 2019). There are several reasons why standardized tests of emotional well-being may be insensitive in caregiver intervention research and fail to capture meaningful change. Firstly, this may happen when emotional well-being variables are more distal to the primary focus of the intervention, such as goal performance or strategy use, and are therefore likely to remain more stable across assessments in the short-term phase of monitoring outcome (Regan et al., 2017). Monitoring long-term outcome postintervention (i.e., at least 6 months poststudy completion) may provide a better index of impact on emotional status, although longer term follow up in an older sample is problematic not only due to the costs involved but also the associated higher rates of attrition (Hayward & Krause, 2016). Secondly, ceiling effects may be a contributor when the sample includes caregivers who are not reporting psychological distress at study baseline, thereby providing little scope for improvement in the psychological outcome measures (Clare et al., 2019). This is a likely explanation for the current study, with a significant change over time in depression scores observed when focusing only on those participants who reported at least some degree of depression at baseline. Third, it is important to note that the bulk of caregiver intervention research to date (including the present study) has tended to focus on decreasing negative outcomes (e.g., depression or burden) rather than capturing positive gains; the benefits caregivers often report at trial exit may therefore relate to an outcome not measured in the current study.

The finding that providing direct training in memory strategy use in addition to a standard psychoeducation program can reduce depression in caregivers who are exhibiting such symptoms is encouraging. These results provide further support for multicomponent psychoeducation interventions, specifically those including modules focused on skill building. It also highlights the value of interventions that are modifiable (rather than a “one size-fits-all” approach) so that they best match the individual needs of caregivers (Gitlin et al., 2003). As each caregiving situation will be different and bring with it unique daily challenges, interventions need to be flexible so that they can be personalized to address the most pressing concerns for each care dyad. This study provides evidence that an individualized approach is not only possible within a structured, group program format but also effective in improving caregiver outcomes.

Further guided by a theoretical stress process model (Pearlin et al., 1990), we investigated the importance of targeting moderating variables in psychosocial interventions for caregivers. We assessed if increased caregiver memory strategy use could buffer the impact of caregiver burden on depression. Previous longitudinal research had suggested the possibility of mastery buffering the effect of stress on negative caregiver outcomes (Mausbach et al., 2007). The present study has demonstrated that caregiver outcomes can be improved by enhancing the use of caregiver personal resources such as mastery (in this instance, by becoming skilled in the use of memory strategies via participation in a multicomponent psychoeducation intervention program). Our moderation analysis provides preliminary support that skill building, and the use thereof, maximizes the beneficial effects of intervention on caregiver perceptions of burden and levels of depression.

Limitations of the study included the sample size, which although comparable to other dementia caregiver intervention research may nonetheless mean the study was underpowered. This suggests that although the study was able to detect moderate to large effects, small effects may have been less reliably identified. Strengths of the study were the inclusion of an active control group (rather than a wait list condition) and the low rate of attrition over the course of the program. The LwML program and RECAPS module were well received by participants, supporting earlier evaluations (Bird et al., 2005; Liddle et al., 2012), with many caregivers commenting that they would call upon the training at some point in the future when care needs increased. While effectiveness is important to establish for new or modified interventions, so too are the practicality of interventions and acceptability to caregivers (Dickinson et al., 2017).

Future studies may consider enhancing the strategy training by dedicating further sessions to facilitated discussion and practice of memory strategies for real-life problems and scenarios. Furthermore, complimenting quantitative data collection with qualitative measures probing the caregivers’ experience of the barriers and enablers in applying strategies in real-life activities may capture more subtle information about the process of participant change that may not be reflected using standardized outcome measures.

Conclusion

Psychoeducation programs delivered to the person with dementia and their family caregiver can improve caregiver outcomes, such as use of memory strategies or skill building. When combined with active training in memory strategy use provided to caregivers, psychoeducation can also lead to significant improvements in levels of depression, specifically for those caregivers who report symptoms of depression on enrollment. Underpinned by the stress process model, this study has also demonstrated that those who more often use memory strategies had concurrent reductions in burden and depression. This suggests that adequately equipping caregivers with information, support, and practical skills in managing the cognitive challenges of dementia has the potential to increase the control caregivers feel they have over their situation, and buffer at least some of the effects of burden on caregiver mental health.

Supplemental Material

Supplementary Material 1 - Supplemental material for Memory Strategy Training Can Enhance Psychoeducation Outcomes for Dementia Family Caregivers: A Randomized Controlled Trial

Supplemental material, Supplementary Material 1, for Memory Strategy Training Can Enhance Psychoeducation Outcomes for Dementia Family Caregivers: A Randomized Controlled Trial by Linda McAuliffe, Bradley J Wright and Glynda Kinsella in The International Journal of Aging and Human Development

Footnotes

Acknowledgments

The authors would like to gratefully acknowledge Jenny Philipp and the Dementia Australia (Vic) Early Intervention Team for their assistance with participant recruitment and program delivery. The authors would also like to thank Mary Castellani and Christine Canty for their assistance with study implementation.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Windermere Foundation Special Grant; and by an Alzheimer’s Australia Research Limited (AAR)/Dementia Collaborative Research Centre - Carers and Consumers (DCRC-CC) Joint Research Grant for Research Focused on Quality in Dementia Care, as part of the Australian Government’s Dementia Initiative. The views in this work are the views of its authors and not necessarily those of the Australian Government.

ORCID iDs

Linda McAuliffe

Glynda Kinsella

Author Biographies

Linda McAuliffe is a PhD candidate in the School of Psychology & Public Health, La Trobe University, Melbourne, Australia. Her research interests include the effect of dementia caregiving on psychological and physical health outcomes and associated interventions.

Bradley J Wright conducts research in the School of Psychology & Public Health, La Trobe University, Melbourne, in the areas of performance psychology (organizational & sport psychology). Dr Wright has researched the links between occupational stress (individual and organisational factors) and ensuing ill-health with numerous large organisations by focussing on pre-clinical indices of stress and ill-health (immune, cardiovascular and hormonal systems).

Glynda Kinsella is an emeritus professor in the School of Psychology & Public Health, La Trobe University, Melbourne, having recently retired from the position of Professor ofClinical Neuropsychology and Coordinator of Postgraduate Programs in Clinical Neuropsychology in 2017. Her recent research addresses the neuropsychological characterisation and consequences of mild cognitive impairment in older age, with a specific interest in evaluating interventions for these changes.

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