REACH VA: A Dementia Caregiver Support Program

It is estimated that the 11 million caregivers in the United States providing 12.5 billion hours of care to individuals with Alzheimer’s disease are providing care valued at, but unpaid, nearly $44 billion. This unpaid value is in addition to long-term care costs of $178 billion (in 2006). The Institute of Medicine’s 2008 report, Retooling for an Aging America: Building the Health Care Workforce, stated that family members are an essential part of the healthcare workforce and should be given data, knowledge, and tools to provide high-quality care. The National Institute on Aging/National Institute of Nursing Research REACH II (Resources for Enhancing Alzheimer’s Caregiver Health) randomized controlled trial provided education, support, and skills building in home and by telephone. The study results demonstrated that when caregivers received such support, there was significant improvement in adverse physical and psychological consequences often associated with caregiving, including depression, anxiety, sleep disturbance, hospitalization, and mortality. To explore the feasibility of extending caregiver assistance into the Veterans Health Administration (VHA), the VHA Patient Care Services, National Caregiver Support Program funded a clinical translation of the REACH II trial. The REACH VA (Department of Veterans Affairs) trial, begun in 2007, was the first national clinical translation of a proven dementia behavioral intervention covering multiple states and facilities. Results of REACH VA were reported in Archives of Internal Medicine [2011;171(4):353-359]. Clinical staff members from 24 VA Medical Center Home–based Primary Care programs in 13 states delivered interventions to caregivers. Caregiver inclusion criteria included being coresident family caregivers providing ≥4 hours of care per day for at least 6 months, and selecting at least 2 caregiving stress behaviors from a list (ie, overwhelmed, often needing to cry, angry/frustrated, cut off from family/friends, moderate/high levels of stress, and declining health). Patient inclusion required Alzheimer’s disease or related dementia and at least 1 limitation in activities and ≥2 instrumental activities of daily living limitations. Patients who were too ill were excluded. The intervention included nine 1-hour individual home sessions, three 0.5-hour individual telephone sessions, and five 1-hour monthly telephone support group sessions. Topics included education, support, and skills training to address 5 caregiving risk areas: safety, social support, problem behaviors, depression, and caregiver health. Staff members at the Memphis VA Medical Center, Tennessee, collected data on burden, depression, health and healthy behaviors, caregiving frustrations, social support, dementia-related behaviors, and time spent providing care and on duty. The study enrolled 127 caregivers at the 24 facilities; caregivers were approximately 72 years of age, primarily white, and wives. The veterans were approximately 12 years older than their caregivers (mean age, 83 years). Fifty-two veterans who were assessed with the Mini-Mental State Examination had moderate dementia. At baseline, 86% of the caregivers said they were overwhelmed, 80% reported feeling like crying, 89% were frustrated as a result of caregiving, 56% reported feeling cut off from family/friends, 53% said they felt lonely, and 39% reported having worse health than in the previous year. When asked about stress, 60% rated their stress as ≥6 on a 10-point scale, with 10 representing extremely stressed. At follow-up, the caregivers showed significant improvements in burden, depression, impact of depression on daily lives, and caregiving frustrations. In addition, the difference of almost 2 hours in the amount of time per day spent on caregiving duty tended toward significance. In subjective assessments of benefits of the intervention, the caregivers felt the program benefited them, helped them understand the disease and their role in caregiving, and increased their knowledge and ability to provide care. In summary, 96% of the participants believed the program should be provided by the VA to caregivers. The researchers concluded by saying that “this clinical translation achieved outcomes similar to the REACH II randomized controlled trial, providing clinically significant benefits for caregivers of a veteran with a progressive dementing disease. This model of caregiver support can inform public policy in providing assistance to caregivers.”