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Correspondence: Address correspondence to Gabriele Wilz, PhD, Department of Clinical and Health Psychology, Technical University of Berlin, Franklinstr. 28/29, D-10587 Berlin, Germany. E-mail: gabriele.wilz{at}gp.tu-berlin.de
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Key Words: Dementia intervention • Depression • Family care • Clinical trial
Extensive existing research has shown that interventions for caregivers can effectively reduce their burden of care (Pinquart & Sörensen, 2006; Schulz, Martire, & Klinger, 2005). The results of existing reviews have indicated that, along with sharing experiences with other caregivers and actively applying behavior strategies, participating in multicomponent interventions that include psychotherapeutic strategies such as problem solving is highly recommended for caregivers (Gitlin, Hauck, Dennis, & Winter, 2005; Kalra et al., 2004; Pinquart & Sörenson, 2006). In a study by Mittelman, Haley, Clay, and Roth (2006), the interventions even resulted in a delayed need for institutional care.
Despite sustained demand, assisted vacations are an important type of potential support for family caregivers and are still too rarely available. An assisted vacation is defined as a shared activity for a caregiver and his or her care recipient. During the assisted vacation, caregivers have the chance to undergo a process of regeneration, recuperation, and relaxation in a nice and calming environment.
Despite extensive research, we found very few evaluation studies on assisted vacations (Perry & Bontinen, 2001; Planques, Jacus, Mailhe, & Di Menza, 1995). The guidelines on which these few studies were based, however, are not comparable to those used in this study. Planques and colleagues, for example, carried out a study on assisted vacations for people living in nursing homes. Perry and Bontinen conducted an evaluation study of assisted weekend vacations for people with dementia and their caregivers. The caregivers, however, did not actively take part in the program; they were only interviewed to determine how helpful they thought the vacation was for their afflicted relatives.
Another form of support is called respite care and is normally designed to give structured temporary relief to caregivers by providing center-based day programs, in-home relief, or short-term institutional respite. Existing studies evaluating effects of respite care on caregiver outcomes have reported mixed results (Gottlieb & Johnson, 2000). Pinquart and Sorensen (2006) concluded that effects of respite interventions on caregiver burden, depression, and subjective well-being were small but significant. Two other existing reviews of controlled trials could not demonstrate any benefits or adverse effects of respite care for the caregivers (Flint, 1995; Lee & Cameron, 2004). In the authors' view, it was more likely that this reflected a lack of high-quality research in this area than a lack of evidence (Lee & Cameron, 2004). Apart from this summary of reviews, some special programs of respite care have reported beneficial effects for caregivers. For example, in Wishart and colleagues' (2000) study of an in-home visiting/walking program for people with dementia, the caregivers in the intervention group reported experiencing more overall improvements and reductions in burden of care than did those in the control group.
However, some caregivers in Scharlach and Frenzel's (1986) study reported deterioration in patients' health and mental functioning as well as in the caregiver–patient relationship. Respite care can exacerbate the memory and behavior problems of people with dementia, and such difficulties can, in turn, increase the degree of burden the caregiver has to shoulder at home.
In contrast to respite care, assisted vacations are activities designed to be shared by caregivers and patients. This kind of care-assisted vacation is, for many caregivers, the only way to both enjoy a vacation with their ill family member and have time to themselves. Readers should regard the following as a pilot study that, by means of a small-scale trial, aimed to do the first evaluation of the effects of assisted vacations on caregivers of persons with dementia. The primary goal of this study was to determine the effectiveness ofcare-assisted vacations in reducing caregivers' susceptibility to depression and physical complaints.
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Description of the Intervention
The assisted vacations concept was developed by the participating counseling centers ("The Workers Welfare Munich" counseling center for caregivers and older people, and the Alzheimer Society Brandenburg and was already in existence years before this evaluation took place.
The aim of the assisted vacations was to improve caregivers' physical and mental health through the following main activities and interventions:
The content of the intervention is described in more detail in the written program. For example, each day there were planned pleasant social activities such as dancing, visiting a restaurant or going to concert, taking a boat trip, visiting the zoo, visiting thermal baths, or having a barbecue with live music as well as free time for relaxation. There were also group discussions and lectures in which health professionals provided information regarding diseases, medication, or care and helped the spouses better understand how to deal with problem behavior in daily life and how to recognize personality changes caused by dementia.
Some activities were offered for couples to participate in together, and some were just for the caregivers. During activities, group sessions, and lectures for caregivers, specialized nurses cared for the spouses suffering from dementia. This was typically for a period of 2 to 3 hr in the morning and afternoon.
Due to the variety of caregiving situations represented, the interventions were oriented to each caregiver's individual needs and problem profile. Therefore, each caregiver had the opportunity to speak about his or her own problems and needs in the group discussion and could decide which activities were most suitable for him or her. In the individual professional care sessions, caregivers had the opportunity to ask questions about care and problem behaviors and get hands-on training and advice for coping with care recipients' problem behaviors.
The couples were asked before the start of the vacation to name their own needs, expectations, and wishes for activities. Two weeks before the trip a meeting was organized with all participating couples and the therapeutic team. During the trip, a daily meeting was organized for participating couples to discuss activities and air suggestions. Even the persons with dementia offered some suggestions for activities. One of them, for example, wanted to play soccer, and as a result, a football team formed and trained during the vacation.
The vacations lasted for 1 week and took place in a hotel or rehabilitation clinic suitable for handicapped people. A team of health professionals, such as nurses qualified in geriatric care, led the vacations. At all times during the vacation week, even during the night, there was one nurse available for every two patients.
Procedure and Participant Characteristics
We examined participants in assisted vacations hosted by two different organizations. We limited the sample to these organizations because at the time of the study they were the only ones providing assisted vacations in Germany.
We invited caregivers who fulfilled the following inclusion criteria to participate: medical diagnoses of dementia in the male spouse, shared household with the care recipient, and principal caregiver female. In order to create a target study group with as much homogeneity as possible, we selected only women caring for husbands suffering from dementia.
Before collecting any data, the interviewers first requested that the caregivers complete a written participation consent form. On account of the severe cognitive impairment of the care recipients, it was not possible to obtain consent from them.
The distribution of the participants into the intervention or the control group was on a first-come, first-served basis. In total, the counseling centers were able to place 18 couples in the vacation group. During the recruitment phase, only 29 potential participants both expressed interest in going on the vacation and fulfilled the selection criteria. Therefore, the intervention group consisted of 18 couples, whereas the control condition only had 11.
For participants in the waiting list control group, caregivers provided ongoing in-home care for the impaired family member during the 3-month wait interval. No additional intervention or professional care was provided for the control group during the 3-month interval between Time 0 and Time 2. The participants on the assisted vacations (n = 18) were interviewed before the vacation (Time 0; range 4–14 days prior to intervention), directly afterward (Time 1; range 2–5 days, measured for intervention group only), and 3 months after the first interview (Time 2; range 2–5 days). All participants in the waiting list comparison group (n = 11) were interviewed twice, at Time 0 and Time 2. Independent assessors (qualified nurses in geriatric care), not the nurses of the counseling centers' therapy teams, took the pre- and postintervention measurements in face-to-face interviews given in the caregivers' homes.
Assessment Instruments and Statistical Analyses
The aim of the study was to test the effects of the intervention on both the subjective physical and mental health of the caregivers.
Furthermore, we selected measurements that have been used and tested in caregiver research and that have available values from the general population. We used the Giessen Subjective Complaints List (GBB-24; Brähler, Schumacher, & Scheer, 1995) to evaluate the subjective physical health of participants and the Beck Depression Inventory (Beck, Steer, & Garbin, 1988) to assess their symptoms of depression. The GBB-24 proved to be a suitable instrument for objectifying subjectively perceived physical complaints and allowed for evaluations of treatment effects. The GBB-24 global score that we used consisted of 24 items that measure physical complaints such as exhaustion, stomach trouble, rheumatic pains, and heart trouble. The caregivers rated how much they had been bothered by each symptom over the past week on a 4-point scale ranging from not at all to strong. Both instruments had already been used with wives of people with dementia and had been tested for internal consistency (Wilz, Küssner, & Kalytta, 2005).
We used the paired T-test to assess immediate postintervention changes (Time 1 was only measured in the intervention group) in the outcome variables. To establish the health effects of the assisted vacation, we carried out analysis of variance with repeated measurements (Time 0 and Time 2), using intervention versus control as the grouping factor. In order to take the participants' subjective evaluation of the assisted vacation into account, we asked them to give feedback in personal interviews after the vacation.
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Immediate Effects of Assisted Vacations (Comparison T0–T1, Intervention Group Only)
Directly after the assisted vacation, there was a significant improvement in participants from the intervention group in physical complaints (df = 1/14; T = 2.36; p =.016).
There was a clear decrease in bodily complaints from an initial mean of 37.3 (SD = 16.3) to a mean of 28.3 (SD = 16.2) at Time 1, reflecting a strong effect (d = 0.653; Kreamer, 1985; Kreamer & Thiemann, 1987). Together, the mean values of physical complaints at each of the measurement points lay well above the level of the general population with a mean for women of 16.48 (SD = 12.20, n = 114; Brähler et al., 2000).
We found a tendency toward a decrease in depressive symptoms (df = 1/14; T = 1.73; p =.053). Depressive symptoms decreased from an initial mean of 15.2 (SD = 7.5) to a mean of 12.9 (SD = 10.7) directly after the assisted vacation (strong effect of d = 0.533). Together, the mean values of depressive symptoms at each of the measurement points lay well above the level of the general population with a mean for women of 9.14 (SD = 6.04, n = 113; Brähler et al., 2000).
Follow-Up Effects of Assisted Vacations: 3 Months Postintervention (Comparison Between Intervention and Control Group, T0 and T2)
As far as physical complaints were concerned, the analysis of variance showed a significant interaction between the repeated measurements and the grouping factor, F(2, 21) = 5.33, p =.031 (see Figure 1). Thus, the physical complaints in the intervention group decreased from 37.3 (SD = 16.5) to 32.3 (SD = 17.2) after 3 months, whereas there was deterioration in regard to physical complaints in the control group (T0: M = 37.9, SD = 17.1; T2: M = 46.1, SD = 18.4), reflecting a medium effect size (d = 0.447).
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The majority of the participants (n = 17) assessed the assisted vacation as having been very helpful and rejuvenating. The following statements of interviews illustrate the personal significance of the care-assisted vacation for the participants:
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The intervention may also have effects on placement of patients in institutional care. As shown in a study by Mittelman and colleagues (2006), improvement in well-being through psychosocial interventions is related with significant postponement of nursing home placement. Even assisted vacations aim to improve well-being of caregivers and their ability to cope with various demands of caregiving; therefore, there may be some delay in time of home placement of the care recipient. Further research should focus on this important area. We recommend that when pursuing this, researchers use longer follow-up intervals in order to allow for the assessment of long-term effects and rates of placement in institutional care. Additionally, we recommend that future studies take measurements to investigate changes in perceived social support, quality of life, and improvements in coping skills.
Although the present study improves knowledge of evaluation of an innovative kind of intervention for family caregivers, it is also limited in several respects. The first of these concerns the generalizability of the present results. In order to reach a high level of homogeneity in the sample, we included only caregiving wives of men with dementia. Therefore, the findings cannot generalize to other family caregivers. Even through we believe that other family caregivers would benefit from the intervention presented here, further research is necessary to evaluate the efficacy of the care-assisted vacation in these populations.
Second, the small sample size was the greatest limitation of the study. Because of it, the statistical power was too small to reach statistical significance for the group differences in depression. Future research with larger sample sizes could confirm the effects of this pilot study and may allow further insight into different effects for different levels of dementia. However, data collection for interventions of this kind is difficult because of the small number of participants in each vacation offered and the small number of counseling centers offering assisted vacations.
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1 Department of Clinical and Health Psychology, Technical University of Berlin, Germany.
2 Institute of Public Health Research, Technische Universität München, Munich, Germany.
Decision Editor: Nancy Morrow-Howell, PhD
Received for publication January 3, 2007. Accepted for publication May 23, 2007.
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