IPA Bulletin
Recent Advances

Wendy Moyle - Australia

Family Caregivers of People with Dementia

The importance of family caregivers to the ongoing care of people with dementia is unquestionable. However, the burden of caregiving on families is also acknowledged and has resulted in research to understand this burden as well as opportunities to manage it. Nurses are often in a key position to assist families. The following papers outline two recent interventions that focus on support for family caregivers. (WM)

Nurse researchers in Hong Kong aimed to investigate the effectiveness of a family-led, mutual support group intervention for people with dementia on caregivers’ quality of life, burden and social support. Additionally, they examined the effect of the intervention on the mental state and institutionalisation of community dwelling people with dementia. Eighty people with dementia and their primary family caregiver were randomly recruited from a large dementia centre in Hong Kong. Participants were randomised into either the Family Mutual Support Program in Dementia Care (FMSP-DC), a community based program developed in Hong Kong, or routine care (control). The FMSP-DC consists of 8, bi-weekly, 2-hour group sessions over 6 months. The program focused on 7 topics including: information about dementia and its treatment; social and support networks; sharing and the emotional impact of caregiving; self-care; interpersonal relationships; support and resources; and problem solving. Outcome measures including caregivers’ burden (Family Caregiving Burden Inventory, FCBI), quality of life (WHOQOL-Bref), social support (Social Support Questionnaire), MMSE, and placement or hospitalisation were collected at baseline and post-test, one week following the intervention. Families were encouraged within the program, under the guidance of a psychiatric nurse to share their personal experiences and problems. Repeated measures MANOVA indicated statistically significant differences between the intervention and control group on the multivariate test of significance for the outcome variables (F=5.1, d.f.=3,78, p=0.0005). There were statistically significant differences between the two groups in family caregivers’ burden and quality of life and clients’ symptoms of severity and frequency as well as duration of institutionalisation at post-test. The findings support the effectiveness of the FMSP-DC and in particular the importance of education and support groups for family caregivers.

Wang & Chien. Randomised controlled trial of a family-led mutual support program for people with dementia. J Clin Nrs 2011, 20, 2362-2366.

North American nurse researchers undertook a secondary analysis of longitudinal data on correlates of care relationship mutuality, the perceived quality of a carer-care recipient relationship. A high level of mutuality, i.e., the perception that the relationship is positive, is thought to reduce negative outcomes. Data from 91 care-carer dyads (carers of people with AD and Parkinson’s disease and people with dementia) who participated in the control group of a randomized trial of skill training in home-care was examined. Multilevel models for change were used to explore correlates related to care relationship mutuality, over a 12-month period. The Mutuality Scale of the Family Care Inventory measured mutuality. Carers who reported lower mutuality were: (1) caring for people with lower functional ability, (2) had less caregiving experience, and (3) more depressive symptoms. High mutuality between carers and recipients increases the likelihood that carers will continue to care for the care recipient and therefore lessen the chance that the carer will place the care recipient into nursing home care. The authors recommend relationship-focused skills training for carers may improve health outcomes for carers and increase mutuality between carer and care recipient.

Shim, Landerman & Davis. Correlates of care relationship mutuality among carers of people with Alzheimer’s and Parkinson’s disease. J Adv Nrs, 67, 1729-1738.

Mark Rapoport - Canada

Antidepressants and Stroke Risk

Evidence is accumulating for the use of antidepressants in the treatment of major depression after a stroke, and even for the prophylactic use of these agents in order to prevent the onset of major depression in this population. Enthusiasm for this must be tempered somewhat with findings from two epidemiological studies from Taiwan and the UK published earlier this year pointing to an increased risk of stroke associated with antidepressants in community-dwelling elderly. In the first study, the risk was associated only with those who had received one or two prescriptions for antidepressants in the previous year, and there was a protective effect among those who received six or more prescriptions. In the second study, strokes and TIAs were among many risks investigated, and while there was a statistically significant increase in relative risk associated with antidepressants, the absolute increase was small.

Wu et al conducted a case crossover study with 24,214 patients who had their first hospitalization for a cerebrovascular event between 1998 and 2007 in Taiwan. They used hospitalization and drug data from their national health insurance program which covered 98% of the population. The average age of the population was 68.6 (SD 12) years, and 67% of their sample was aged 65 years or older. They compared the odds of exposure to antidepressants in the 14 days prior to hospitalization for stroke with the odds of exposure to antidepressants in the 15 to 28 days prior to the index stroke hospitalization. Time windows of seven and 28 days were also used for sensitivity analyses. In their primary analysis, they controlled for outpatient visits, and exposure to other drugs such as antipsychotics, antithrombotics, diuretics, antihypertensives, lipid lowering medications, and medications for diabetes. With the primary analysis, they found an increased risk of exposure to antidepressants in the time window immediately preceding the stroke compared with the control time interval, with an OR of 1.48 (95% CI 1.37 to 1.59). This odds ratio for the sample as a whole was comparable to the odds ratio for those between the ages of 65 and 75 (OR 1.48, 95% CI 1.30 – 1.68), and for those aged 75 and over (OR 1.56, 95% CI 1.37 to 1.78). The risk seemed to be higher for drugs which strongly inhibited the serotonin transporter, or had low-to-intermediate inhibition of the noradrenergic transporter. SSRIs posed higher risks than tricyclics or monoamine oxidase inhibitors, and the risk increased with average daily dose. Interestingly, this risk only applied to subjects with only one or two antidepressant prescriptions in the year prior to stroke. For subjects who had more than six prescriptions for antidepressants in the year prior to stroke, there seemed to be a protective effect (OR 0.62, 95% CI 0.53 – 0.72). The case-control design is an important advantage here in that controls for between-subject confounds, but it is important to bear in mind some limitations of this research. The study time period of 1998 to 2007 is quite long, and a case control study such as this does not adjust for temporal trends in the prescribing of antidepressants. Second, it is possible that change in severity of psychiatric symptoms between the exposure and control intervals confounds the situation, and this is not measurable in such a study, nor are assessments of adherence.

Wu, C-S., Wang, S-C, Cheng, Y-C., Gau, S.S-F., Association of cerebrovascular events with antidepressant use: A case-crossover study. Am J Psychiatry 2011, 168, 511-521.

Coupland et al report on the cohort study of 60,746 patients from 570 general practices in the United Kingdom, mostly from England. The diagnostic and prescription data were from primary care research databases from these practices, which represents 7% of general practices in the United Kingdom. Entry into the cohort study was the time of first diagnosis of depression after the age of 65, or first prescription for an antidepressant, between January of 1996 and December of 2007. The cohort was followed through to the end of December 2008. The average age of the sample was 75.0 (SD 7.6), and the sample was followed for an average of five years (SD 3.3). Of the sample, 89% received at least one prescription for an antidepressant, 10% of whom received only one prescription, and 10.9% of whom received 60 prescriptions or more. The median duration of prescription was 364 days. Many outcomes other than stroke were studied including all-cause mortality, attempted suicide, falls, fractures, hyponatremia, and G.I. bleeding. Analyses were adjusted for age, sex, previous depression prior to the age of 65, the severity of depression, smoking, medical comorbidities, other drugs, and previous falls. The risk of stroke or TIA associated with tricyclic antidepressants was not significant (HR 1.02, 95% CI 0.93 – 1.11). The risk of stroke or TIA was significant with the SSRIs (HR 1.17, 95% CI 1.10 – 1.26), and with other antidepressants (HR1.37, 95% CI 1.22 – 1.55). The risk of stroke or TIA associated with SSRIs was greater than that for TCAs (HR 1.15, 95% CI 1.05 – 1.26). Interestingly this study showed also a similar increased risk associated with SSRIs in some of their other outcomes including all-cause mortality, falls, fractures, bleeding, and hyponatremia. It is important to note that while the relative risk of stroke with antidepressants was significant in this study, the absolute annual risk of stroke or TIA in those not taking antidepressants was 2.23%, and the risk in those taking SSRIs was 2.61%, and this yields a number needed to harm of 263 (1/0.0261-0.0223). Furthermore, indication and channeling bias may confound the results of this study.

Coupland, C., Dhiman, P., Morriss, R., Arthur, A., Barton, G., Hippisley-Cox, antidepressant use and risk of adverse outcomes in older people: a population-based cohort study. BMJ 2011, 343; d4551.


Reprinted from IPA Bulletin, Volume 28, Number 4