Effects of a Modified Mindfulness-based Cognitive Therapy for Family Caregivers of People With Dementia

Effects of a Modified Mindfulness-based Cognitive Therapy for Family Caregivers of People With Dementia

Effects of a Modified Mindfulness-based Cognitive Therapy for Family Caregivers of People With Dementia in Stress Reduction: A Randomized Controlled Trial

Caring for people with dementia (PWD) poses many challenges which may cause high levels of caregiver stress. This study aims to investigate the effects of a modified Mindfulness-based Cognitive Therapy for stress reduction in the family caregivers of PWD. A prospective, single-blind, parallel-group randomized controlled trial (RCT) of 76 family caregivers of PWD will be recruited and randomized to either the MBCT or the control groups.The primary outcomes (stress) and secondary outcomes (anxiety, depression, burden, quality of life and resilience) will be measured at immediate post-intervention (T1) and at 3 months follow up (T2) which will be compared with the baseline (T0). Mixed repeated measure MANOVA will be performed to assess the effects of time, group, and time-group interaction on all outcome measurements.To understand the therapeutic components and identify the strengths, limitations, and difficulties of the MBCT program, process evaluation will be conducted through focus group interviews with 15 participants from the MBI group. It is hypothesized that the MBCT group will have a significantly greater reduction of stress (primary outcome) and improvement in the secondary outcomes, namely depression, anxiety, and burden, at T1 and/or T2 than the control group.

Background: Caring for people with dementia (PWD) poses many challenges which may cause high levels of caregiver stress. Mindfulness-based intervention (MBI) is a newly adopted psychosocial intervention through an integration of the mind and body to reduce stress of the participants. A systematic review was conducted with five studies (four RCTs and one quasi-experimental study) to investigate the effect of MBI in stress reduction in the family caregivers of PWD. Of these, three trials involving 144 participants were eligible for the meta-analysis. The result showed that the stress levels dropped significantly after an 8-week MBI in the family caregivers of PWD with a moderate aggregated effect size of 0.57 (95% CI [0.23, 0.92], overall effect Z= 3.25 at p= 0.001). While MBI's immediate effect was found, the long term effect was unclear. Besides a limited number of clinical trials and several limitations (such as poor study design and small sample size) were also identified in this review. It signifies that more studies are still required to examine the effects of MBI for family caregivers of PWD. Since MBI is a new intervention for stress management among the family caregivers of PWD, a feasibility study was conducted between 2016 and 2017. It found that the family caregivers could master the mindfulness skill after the mindfulness sessions with a low attrition rate of 3.8%. A modified Mindfulness-based cognitive therapy (MBCT) protocol was also validated in the study to fit the local need and address the limitations identified in previous studies. Objective: This study aims to investigate the effects of a modified MBCT for stress reduction in the family caregivers of PWD in Hong Kong. Methods: A prospective, single-blind, parallel-group randomized controlled trial (RCT) of 76 family caregivers of PWD will be recruited and randomized to either the MBCT or the control groups. The MBI groups will receive a seven-week, group-based MBCT training whereas the control group will receive social interactions and routine education on dementia care program of a frequency and timing similar to those of the MBI group. The primary outcomes (stress) and secondary outcomes (anxiety, depression, burden, quality of life, resilience) will be measured at immediate post-intervention (T1) and at 3 months follow up (T2) which will be compared with the baseline (T0). Mixed repeated measure MANOVA will be performed to assess the effects of time, group, and time-group interaction on all outcome measurements. Both per-protocol (PP) and intention-to-treat (ITT) analysis will be performed in order to find out more factors affecting the use and effectiveness of MBCT such as non-compliance and acceptability. To understand the therapeutic components and identify the strengths, limitations, and difficulties of the MBCT program, process evaluation will be conducted through focus group interviews with 15 participants from the MBI group. It is hypothesized that the MBCT group will have a significantly greater reduction of stress (primary outcome) and improvement in the secondary outcomes, namely anxiety, depression, burden, quality of life, and resilience at T1 and/or T2 than the control group. Significance and Value: Reducing the caregiving stress level can promote the well-being of the family caregivers to maintain their sustainability in terms of providing daily care for their family members with dementia for a longer period of time. Evidence shows a minimal and short term effects of other psychosocial interventions (such as respite care, mutual support group) for reducing caregivers' stress. On the other hand, the MBCT is found effective in stress reduction in other populations. This finding is also supported by a feasibility study of using the MBI in family caregivers of PWD. The results of this study may be able to provide us with evidence for using MBCT as a standard supportive intervention for the family caregivers of PWD.

A prospective, single-blind, parallel-group randomized controlled trial (RCT) will be adopted to test the hypotheses and compare the immediate effects and its effects over a 3-month follow up between the MBCT program and an active control group (social interactions and routine education on dementia care) for the family caregivers of PWD in the community. The MBCT program consists of seven sessions, including different mindfulness activities (such as mindful eating and mindful walking) and peer sharing, while the parallel active control group will have the social interactions and routine education on dementia care, including seven education sessions on dementia care, caregiver skills training and group sharing, aiming to control/balance the social interaction effects that can also be found in the MBI group. The study will also follow the guideline recommended by the latest Consolidated Standards of Reporting Trials (Schulz et al., 2010) statements.

The eligible participants will be randomized into the 2 groups (MBCT and SIRE), following the allocation concealment mechanism by an independent assistant. The research assistants who were blinded to the group assignment performed all of the outcome measurements and data entries. The procedure and treatment allocation will be blinded to the investigator and the interventionists until the baseline measurement is completed.

A group-based, 10-week, 7-session modified Mindfulness Based Cognitive Therapy (MBCT) will be adopted in the MBCT intervention group with a group size of 15-20. The program includes different mindfulness activities (such as mindful eating and mindful walking) and peer sharing.

The frequency of the Social Interactions and Routine Education (SIRE) program is the same as that of modified MBCT which consists of seven sessions (weekly for the first four sessions and bi-weekly for the last three sessions) and each session will last about two hours for 10 weeks with group size 15-20.

Compared with the original protocol of Mindfulness-based Cognitive Therapy (Segal et al., 2002), the modified MBCT protocol in this pilot study has the following changes: Outline: Session 1 Awareness and automatic pilot: Session 2 Living in our head Session 3 Gathering the scattered mind Session 4 Recognizing aversion & allowing Session 5 Thoughts are not facts Session 6 Take care of myself Session 7 Maintaining and extending new learning

The SIRE program includes routine education sessions on dementia care, caregiver skills training, and group sharing on caregiving tasks. Outline: Overview of dementia Pharmacological and non-pharmacological treatment of dementia BPSD in dementia care Person center care Advance planning in people with dementia Principle of mindfulness Non-pharmacological intervention on stress reduction

Perceived Stress Scale contains 10 items with 5-point Likert-type scale rating from 0 (never) to 4 (very often). The total score can range from 0 to 40 with higher scores indicating higher perceived stress. Comparisons of changes of Perceived Stress Scale will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

Zarit Burden Scale comprises of 22 items including factors most frequently mentioned by caregivers as problem areas such as carer's health, psychological well-being, and the relationships between the carer and the patient with dementia. The score can range from 0 to 88. A higher score indicates greater carer distress. Comparisons of changes of Zarit Burden Scale will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

Center for Epidemiologic Studies Depression Scale is a self-reported measure of depression containing 20 items. It measures the common symptoms of depression in term of depressed mood, feelings of guilt and worthlessness, and feelings of helplessness. The scores can range from 0 to 60 and higher CESDS scores indicate increasing levels of depression. Comparisons of changes of Center for Epidemiologic Studies Depression Scale will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

The level of anxiety will be measured by the Hospital Anxiety and Depression Scale which is a 7-item self-report instrument including specific items that assess generalized anxiety including tension, worry, fear, panic, difficulties in relaxing, and restlessness. The scores range from 0 to 21 and higher scores indicate increasing levels of anxiety Comparisons of changes of Hospital Anxiety and Depression Scale will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

The level of resilience (the ability to bounce back or recover from stress) will be measured by the Brief Resilience Scale, which is a 6-item, self-report and 5-point rating scale. The scores can range from 6 to 30 with higher scores indicating higher level of resilience. Comparisons of changes of Brief Resilience Scale will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

Caregivers' health-related quality of life will be measured by 12-Item Short Form Health Survey. It contains twelve questions and ranges from 0 to 100, where a zero score indicates the lowest level of healthmeasured by the scales and 100 indicates the highest level of health Comparisons of changes of 12-Item Short Form Health Survey will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

Caregivers' level of mindfulness will be measured as the process indicator by using the Five Facets Mindfulness Questionnaire Short Form. It is a self-report questionnaire measuring the five facets of mindfulness which includes observing, describing, acting with awareness, non-judging of inner and non-reactivity to inner experience (e.g., "I'm good at finding words to describe my feelings"). The total score ranges from 20 to 100 and the higher the score, the higher level of mindfulness. Comparisons of changes of Five Facets Mindfulness Questionnaire-Short Form will be considered as follows: T0 - T1; T0 - T2; T1 - T2

At baseline (T0), 10th week (immediately post- intervention; T1), and 3 months after the intervention (follow-up assessment, T2)

Weekly mindfulness practice will be measured by the average number of hours in practicing mindfulness per week from T0 to T2.

The (Number of sessions a participant is present) / (Total number of intervention sessions) will be measured to indicate the adherence rate

Inclusion Criteria: aged 18 years or above; the blood or by-marriage relatives (e.g. spouses, siblings, children, and grandchildren) of a person who has been clinically diagnosed with dementia, regardless of its types (as mentioned in the operational definitions section (p. 1) and these relatives are taking up the caring responsibilities ranging from physical aids to emotional supports, in the form of transportation, financial assistance, personal hygiene, and decision-making.; providing most of the daily care and support for PWD (daily contact for at least four hours); and able to speak Cantonese (for understanding about all teaching materials and instructions). Exclusion Criteria: are practicing or recently learned meditation, mindfulness activities, and/or relaxation training in the past 6 months; are diagnosed with a mental disorder such as bipolar disorder, schizophrenia, dementia, or depression; and/or, are taking anticonvulsants, or any kind of psychotropic drugs, and/or identified with a self-reported suicidal thought or drug abuse in the past 6 months.

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