CP

Counseling Points
An Official Publication of the National Conference of Gerontological Nurse Practitioners
and the National Gerontological Nursing Association

May 2008

Alzheimer’s Disease: Caring for the Caregiver

™

Volume 1, Number 3

Part 3 of a 3-Part Continuing Education Series

Sponsored by:

This activity is supported by an educational grant from Eisai Inc.

Faculty:
Virginia Burggraf, DNS, RN, FAAN
Counseling Points™
Professor of Gerontological Nursing Alzheimer’s Disease: Caring for the Caregiver
Radford University School of Nursing
Radford, Virginia
Continuing Education Information
Evelyn G. Duffy, DNP, APRN, BC,
FAANP Target Audience
Assistant Professor This educational activity is designed to meet the needs of gerontological nurses and
Director of the Gerontological Nurse advanced practice nurses who are on the front lines of treating and managing
Practitioner Program
Alzheimer’s disease and related dementias.
Frances Payne Bolton School of
Nursing Learning Objectives
Case Western Reserve University
Upon completion of this educational activity, the participant should be able to:
Cleveland, Ohio
• Discuss ethical issues in caring for the patient with Alzheimer’s disease (AD),
Susan Engel, RN-BC, MSN including end-of-life care
Dementia Care Coordinator
Veterans Affairs Western New York
• Describe the psychosocial, physical, and financial burdens of AD on the family and
Healthcare System caregivers
Buffalo, New York • Review educational counseling for caregivers
Faculty Disclosure Statements: • Name effective techniques and strategies to reduce stress on caregivers
Virginia Burggraf, Evelyn Duffy, and
Susan Engel have nothing to disclose.
Continuing Education Credit
This continuing nursing education activity was approved by the National Con-
Publishing Information: ference of Gerontological Nurse Practitioners. Successful completion of this
Publishers activity awards 1.2 contact hours.
Joseph J. D’Onofrio The National Conference of Gerontological Nurse Practitioners is accredited as a
Frank M. Marino provider of continuing nursing education by the American Nurses Credentialing
Delaware Media Group
Center’s Commission on Accreditation.
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Website: www.delmedgroup.com This educational activity may contain discussion of published and/or investigational
uses of agents that are not indicated by the FDA.The National Conference of Geron-
Editorial Director tological Nurse Practitioners, the National Gerontological Nursing Association, Eisai
Nancy Monson
Inc., and Delaware Media Group do not recommend the use of any agent outside of
the labeled indications.The opinions expressed in the educational activity are those of
Art Director
James Ticchio
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Gerontological Nurse Practitioners, the National Gerontological Nursing Association,
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©2008, Delaware Media Group, Inc. All Disclaimer

rights reserved. None of the contents may
be reproduced in any form without prior
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opinions expressed in this publication are
those of the faculty and do not necessarily
reflect the opinions or recommendations of
their affiliated institutions, the publisher, the
National Conference of Gerontological
Nurse Practitioners, the National Geronto-
logical Nursing Association, or Eisai Inc.
Participants have an implied responsibility to use the newly acquired information to
enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management.
Any medications, diagnostic procedures, or treatments discussed in this publication
should not be used by clinicians or other health care professionals without first evalu-
ating the patient’s condition, considering possible contraindications or risks, reviewing
any applicable manufacturer’s product information, and comparing any therapeutic
approach with the recommendations of other authorities.

2
COUNSELING POINTS™
welcome
Dear Colleague,

In the third and final issue of this Counseling Points™ series on Alzheimer’s disease
(AD) and related dementias, we focus on the topic of caring for the caregiver. As the
burden of AD becomes greater with the aging of the American population, the burden
on caregivers also increases. Caregivers are beset by psychosocial, physical, financial,
and ethical challenges attendant to caring for loved ones. In turn, nurses and nurse
practitioners who care for patients with AD must also care for the caregivers, offering
education, counseling, and support services to preserve caregiver health.

Counseling Points™ is an official publication of the National Conference of Geronto-

logical Nurse Practitioners (NCGNP) and the National Gerontological Nursing Asso-
ciation (NGNA).We have been gratified by the response to the first two issues in this
series. We hope you will consider becoming involved with the NCGNP and NGNA,
if you’re not already, to take advantage of the many other educational and networking
opportunities membership affords. Please visit our websites at www.ncgnp.org and
www.ngna.org for information.

Finally, we would like to thank Eisai Inc. for sponsoring this and the other publications
in this series under an educational grant.

Sincerely,

Debra Bakerjian, PhD, MSN, RN, FNP

PRESIDENT, NCGNP

Judith E. Hertz, PhD, RN

PRESIDENT, NGNA

3
MAY 2008
 Alzheimer’s Disease:
Caring for the Caregiver
Introduction
According to the Alzheimer’s Association, 5 million
Americans are estimated to have Alzheimer’s disease
(AD), and an additional 360,000 are diagnosed yearly.1
Patients with the disease typically live 8 to 10 years after
diagnosis, but some live as long as 20 years.1
A majority of the nation’s nursing home residents have
significant cognitive impairment, most likely due to AD.
Most people with the disease, however, live in their own
homes or with relatives and are cared for by loved ones.
Family members, particularly wives and daughters, are
often called upon to assume the role of caregiver, and
may spend up to three-quarters of their day looking after
a patient.2 The burden becomes greater as the disease
progresses.2
Caregiver stress is now recognized as a significant
byproduct of a diagnosis of AD.
These unpaid caregivers are at great risk for stress-
related signs and symptoms; indeed, caregiver stress is now
recognized as a significant byproduct of a diagnosis of AD.
Regardless of gender and approach to patient manage-
ment, nearly all caregivers experience emotional and
physical strain and many suffer from clinical depression,
anxiety, and other health problems.3
Given this emerging trend, gerontological nurses and
advanced practice nurses must now not only care for
individuals with AD but also for their caregivers, offering
psychosocial assistance, education, and referrals to organi-
zations and support groups. By improving the health and
well-being of caregivers, research suggests that nursing
home placement of patients with AD may be delayed.4
Ethical Issues in Caring for the Patient
with AD
Dementia is characterized by an insidious onset and a
slow, continual decline. Because of the nature of the dis-
ease, families often are unaware of its development until
patients are no longer mentally capable of participating in
decision-making regarding their care and long-term
plans. As dementia progresses, many issues that families
face present ethical dilemmas that require guidance from
4
COUNSELING POINTS™
health care providers. Not all clinicians, however, are
familiar with ethical principles that could help families
find their way through the maze.
The principles of biomedical ethics provide a
framework for the moral standard for practice.
Biomedical Ethics
The principles of biomedical ethics provide a framework
for the moral standard for practice. Four key principles
were identified in a classic reference by Beauchamp and
Childress: respect for autonomy, nonmaleficence, beneficence, and
justice.5 These principles were first developed in response
to the need for ethical medical research. Once established,
they continued to be the measure used for decision-mak-
ing in complex medical situations such as during the
course of caring for a demented older adult. Still, it is
crucial for nurses/advanced practice nurses to keep in
mind that even well-established principles have their lim-
itations and that “gut feelings,” intuition, and conscience
should not be ignored.
Respect for autonomy. Autonomy is central to our
American life. The freedom to choose without interfer-
ence from others is perceived as an essential right in our
country. The ethical principle of respect for autonomy
recognizes the individual’s right to these choices.5 The
practice of informed consent emanates from this princi-
ple. In patients with dementia, however, the capacity to
make decisions is compromised, although not all deci-
sion-making is compromised to the same extent. With
regard to medical decisions, patients need to be able to
understand what a procedure entails and the risks and
benefits of refusing or accepting the procedure. Patients
may no longer be capable of making independent med-
ical decisions because of cognitive impairment (which
tends to affect abstract thinking early in the course of the
disease), but they may be capable of making a will as long
as they can identify to whom they want to leave their
worldly goods.6 Even in advanced dementia, it may be
possible for patients to make some individual decisions,
such as what they like or dislike to eat or the type of
clothing they like to wear.
When surrogate decision-making is needed, families
should consider patients’ beliefs and values and prior
wishes. When possible, their input should be sought.
However, families need to realize that a priority must be
to keep patients safe and prevent them from injuring oth-
ers. For example, families may feel it is not fair to keep
patients from driving because it restricts their autonomy,
but they need to understand that dementia affects judg-
ment, and poor judgment while driving can result not
only in harm to patients but to others. They cannot wait
to stop loved ones from driving until patients accept that
they are no longer capable of driving, or expect patients
to have the insight necessary to know that it is not safe
for them to drive. Issues of safety take precedence over
the principle of respect for autonomy.
Nonmaleficence and beneficence.The principles of non-
maleficence and beneficence are difficult to separate.
Nonmaleficence has been summarized concisely as “do
no harm,” while beneficence requires one to do good or
to prevent or remove harm.5 When the intent to do good
results in harm, this is referred to as the principle of double
effect. Examples of this principle are numerous in caring
for demented older adults. For instance, there is the
dilemma of allowing severely demented patients to con-
tinue eating solid foods because they enjoy eating them,
despite the risks of aspiration and pneumonia. If families
decide to allow patients to continue to eat solid foods,
they are intending to do well, but eating such foods may
result in harm. Ethical principles do not have a priority
ranking. As Barnes describes it, the application of ethical
principles in a “messy” environment means that there
may not be a clear right or wrong, good or bad, but
rather that nurses and families must rely on their best
judgment and “let their conscience be their guide” when
making decisions for patients.7
When families have exceeded their capacity to meet
the needs of patients with dementia, they may feel
trapped by a promise they made to always keep patients at
home. The principles of nonmaleficence and beneficence
may be helpful to guide families who have a prior duty
that can no longer be met without causing harm, while
abandoning that duty will actually result in the good of
improved care for patients.These principles won’t prevent
families from feeling regret or remorse at the inability to
keep their promise, but it may help them accept that the
greater good is accomplished by breaking it.
Justice. The fourth principle is justice.5 This is a com-
plex principle and one with many interpretations. One
definition is “treating people who are equal in an equal
manner.”8 This definition allows for ambiguous interpre-
5
tation. Possibilities may extend from “each person an
equal share” to “each person according to their merit.”5
The principle of justice is central to the issue of provid-
ing health care to patients with dementia. In America, the
majority of health care services for older adults are paid
for by the government programs Medicare and Medicaid.
Health care is not provided to each person in an equal
share, but rather to each person according to their merit.
If a patient has Medicare but not Medicaid, the govern-
ment will not pay for long-term care, eyeglasses, hearing
aids, etc. While more financially secure patients are not
eligible for Medicaid, they may not have enough
resources to afford health necessities that the government
will provide to the indigent. Little assistance is available
for help at home, requiring many families to prematurely
place patients with dementia in a long-term care facility.
Family caregivers may be forced to make decisions that
go against their moral fiber because they cannot meet
their obligations. When families must decide between
buying food or expensive medications for patients that
are not covered by Medicare, they are faced with an
unfortunate ethical dilemma as a result of our system of
health care delivery.
Nurses and families must rely on their best judgment
and “let their conscience be their guide” when
making decisions for patients.
Patients with dementia may not be highly valued by
society, but their families still see the spouses they mar-
ried, the parents that lovingly raised them, and the special
grandparents. Nurses need to see patients through their
family members’ eyes to better assist in ethical decision-
making. In a recent article by Post, she discusses the role
of the nurse in taking on some of the responsibility for
guiding families through decision-making.9 She notes that
it is not helpful for the nurse to ask “What do you want
us to do?” without giving caregivers some options and
helping them understand how they might rank those
options. Post describes leaving families to an autonomous
choice that may haunt them forever as “an act of aban-
donment.”9 When families are struggling with the idea
that they may not be doing everything for patients with
dementia, nurses can help them understand that doing
everything will not change the end result—and doing
good might actually mean doing less than everything.
Dementia is a terminal illness and nurses/advanced
practice nurses can help shift the focus to supporting the
last portion of life in an ethical manner. Both nurses/
MAY 2008
advanced practice nurses and families need to examine
the alternatives available in these difficult situations and
use ethical principles as a framework for determining
how they will act.
Caregiver Stress
As busy clinicians, we often neglect to ask our adult
patients “Are you caring for an older person/relative?”
Frequently during our 5-minute office visits we care for
the presenting problem whatever that may be without
considering that it may be induced by stress. For a care-
giver, that stress-induced symptom may be caused by his
or her caregiving duties. In addition, this stress can often
go on for years without being noted or managed.10,11
A seminal study conducted by Zarit and Zarit in 1983
defined caregiver burden as relating to the perception that
physical and/or emotional health, social life, or financial
status has suffered as a result of caring for someone.12
Many health professionals refer to caregiver stress as
“caregiver syndrome,” a condition of chronic stress
accompanied by depression, anger, guilt, and/or deterio-
rating health.13 This stress often contributes to hyperten-
sion, diabetes, compromised immunity, and an increased
risk of death.
A number of studies have examined caregiver stress. In
1990, Pearlin and colleagues were the first investigators to
address caregiver stress as a consequence of interrelated
processes, including both the socioeconomic characteris-
tics and resources of caregivers, as well as the emotion-
al/psychic strains they experienced.14 Primary stressors
were identified as hardships and problems directly related
to caregiving. Secondary stressors included the strains
caregivers experienced outside their role as caregiver and
intrapsychic strains and the diminishment of self-concept.
More recently, the PIXEL study conducted in France
investigated the quality of life of caregivers (65.7±12.8
years old) and their demented care recipients (80.2±6.8
years old).15 The Alzheimer’s Disease Related Quality of
Life Scale was used with a neuropsychological inventory,
the Folstein Mini Mental State Examination (MMSE),
Cornell’s depression scale, and the Katz index. Caregiver
quality of life was correlated to the quality of life of the
persons being cared for, their particular behavioral disor-
der, and the duration of the illness.Women caregivers had
a worse quality of life and were more depressed than male
caregivers in this study. Research by Parks and Novielli
emphasized the value of screening for anxiety and depres-
sion in caregivers, while Clipp and George’s findings
indicated that caring for someone with dementia is asso-
6
COUNSELING POINTS™
ciated with higher levels of stress than is caring for some-
one with a functional impairment/chronic illness.16,17
Max, Weber, and Fox surveyed caregivers to assess the
unpaid burden of informal caregiving and found that an
average of 70 hours of care per week, with 62 hours pro-
vided by the primary caregiver, was needed for patients
with dementia. 18 The more severe the dementia, the
greater the demands on caregivers’ time.
The relationship between immunity and the stress of
caregiving was investigated in the work of Kielcolt-Glaser
et al, who compared the immune response to an influen-
za virus vaccine in 32 caregivers and 32 controls.19 Care-
givers had a poorer antibody response to the vaccine than
controls and lower levels of in vitro virus-specific-
induced interleukin 2 and interleukin 1β levels. This
study supports the need for objective physiologic meas-
ures of health in order to better understand the health-
related consequences of caregiving.These researchers also
looked at the relationship between the dementia caregiv-
er and multiple variables that influence immunity and
found increased sleeplessness, depression, and a lack of
social support existed in the caregiver group.
A 63% greater risk of mortality [was found] among
unpaid caregivers who characterized themselves as
being emotionally or mentally strained by their
role versus non-caregivers.
In the landmark trial known as the Caregiver Health
Effects Study, Schulz et al used an epidemiologic
approach to investigate caregiving as a risk factor for
mortality over 4 years of follow-up.20 In a population
sample of 392 elderly spousal caregivers (ages 66 to 99
years) compared with 427 non-caregivers of a similar age
living with their spouses, they showed a 63% greater risk
of mortality among unpaid caregivers who characterized
themselves as being emotionally or mentally strained by
their role versus non-caregivers. Caregivers who did not
report strain and those with a disabled spouse did not
have increased mortality rates. Half of caregivers reported
spending ≥46 hours a week caring for a patient with
dementia, and more than half said they felt that they were
“on duty” 24 hours a day. Caregivers had high levels of
depressive symptoms. Their depression eased within 3
months of the patient’s death, however, and had declined
significantly by 12 months. Caregivers reported that the
death was a relief to them.
Like the Caregiver Health Effects Study, the Resources
for Enhancing Alzheimer’s Caregiver Health (REACH)
study demonstrated early mortality for highly stressed
caregivers:This study showed that 40% of those who cared
for a spouse with AD and who experienced stress from
their responsibilities died sooner than caregivers who did
not report stress.20 These data suggest that a caregiver’s
stress is an independent risk factor for early mortality.
The Caregiver at Risk
The research we have just reviewed informs us that care-
givers are vulnerable to poor physical and/or emotional
health. Caregivers at risk include those:
• who have been caregiving for a prolonged period of
time;
• are caregiving in their own home versus an institu-
tional setting;
• have a chronic illness themselves;
• have little or no social support networks;
• utilize resources (social service, respite) sparingly;
• are not financially stable or had to give up working
to perform caregiving duties;
• have a lower educational level;
• are caring for a person with dementia, multiple
symptoms/conditions, or someone with impaired
activities of daily living (ADLs) or instrumental
activities of daily living (IADLs);
• are caregiving full time versus part time;
• possess inadequate levels of empathy/affect; and
• are assessed to be in a state of denial.20-22
Table 1 offers questions to help clinicians assess care-
giver burden during an office visit, while Table 2 lists
resources for caregivers.
Financial Burden on Families
Most people prefer to live in their home as long as they
can.23 Informal caregivers make this possible for millions
of older Americans and are the only source of care for
80% of those who remain at home.24 An Association of
Retired Persons study conducted in 2006 found that
there were 30 to 38 million family caregivers providing
care to functionally impaired older adults.25 The value of
this care was estimated to be worth $350 billion. This
exceeds the amount spent on either home health care or
nursing home care.The value of care for older adults with
Alzheimer’s-type dementia has been estimated to be 41%
greater than that of caregiving for an adult with a physical
illness.26 If the informal caregiver can no longer function
in that role because of physical or mental health problems,
7
Table 1. Questions for Assessing Care-
16
giver Burden During an Office Visit
Screening Question Area of Concern
Do you feel that you are currently Mental health
under a lot of stress? What aspects of
your day are the most stressful?
Have you been feeling down or blue Mental health
lately?
Have you been feeling more anxious Mental health
and irritable lately?
Do your family and friends visit often? Social support
Do they telephone often?
Do your friends and family watch your Social support
relative for you so that you have time
for yourself?
Do you have any outside help? Resources
Is your relative with dementia Behavioral
displaying any behaviors, such as management
wandering, that are difficult to
manage?
What do you do to relieve your stress Coping
and tension?
Adapted with permission from American Family Physician.
the result is often the admission of the care recipient to a
long-term care facility. Hence, when the caregiver can no
longer give care, there is a tremendous loss to the individ-
uals involved, as well as to society.
The value that the family caregiver offers is huge, but
what about the cost to families? The financial burden on
families includes multiple factors. Attempting to put a
dollar amount on the cost of caregiving is difficult
because of the multiple ways of defining the components
of caregiving. A 2006 study of caregivers completed by
Metropolitan Life Insurance Company estimated the cost
of caring for a person with AD was between $12,000 and
$60,000 a year.26 A Henry J. Kaiser Family Foundation
national survey conducted in 1998 of over 1,000 informal
caregivers noted that 14% of caregivers spend more than
$1,000 of their own funds to meet the care recipient’s
needs.27 This out-of-pocket expense represents only a
portion of the financial picture for caregivers; there are
also less specific costs, including time off from work, the
need to stop working outside the home entirely, travel
expenses, increased mental health issues, and the cost to
physical health, to name a few. One study found that over
their lifetimes caregivers lose >$650,000 in salary and
MAY 2008
retirement benefits, a loss that far exceeds their out-of-
pocket expenses.28
When the needs of patients exceed what families can
offer, paid care is required. Many families as well as health
professionals are not familiar with the options for home
support services, their costs, and the available resources to
cover these costs. Support at home often comes from
aides who provide personal care or housekeeping services.
Agencies as well as private sources may provide these
aides, but regulation of home health aides is done on a
state-by-state basis and aides acquired from private
sources may not be regulated at all. Another option is
adult day care, where the services offered range from the
provision for all ADLs to meals and activities.The nation-
al average cost of help at home is $19 an hour; the cost
for adult day care is $61 a day.29 These costs vary widely
from state to state and region to region.
Many families expect that Medicare will pay for the
help needed, but coverage by Medicare is very limited
and only provides for home health care for intermittent
or short-term periods. In addition, in order for patients to
be eligible for Medicare coverage, they must have a need
for physical therapy or skilled nursing care. Alternatively,
many families are resistant to utilizing benefits available
from Medicaid because of a fear of losing their home or
the stigma of receiving “welfare.”
An important resource for family caregivers came as a
result of the Older Americans Act Amendments of
2000.30 The National Family Caregiver Support Program
that arose as a result of these amendments established
Table 2. Resources for Caregivers
Administration on Aging American Association of Retired
202-619-0724 Persons
www.aoa.gov/eldfam/eldfam.asp 888-687-2277
www.aarp.org/family/caregiving/
Aging Care: The Community for
Caregivers Care.com
866-627-2467 or 239-594-3200 www.care.com/senior-care-p1006.html
www.agingcare.com
Caregiving Online
Alzheimer’s Association 773-343-6341
800-272-3900 www.caregiving.com/
www.alz.org/
Caring Today Magazine Online
Alzheimer’s Disease Education and www.caringtoday.com
Referral Center, National Institute
Children of Aging Parents
on Aging
800-227-7294
800-438-4380
www.caps4caregivers.org
www.alzheimers.org/
or www.nia.nih.gov/alzheimers
8
COUNSELING POINTS™
partnerships with local Agencies on Aging and communi-
ty services to provide: (1) information about available
services; (2) assistance in gaining access to services; (3)
support groups and training; (4) respite care; and (5) serv-
ices to complement and support the work of family
caregivers. Support from this program is available to
Alzheimer’s caregivers regardless of the age of the patient.
While not exclusively for caregivers with lower incomes,
such applicants receive priority consideration. The ability
of this program to meet the demand is limited by the
amount of federal funding received in any given year and
the funds provided by the state.
Educating the Caregiver
Education about AD and available resources is a critical
component of caregiver well-being. A study by Walker
and Dewar reported that there are four markers of satis-
factory caregiver involvement in the care of older per-
sons: (1) feeling that information was shared; (2) feeling
included in decision-making; (3) feeling that there was
someone to contact if they needed to; and (4) feeling that
the service was responsive to their needs.31 The majority
of caregivers in this study reported feeling dissatisfied
with the level of their involvement. Hospital systems and
processes and the relationship between nursing staff and
caregivers were the two main sources of barriers.
In a qualitative study by Bruce and Paterson, it was
found that most caregivers perceived that general practi-
tioners had been late in referring dementia sufferers for
Eldercare Locator
800-677-1116
www.eldercare.gov
Family Caregiver Alliance
800-445-8106 or 415-434-3388
www.caregiver.org
National Council on the Aging
202-479-1200
www.ncoa.org
National Family Caregivers
Association
800-896-3650
www.nfcacares.org
The Well Spouse Foundation
800-838-0879
732-577-8899
www.wellspouse.org

GRECC Dementia-related
Educational Pamphlets33
Download for caregiver teaching at:
www1.va.gov/minneapolis/services/grecc
/serv_grecc_care.html
Excellent sources of caregiver information are the
Geriatric, Research, Education and Clinic Centers
(GRECCs), “centers of excellence” that are
designed to improve health care and quality of life
for older veterans through the advancement and
integration of research, education, and clinical
achievements in geriatrics and gerontology into the
total Veterans Affairs (VA) health care system and
broader communities.33 The VA has long recognized
geriatrics as a priority area because the demographic
imperative of an aging population impacted the VA
system earlier than it did the general health care
community in the United States. Below, you will
find a list of full-text pamphlets in a GRECC series
on dementia-related diseases that nurses/advanced
practice nurses can share with caregivers.*
GENERAL INFORMATION
What is Alzheimer's Disease?
The Role of the Caregiver
MANAGING DAY TO DAY
Dealing with Decline in the Patient's Ability
Creating a Safe and Workable Environment
WORKING WITH...
Health Care Professionals
Bureaucracies:What to Do
Family and Friends
COMMUNICATION TOPICS
Basic Issues and Techniques
Hearing Problems
Vision Problems
SPECIAL CARE ISSUES
Aggressive and Violent Behavior
Inappropriate Sexual Behavior
Restlessness,Wandering and Sleep Disturbances
Bowel Incontinence
Urinary Incontinence
FINANCIAL AND LEGAL ISSUES
Where to Begin
Planning for Now and the Future
Guardianships and Involuntary Treatment
Respite Care:When You Need a Break
Choosing a Nursing Home: Institutional Care
The Move to a Nursing Home:The Planned and
Unplanned Move
*Pamphlets authored by Kenneth Hepburn, Ph.D.
9
community care, despite the fact that the caregiver had
reported experiencing difficulties with the patient for a
considerable period of time.32 Caregivers also complained
that they received too little information about the diag-
nosis of dementia and how to deal with problem behav-
iors. Earlier recognition of the caregivers’ problems and
the provision of better education and earlier access to
support services may lessen the degree of stress experi-
enced by caregivers. Needs common to caregivers across
all care groups were identified as access to information
(diagnostic, prognostic, and where to obtain help),
improved communication with professionals, relief from
stress, and proactive support.
Medication Guidelines for Caregivers
Antipsychotic medication has routinely been prescribed
to manage problem behaviors in patients with AD when
nonpharmacologic strategies fail. Families must now be
educated that atypical antipsychotics such as aripiprazole
(Abilify®), olanzapine (Zyprexa®), quetiapine (Seroquel®),
and risperidone (Risperdal®) may prolong the QT inter-
val, predisposing patients to arrhythmias and sudden car-
diac death, sedation, and accelerated cognitive decline,
and may increase the risk for aspiration, pneumonia,
venous thromboembolism, pulmonar y embolism,
cerebrovascular events, and falls leading to hip frac-
tures and premature death.34 The most recent placebo-
controlled study on this topic, published in the April 2008
issue of the journal Public Library of Science Medicine, found
that prescription of antipsychotic drugs to 165 people
with severe AD living in nursing homes led to a signifi-
cant deterioration in verbal ability and didn’t appear to
provide any benefit.35 These authors suggested that use of
antipsychotics may be beneficial for some patients with
severe neuropsychiatric symptoms, but the benefits of use
must be carefully weighed against the risks of side effects.
Caregivers need to be educated not only about the
different medications used to manage AD symptoms, but
also about more subtle issues of adherence and persistence
with medication use. Medication guidelines for caregivers
may include such assessments as:
• Can patients take their medications or do they forget
to take them?
• Can patients read the medication label?
• Can patients hear the instructions of the health care
provider?
• Do patients have the dexterity to open bottles, break
tablets, and/or handle medicines such as eye drops or
inhalers?
MAY 2008
 • Do patients have difficulty swallowing?
• Are patients experiencing difficulty in scheduling
when to take their various medications?
• Are patients taking too many medications, including
over-the-counter drugs and herbs?
For a fact sheet to guide caregivers about medication
challenges, visit www.caregiver.org/caregiver/jsp/content_
node.jsp?nodeid=1104.36
Evidence is weak that drugs or herbs other than
cholinesterase inhibitors have important benefits for peo-
ple with AD, including g inkgo biloba, seleg iline
(Eldepryl®), vitamin E, and estrogen.37-39 Caregivers need
to be aware of the symptoms of anticholinergic toxicity,
which are delirium or confusion, memory impairment,
and obtundation. 40 They must be aware of over-the-
counter medications (antihistamines and bladder control
drugs) that may be harmful when taking anticholinergics
for dementia.40 For more information and educational
help regarding medications, visit www.fpnotebook.com/
Geri/index.htm
Vulnerable elders fill an average of 20 prescriptions
annually.41 Aging can be associated with decreased metab-
olism and excretion of prescription drugs and their
metabolites, placing elderly patients at risk for side effects
and complicating appropriate dosing. Medication reviews
should take place annually to discontinue unnecessary
medications.41
Cholinesterase Inhibitors
The cholinesterase inhibitors prescribed for dementia are
donepezil (Aricept ® ), galantamine (Razadyne ® ), and
rivastigmine (Exelon®).
According to research data, donepezil significantly
benefits patients in early-stage AD by improving daily
cognitive functioning.42 It is used to treat mild to moder-
ate dementia (Folstein MMSE scores of 10-26). Patients
will revert to their prior level of decline when the drug is
withdrawn; therefore, they should be warned not to dis-
continue without contacting their provider.42 Long-term
use has minimal to no effect.42 Donepezil does not pre-
vent nursing home placement and does not protect
against long-term functional decline.42
Ekinjuntti et al found that galantamine stabilizes and
even delays cognitive deterioration among patients with
vascular dementia as well as patients with AD combined
with cerebrovascular disease.43 Adverse effects of this
drug include gastrointestinal (GI) upset, dizziness, and
bradycardia.43
10
COUNSELING POINTS™
Rivastigmine modestly improves scores on neuropsy-
chological tests; benefits decrease after 40 weeks of treat-
ment. GI discomfort can occur as a side effect of this
medication.44
Strategies for Reducing Caregiver
Stress
The vast majority of patients with dementia receive
their care in primary care settings. It is a challenge for
clinicians to provide optimal care for patients and their
stressed and overburdened caregivers who require time-
intensive, team-based processes of care. To address this
issue, Vickrey and colleagues developed a novel disease
management program for patients with dementia and
their caregivers seen in primary care. 45 Those in the
control group were assigned a case manager who
worked with and trained the caregiver, assessed and pri-
oritized patient and caregiver needs, and recommended
interventions. Quality of care, as measured by adherence
to guidelines, was dramatically higher in patients
who received the intervention. Patients’ quality of life
improved, and caregivers reported improved social sup-
port, mastery of caregiving, and confidence. This inter-
vention bears many similarities to a collaborative care
approach described by Callahan and colleagues that also
improved the process and outcomes of dementia care.46
In this latter study, dementia patients received 1 year of
care management by an interdisciplinary team led by an
advanced practice nurse working with the patient’s fam-
ily caregiver and integrated with primary care services,
resulting in a significant improvement in the quality of
care. The intervention also improved behavioral and
psychological symptoms of patients and the well-being
of caregivers.
Belle tested an intervention to improve the quality of
life in a multiethnic group of distressed caregivers.47 This
intervention focused on five domains that are important
to caregivers: reducing depression, decreasing burden,
improving self-care, enhancing social support, and manag-
ing problem behaviors. The trained care manager assessed
the caregivers’ needs and functioned as a coach. The
innovative features of the intervention included tailoring
its components to the unique needs and concerns of each
caregiver and emphasizing self-empowerment. More than
90% of caregivers reported that the intervention made
their lives easier and improved their ability to provide
care. There were also encouraging trends toward lower
rates of nursing home placement.The benefits and quality
of evidence supporting these interventions considerably
exceed those of currently approved pharmacologic thera-
pies for dementia, according to Schneider.48
These studies illustrate several principles that should
guide how care is delivered to patients with dementia.
First, caregivers need to be a dominant focus of any effec-
tive dementia management strategy because caring for a
loved one with dementia can present enormous physical,
psychological, and emotional difficulties and is an inde-
pendent risk factor for early mortality.20,21 For instance,
the REACH study focused on increasing self-efficacy by
encouraging caregivers to be less emotional and develop
more effective problem-solving skills.21 This was achieved
by teaching caregivers how to manage their time better
and become more assertive in asking for help from others,
channeling their thoughts more positively, and preparing
for the future.
The research on dementia caregivers also emphasizes
the importance of intrapersonal mediators in affecting the
outcome of the stress process associated with caregiving.
The Savvy Caregiver program, for example, is predicated
on the notion that by strengthening caregivers’ knowl-
edge, skills, and outlook for caregiving—in effect, by pro-
viding training for the role in which they find them-
selves—the deleterious effects of caregiving can be
ameliorated.49 In another study, it was found that case
managers at a master’s level of health care could effect sig-
nificant improvements in depression, burden, and reaction
to behavior problems in caregivers, which decreased the
severity of care recipients’ behavior problems.50 It has also
been demonstrated that an in-home skills training pro-
gram helps to sustain caregiver effectiveness, according to
Gitlin et al.51 They also conclude that more frequent pro-
fessional contact and on-going skills training may be nec-
essary to maintain other clinically important outcomes
such as reduced upset with behaviors.51
A project known as the Chronic Care Networks for
Alzheimer’s Disease Initiative (CCN/AD), national and
local partnerships of the Alzheimer’s Association and the
National Chronic Care Consortium members, is one of
the largest demonstrations of Alzheimer’s and dementia
evidence-based care to date, and one of the first to focus
on the coordination of health care and supportive
services.52 People with dementia and their family care-
givers benefited from the services they received through
this project, and patients, caregivers, primary health care
providers, and Alzheimer’s Association chapter staff
reported high levels of satisfaction with these networks.
In particular, caregivers reported that they received ade-
11
quate help on important topics, were more satisfied with
care, and experienced less strain in their relationships with
other family members. The goal of this initiative is to
offer tools to providers for early identification of AD,
diagnostic assessment, care management and programs,
and materials for the caregiver. A toolbox containing the
mater ials used to educate pr imary care and other
providers is available at www.nccconline.org/pdf/CCN-
AD_tools6-03.pdf.
In short, research shows that much of the distress of
families can be prevented when primary care practition-
ers work closely with gerontological nurses and nurse
practitioners and form community partnerships with
people with dementia and their families.53 These partner-
ships are now the expected norm.
Books for Caregivers
The 36-Hour Day:A Family Guide to Caring for Persons with
Alzheimer’s Disease, Related Dementing Illnesses, and Memory
Loss in Later Life
Nancy L. Mace, MA, and Peter V. Rabins, MD
The Loss of Self:A Family Resource for the Care of Alzheimer’s
Disease and Related Disorders
Donna Cohen, PhD, and Carl Eisdorfer, PhD, MD
Alzheimer’s Disease:A Guide for Families
Lenore S. Powell, EdD, with Katie Courtice
The Complete Guide to Alzheimer’s-proofingYour Home
Mark Warner and Ellen Warner
When Memory Fails: Helping the Alzheimer’s and Dementia
Patient
Allen Jack Edwards, PhD
Summary
As AD becomes an increasingly prevalent health problem
in the United States, the needs and well-being of care-
givers must be taken into account. Caregivers experience
physical and psychological stressors, the effects of which
may be underestimated or missed. Gerontological nurses
and advanced practice nurses can perform a significant
service to caregivers by inquiring at routine visits about
patients’ caregiving status, offering support, and providing
referrals to educational materials, support groups, and
adult day care programs.
References
1. The Alzheimer’s Association. Alzheimer’s Disease Facts and Figures
2007. Accessed October 24, 2007 at www.alz.org/national/documents/
report_alzfactsfigures2007.pdf.
2. Aguglia E, Onor ML, Trevisiol M, et al. Stress in the caregivers of
Alzheimer’s patients: An experimental investigation in Italy. Am J
Alzheimers Dis Other Demen. 2004;19:248-252.
MAY 2008
 3. Mahoney R, Regan C, Katona C, et al. Anxiety and depression in family
caregivers of people with Alzheimer disease. Am J Geriatr Psychiatry.
2005;13:795-801.
4. Mittelman MS, Haley WE, Clay OJ, et al. Improving caregiver well-being
delays nursing home placement of patients with Alzheimer disease. Neu-
rology. 2006;67:1592-1599.
5. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New
York, NY: Oxford University Press. 2001.
6. American Geriatrics Society. Geriatric Nursing Review Syllabus: A Core
Curriculum in Advanced Practice Geriatric Nursing. 2nd ed. New York, NY:
American Geriatrics Society. 2007.
7. Barnes S. Reflections on the applications of ethical theory. Appendix 14-1.
In: Mauk K (ed). Gerontological Nursing: Competencies for Care. Boston,
Ma: Jones and Bartlett. 2006.
8. Stanley M, Blair KA, Beare PG. Gerontological Nursing: Promoting Suc-
cessful Aging with Older Adults. 3rd ed. Philadelphia, Pa: FA Davis. 2005.
9. Post LF. Supporting families in ethical decision-making. LTC Nurs Compan.
2008;6:4-6.
10. Musil CM, Morris DL, Warner CB, et al. Issues in caregivers stress and
provider support. Res Aging. 2003;25:505-526.
11. Lantz MS. Caregiver burden: When the family needs help. Clin Geriatr.
2004;12:29-32.
12. Zarit S, Zarit, J. Cognitive impairment of older persons: Etiology evaluation
and intervention. In: Lewison PM, ed. Clinical Psychology. New York, NY:
Pergamon Press. 1983, pp 225-232.
13. American Geriatrics Society Healthcare Professionals Say Signs and Symp-
toms Associated with Caregiver Stress amount to “Caregiver Syndrome.”
Accessed April 10, 2008 from the AGS Web site: www.americangeri-
atrics.org/listserv/newsletter_082107.shtml#8.
14. Pearlin LI, Mullan JT, Semple SJ, et al. Care giving and the stress
process: An overview of concepts and their measures. Gerontologist.
1990;30:583-594.
15. Thomas P, Lalloue F, Preux P, et al. Dementia patients caregivers quality
of life: the PIXEL study. Int J Geriatr Psychiatry. 2006;21:50-56.
16. Parks SM, Novielli KD. A practical guide to caring for caregivers. Am
Fam Physician. 2000;62:2613-2622.
17. Clipp EC, George LK. Dementia and cancer. A comparison of spouse
caregivers. Gerontologist. 1993;35:534-541.
18. Max W, Webber P, Fox P. Alzheimer’s disease: The unpaid burden of
caring. J Aging Health. 1995;7:179-199.
19. Kiecolt-Glaser J, Glaser R, Gravenstein S, et al. Chronic stress alters the
immune response to influenza virus vaccine in older adults. Proc Natl
Acad Sci USA. 1996;93:3043-3047.
20. Schulz R, Beach SR. Caregiving as a risk factor for mortality: The care-
giver health effects study. JAMA. 199;282:2215-2219.
21. REACH Principle Investigators. Resources for enhancing Alzheimer’s
caregiver health (REACH): Overview, site-specific outcomes and future
directions. Gerontologist. 2003; 43:512-520.
22. National Center on Elder Abuse, Institute on Aging. A Fact Sheet on Care-
giver Stress and Elder Abuse. 2002. Accessed April 21, 2008 at
www.ncea.aoa.gov/ncearoot/main_site/pdf/family/fact_sheet.pdf.
23. Feinberg LF, Newman SL. A study of 10 states since passage of the
National Family Caregiver Support Program: Policies, perceptions, and
program development. Gerontologist. 2004;44:760-769.
24. Coleman B, Pandya SM. Family Caregiving and Long-Term Care. Fact
sheet. Washington, DC: AARP. 2002. Accessed April 21, 2008
at www.aarp.org/research/housing-mobility/caregiving/aresearch-
import-779-FS91.html.
25. Gibson MJ, Houser J. Valuing the Invaluable: A New Look at the Eco-
nomic Value of Family Caregiving. AARP Public Policy Institute Issue
Brief. Washington, DC: AARP. 2007. Accessed February 10, 2008 at
www.aarp.org/ppi.
26. MetLife Mature Market Institute. The MetLife Study of Alzheimer’s Dis-
ease: The Caregiving Experience. New York, NY: Metropolitan Life
Insurance Company. 2006.
27. Henry J. Kaiser Family Foundation. The Wide Circle of Caregiving. Key
Findings from a National Survey: Long Term Care from a Caregiver’s
Perspective. New York, NY: Henry J. Kaiser Family Foundation. 2002.
28. Women’s Institute for a Secure Retirement (WISER). Financial Steps for
Caregivers: What You Need to Know About Money and Retirement.
Washington, DC: Women’s Institute for a Secure Retirement. 2004.
12
COUNSELING POINTS™
29. MetLife Mature Market Institute. The MetLife Market Survey of Adult
Day Services & Home Care Costs. New York, NY: Metropolitan Life
Insurance Company. 2007.
30. Administration on Aging. National Family Caregiver Support Program.
Washington, DC: Administration on Aging. 2007.
31. Walker E, Dewar J. How do we facilitate carers’ involvement in
decision making? J Adv Nurs. 2001;34:329-337.
32. Bruce D, Patterson A. Barriers to community support for the dementia
carer: a qualitative study. Int J Geriatr Psychiatry. 2000;5:451-457.
33. Geriatric Research, Education, and Clinical Center. GRECC Pamphlets.
Accessed April 4, 2008 at www1.va.gov/minneap9lis/services/grecc/
serv_grecc_pamphlets.html.
34. Gills SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and
mortality in older adults with dementia. Ann Intern Med. 2007;146:
775-786.
35. Ballard C, Lana MM, Theodoulou M, et al. A randomised, blinded, place-
bo-controlled trial in dementia patients continuing or stopping neurolep-
tics (the DART-AD trial). PLos Med. 2008;5:e76 [Epub ahead of print].
36. Family Caregiver Alliance. Medications: A Double-Edged Sword.
Accessed April 4, 2008 at www.caregiver.org/caregiver/jsp/content_
node.jsp?nodeid=1104.
37. Oken B, Storzback DM, Kaye JA. The efficacy of ginkgo biloba on
cognitive function in Alzheimer disease. Arch Neurol. 1998;55:1409-1415.
38. Birks J, Flicker L. Selegiline for Alzheimers disease. Cochrane Database
Syst Rev. 2000(2):CD000442.
39. Asthana S, Baker LD, Craft S, et al. High-dose estradiol improves cognition
for women with AD: Results of a randomized study. Neurology.
2001;57:605-612.
40. Moses S. Geriatric Medicine Book. Family Practice Notebook. Accessed
April 10, 2008 at www.fpnotebook.com/Geri/index.htm.
41. Shrank W, Polinski J, Avorn J. Quality indicators of medication use in
vulnerable elders. J Am Geriatr Soc. 2007;55(suppl 2):S373-S382.
42. Seltzer B, Zolnouni, Nuncz, M, et al. Efficacy of donepezil in early stage
Alzheimer’s disease: A randomized placebo controlled trial. Arch Neurol.
2004;61:1852-1856.
43. Erkinjuntti T, Kurz A, Gauthier S, et al. Efficacy of galantamine in probable
vascular dementia and Alzheimers disease combined with cerebrovascular
disease: A randomized trial. Lancet. 2002; 359:283-1290.
44. Moses S. Neurology Book. Rivastigmine. Family Practice Notebook.
Accessed April 21, 2008 at www.fpnotebook.com/Neuro/Pharm/
Rvstgmn.htm.
45. Vickrey BG, Mittman BS, Connor KI, et al. The effect of a disease
management intervention on quality and outcomes of dementia care: A
randomized, controlled trial. Ann Intern Med. 2006:145:713-726.
46. Callahan CM, Boustani MA, Unverzagt FW, et al. Effectiveness of
collaborative care for older adults with Alzheimer disease in primary care:
A randomized, controlled trial. JAMA. 2006;295:2148-2157.
47. Belle SH, Burgio L, Burns R, et al. Enhancing the quality of life of dementia
caregivers from different ethnic and racial groups. A randomized,
controlled trial. Ann Intern Med. 2006;145:727-738.
48. Schneider LS, Tariot PN, Dagerman KS, et al. Effectiveness of atypical
antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med.
2006;355:1525-1538.
49. Hepburn K, Lewis M, Tornatore J, et al. The Savvy Caregiver: The
demonstrated effectiveness of a tranportable dementia caregiver
psychoeducation program. J Gerontol Nurs. 2007;33:30-36.
50. Teri L, McCurry S, Logsdon R, Gibbons L. Training community consultants
to help family members improve dementia care: A randomized controlled
trial. Gerontologist. 2005;45:802-811.
51. Gitlin LN, Hauck WW, Dennis MP, et al. Maintenance of effects of the
home environmental skill-building program for family caregivers and
individuals with Alzheimer’s disease and related disorders. J Gerontol A
Biol Sci Med Sci. 2005;60:368-374.
52. Chronic Care Networks for Alzheimer’s Disease Initiative. Tools for Early
Identification, Assessment, and Treatment for People with Alzheimer’s
Disease and Dementia. 2003. Accessed April 2, 2008 at www.ncconline
.org/pdf/CCN-AD_tools6-03.pdf.
53. Downs M, Bowers B. Caring for people with dementia. BMJ.
2008;336:225-226.
CP
Counseling Points
Alzheimer’s Disease:
™

Caring for the Caregiver

• The majority of people with Alzheimer’s disease (AD) live in their own homes or with
relatives and are cared for by loved ones.

• Unpaid caregivers are at significant risk for stress-related signs and symptoms, clinical
depression, anxiety, health problems, and early death.

• Principles of biomedical ethics can help clinicians guide families through the decision-
making processes attendant to caring for patients with AD.

• Many health professionals refer to caregiver stress as “caregiver syndrome,” a condition

of chronic stress accompanied by depression, anger, guilt, and/or deteriorating health.

• Caregivers at greatest risk for poor physical and/or emotional health include those who
have been caregiving for a prolonged period of time; are caregiving in their own home
versus an institutional setting; have a chronic illness themselves; have little or no social
support networks; utilize resources (social service, respite) sparingly; are not financially
stable or had to give up working to perform caregiving duties; have a lower education-
al level; are caring for a person with dementia, multiple symptoms/conditions, or a
someone with impaired activities of daily living or instrumental activities of daily living;
are caregiving full time versus part time; possess inadequate levels of empathy/affect;
and are assessed to be in a state of denial.

• Caregivers need to be educated about the different medications used to manage AD

symptoms, but also about more subtle issues of adherence and persistence with
medication use.

• Most patients with dementia receive their care in primary care settings.

• Research shows that much of the distress of families can be prevented when primary
care practitioners work closely with gerontological nurses and nurse practitioners and
form community partnerships with people with dementia and their families.

• Caregivers need to be a dominant focus of any effective dementia management strategy.

13
MAY 2008
Counseling Points™
Alzheimer’s Disease: Caring for the Caregiver
Continuing Education Posttest
To receive credit, read the newsletter in its entirety and answer the posttest and program evaluation questions
using the answer key on page 15. Fax the form to Delaware Media Group at (201) 612-8282. A certificate
will be awarded for a score of 80% (8 correct) or better and will be mailed within 4-6 weeks.There is no charge
for CE credit.

1. Research suggests that improving caregiver well- 6. A study by Walker and Dewar found that markers of
being can delay nursing home placement of satisfactory caregiver involvement include:
patients with Alzheimer’s disease (AD). A. feeling that information was shared
A. True B. feeling included in decision-making
B. False C. both A and B
D. neither A or B
2. Which of the following is NOT one of the four
biomedical ethics principles identified by 7. A placebo-controlled study published in Public
Beauchamp and Childress? Library of Science Medicine found that prescription of
A. Respect for autonomy antipsychotic drugs to people with severe AD
B. Nonmaleficence living in nursing homes led to:
C. Double effect A. a significant deterioration in verbal ability
D. Justice B. a significant deterioration in memory
C. a significant improvement in verbal ability
3. The PIXEL study found that caregiver quality of D. a significant improvement in memory
life was correlated to:
A. the quality of life of the person being cared for 8. Nonprescription drugs that can be harmful when
B. the particular behavioral disorder of the person being patients are using cholinesterase inhibitors for
cared for dementia include:
C. the duration of the illness A. multivitamins
D. all of the above B. antihistamines
C. decongestants
4. The Caregiver Health Effects Study found that eld- D. analgesics
erly spousal caregivers who characterized them-
selves as being emotionally or mentally strained by 9. In a study by Vickrey and colleagues, it was found
their role had what percent greater risk of mortali- that a novel disease management program for
ty than non-caregivers? patients with dementia and their caregivers seen in
A. 35% primary care led to all BUT which of the following?
B. 48% A. improved caregiver social support
C. 63% B. improved caregiver mastery of caregiving
D. 75% C. improved caregiver confidence
D. improved caregiver time management
5. An Association of Retired Persons study conducted
in 2006 found that there were between ___ and ___ 10. The Savvy Caregiver program is predicated on the
million family caregivers providing care to func- notion that by strengthening caregivers’ knowledge,
tionally impaired older adults. skills, and outlook on caregiving:
A. 20-26 A. the deleterious effects of caregiving can be ameliorated
B. 30-38 B. the deleterious effects of caregiving can be eliminated
C. 40-42 C. the positive effects of caregiving can be increased
D. 48-51 D. the positive effects of caregiving can be decreased

14
COUNSELING POINTS™
 Fax form to (201) 612-8282
EVALUATION FORM
Counseling Points™
Alzheimer’s Disease: Caring for the Caregiver
To assist us in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please take a few minutes to
complete this evaluation form. You must complete this evaluation form to receive acknowledgment for completing this activity.

Please answer the following questions by circling the appropriate rating:

1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree

Extent to Which Program Activities Met the Identified Objectives (After completing this activity, I am now better able to):

1. Discuss ethical issues in caring for the patient with Alzheimer’s disease (AD), including end-of-life care.......................................... 1 2 3 4 5
2. Describe the psychosocial, physical, and financial burdens of AD on the family and caregivers.......................................................... 1 2 3 4 5
3. Review educational counseling for caregivers......................................................................................................................................... 1 2 3 4 5
4. Name effective techniques and strategies to reduce stress on caregivers................................................................................................ 1 2 3 4 5
Overall Effectiveness of the Activity (The content presented):

5. Was timely and will influence how I practice.......................................................................................................................................... 1 2 3 4 5

6. Enhanced my current knowledge base..................................................................................................................................................... 1 2 3 4 5
7. Addressed my most pressing questions ..................................................................................................................................................... 1 2 3 4 5
8. Provided new ideas or information I expect to use ................................................................................................................................ 1 2 3 4 5
9. Addressed competencies identified by my specialty ................................................................................................................................ 1 2 3 4 5
10. Avoided commercial bias or influence .................................................................................................................................................. 1 2 3 4 5
Impact of the Activity
Name one thing you intend to change in your practice as a result of completing this activity: ________________________________________________________
______________________________________________________________________________________________________________________________________________________

Please list any topics you would like to see addressed in future educational activities: ________________________________________________________________

______________________________________________________________________________________________________________________________________________________

Additional comments about this activity: ____________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________
Follow-up
As part of our continuous quality improvement effort, we conduct postactivity follow-up surveys to assess the impact of our educational interven-
tions on professional practice. Please indicate if you would be willing to participate in such a survey:
❒ Yes, I would be interested in participating in a follow-up survey. ❒ No, I’m not interested in participating in a follow-up survey.
If you wish to receive acknowledgment for completing this activity, please complete the posttest by selecting the best answer to each question,
complete this evaluation verification of participation, and fax to (201) 612-8282.

Posttest Answer Key 1 2 3 4 5 6 7 8 9 10

Request for Credit

Name _________________________________________________________________ Degree ________________________________________

Organization___________________________________________________________ Specialty ________________________________________
Address_________________________________________________________________________________________________________________
City _____________________________________________________________________________ State __________ ZIP ________________
Phone _____________________________ Fax _____________________________ E-mail __________________________________________

Signature_________________________________________________________________ Date ______________________________________

Fax form to (201) 612-8282

15
MAY 2008
CP

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