Family Telemental Health Intervention for Veterans with Dementia

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Summary/Abstract Background: Nearly 300,000 Veterans served by the Department of Veteran Affairs have dementia. 1,2 Related behavioral symptoms such as agitation, repetitive behaviors, and apathy are interpersonally challenging and associated with institutionalization, morbidity and mortality for these individuals. These behaviors are also associated with depression, burden, and frustration for family caregivers. 3-5 Despite significant investment in caregiver interventions to reduce behavioral symptoms, symptom improvement as well as change in caregiver depression, burden, and frustration remain modest. 6 Although a variety of factors may impact treatment response, we have identified interpersonal skills deficits as a significant predictor of response to caregiver interventions. 7-10 Deficits in interpersonal skills may interfere with a caregiver’s successful implementation of behavioral strategies taught in current caregiver interventions. Although some caregivers self-identify deficits in interpersonal skill, many lack insight into how such deficits may affect behavioral symptom. 11,12 Existing interventions have not sufficiently focused on assessing caregiver interpersonal skills and, when identified, providing caregivers with relevant training prior to implementing behavioral management strategies. Objectives/Methods: This project involves two simultaneous activities: (1) refinement and pilot testing of a tele-health based observational coding manual (OCM) to evaluate the interpersonal skills of family caregivers interacting with care-recipients with dementia (hereafter referred to as “dyads”) who display behavioral symptoms, and (2) development and pilot testing of a tele-health family intervention to improve caregiver interpersonal skills. (1) Refining and pilot testing the OCM: We will convene an Expert Advisory Panel (EAP) with expertise in interpersonal and family caregiving processes and family psychotherapy to provide feedback on the OCM. The OCM represents an adaptation of previously established and reliable coding manuals developed for assessing interaction patterns in couples, families, and dementia caregiver research. 13-15 Using an iterative process of refinement based on EAP feedback, pilot coding of video from five initial dyads, and feedback from those dyads we will use coding schemes originally developed for research and adapt them for clinical use. We will then recruit 15 additional dyads and videotape their interactions. Five Psychology Trainees will be trained on the OCM. The PI and pairs of Psychology Trainees will independently code each video to assess validity (face, concurrent, convergent, discriminant, content, and criterion), reliability (alternate form, inter-rater, and internal consistency) and analyze qualitative data from semi-structured interviews of caregivers, care-recipients, and clinicians to assess acceptability and utility of the OCM. (2) Development and pilot testing of the Family Intervention: As the OCM is being created, we will draft a treatment manual for a family intervention informed by established empirically supported interventions for couples and families65-69. The treatment manual will specifically target the identified interpersonal skills deficits in the OCM. A draft of the Treatment Manual will be presented to the EAP, eliciting feedback for further refinement. We will pilot test the family intervention via telehealth with the dyads who received the OCM and assess feasibility of delivery, dyad benefit from dyad and therapist report, and descriptive analyses of changes in interpersonal conflict, caregiver depression, anxiety, and burden. These data on the OCM and the family intervention will serve as the basis of an application for Investigator Initiated Research (IIR) funding for a Randomized Clinical Trial (RCT) of the OCM + family intervention applied to tele-health dementia care management (DCM) to a non-telehealth DCM program alone for high risk PWD (i.e. those with high levels on behavioral assessments and high healthcare utilization).