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By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SYNOPSIS: A Cochrane Review regarding efficacy of mindfulness-based stress reduction (MBSR) for family caregivers of dementia patients revealed low-quality evidence that MBSR reduces short-term anxiety and depressive symptoms in this population.
SOURCE: Liu Z, Sun YY, Zhong BL. Mindfulness-based stress reduction for family carers of people with dementia. Cochrane Database Syst Rev 2018;8:CD012791.
“With Alzheimer’s disease, it is not just those with the disease who suffer. It’s also their caregivers — a job that usually falls on family and friends.” — Alzheimer’s Association1
Because of the highly stressful nature of caring for a family member with dementia and the association of such caregiving with physical disorders, psychological morbidity, and even early mortality, family caregivers of dementia patients also are known as “the invisible second patient.”2 In 2017, 16.1 million family and friends in the United States held this unpaid role.1 There have been multiple investigations into various interventions, including mindfulness-based stress reduction (MBSR), to reduce risk in this population.
Developed by Jon Kabat-Zinn in the late 1970s, MBSR use has grown rapidly and its popularity has increased in subsequent decades. MBSR is a structured program with a range of different practices united by a focus on mindfulness or “the awareness that emerges through paying attention on purpose ... non-judgmentally ....” Techniques include meditation, yoga, and mindful movement.3 Studies of MBSR in family caregivers of dementia patients have begun to increase in number, but neither a quality meta-analysis nor a systematic review of these studies had been completed. Cochrane Reviews are systematic, evidence-based, commercial-free studies that provide current synthesized information to clinicians, patients, and policymakers.4
Liu et al conducted a Cochrane Review to evaluate the effectiveness of MBSR for family caregivers of dementia patients. They performed a comprehensive database search for quality studies investigating MBSR use in family caregivers of dementia patients and identified five trials suitable for inclusion in this meta-analysis. The five trials, which included 201 caregivers, carried a high risk for bias because of the difficulty of blinding the subjects and investigators. Three trials included active control groups, such as progressive muscle relaxation, and two trials included inactive control arms, such as respite care. Considering these and other factors, the Cochrane rating of the evidence in general is of low quality.
When compared with active control after eight weeks of intervention, there was low-quality evidence that MBSR reduces symptoms of anxiety and depression in family caregivers of dementia patients. On the other hand, when MBSR was compared to inactive controls over this same period, there was no evidence of an effect on depressive symptoms and very limited evidence regarding an effect on anxiety. Since the quality of the evidence was low, it is not possible to draw firm conclusions. Three trials with 135 participants suggested that caregivers who received MBSR vs. active control may have reported more incidents of feeling burdened. No determination could be drawn for this category for MBSR vs. inactive control because of the low-quality evidence. High-quality research is needed to determine how, and even if, MBSR is effective in alleviating stress for family caregivers of dementia patients. However, while waiting for such results, there is little risk in offering the results of this review as preliminary guidelines for caregiver self-care.
For now, clinicians should be mindful of the importance of addressing “the invisible patient” in the office when caring for patients with dementia. Educating caregivers regarding this and other similar studies may be helpful in validating caregiver feelings and provide a springboard to further discussion and possible intervention.
Financial Disclosure: Internal Medicine Alert’s Physician Editor Stephen Brunton, MD, is a retained consultant for Abbott, Acadia, Allergan, AstraZeneca, Avadel, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Mylan, and Salix; he serves on the speakers bureau of AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, and Novo Nordisk. Peer Reviewer Gerald Roberts, MD; Editor Jonathan Springston; Executive Editor Leslie Coplin; and Editorial Group Manager Terrey L. Hatcher report no financial relationships relevant to this field of study.