Effectiveness of Acceptance and Commitment Therapy for distressed family caregivers of patients with dementia: a case control study

doi:10.21203/rs.3.rs-4173976/v1

Background: Recently, psychoeducational support to caregivers of patients with dementia (CPWD) has been much interested. Acceptance and commitment therapy (ACT) which accept negative thought has been arising as a next generation of CBT. Here, we investigate the effect of ACT on emotional stress of caregivers of patients with dementia.

Method: The family caregivers of patients who have behavioral psychomotor symptom in dementia were recruited in this study. 13 intervention group and 13 control group were analyzed. The participants in experimental group were underwent a 6-week ACT program in one on one, face to face format. The outcome measurement are Beck anxiety inventory (BAI), Beck depression inventory-Ⅱ (BDI-Ⅱ), Zarit burden inventory (ZBI) and acceptance action questionnaire-16 (AAQ-16).

Results: In experimental group, the score of BAI, BDI-Ⅱ, ZBI and AAQ-16 significantly improved compared to baseline score. The difference of the change of the score of BAI, BDI-Ⅱ and ZBI after ACT program showed significant difference between intervention and control group. The change of BDI-Ⅱ significantly correlated with the changes of AAQ-16

Conclusion: The result of this study showed that the depression, anxiety, and caregiver burden markedly reduced in intervention group compared to control group. The change of depression is correlated with the change of the degree of acceptance. Our results support that ACT can be useful counselling program for caring of family CPWD.

With increasing number of patients with dementia, it has been much interested not only patients with dementia themselves but also in caregiver of patient with dementia (CPWD) and their psychosocial status. It has been reported that 60% of patient with dementia are cared for by family members in South Korea. A survey targeting caregivers of dementia patients indicate that 14% of caregivers quit their jobs to provide care, and 33% of them reduced their working hours. Furthermore, financial burden of caring has led to increased family conflicts among relatives of dementia patients. The probability of developing depression is 2 to 3 times higher than general population with one-third of family caregiver exhibiting symptoms of depression [1]. It last decades, there has been significantly policy and academic advancement in the education and support of CPWD. It has been frequently reported that cognitive behavior therapy (CBT) is considered the effective treatment for emotional and psychological stress in CPWD [2, 3]. In recent days, the importance of counselling for emotional support has been receiving as much attention as the treatment and education. Family CPWD are likely to engage emotional avoidance or suppression due to miss the opportunity to address their emotion [4]. Recently, the ACT, which induced to accept negative thought, has been introduced as third generation of CBT [5]. ACT can enhance psychological flexibility which lead to experience their emotion and though without unnecessary defense [6]. We assume that ACT is suitable psychological intervention method for family CPWD. There have been few reports for investigating effect of ACT in CPWD. Here, we evaluate the effectiveness on emotional burden including depression and anxiety in family caregivers of patients with dementia.

1) Study design

This is prospective, single-center, rater-blind, case-controlled trial. Inclusion criteria are as follows, 1) Family caregivers of patients with dementia, 2) Aged between 40 to 80 years of age, 3) caregivers living with dementia patients and dedicated at least 40 hours per week to care for patient, 4) dementia patients being cared for exhibits behavioral psychological symptoms in dementia. Exclusion criteria are as follows. 1) Participants who have history of underlying psychological disorders, 2) Patients who have comorbid disease other than dementia, 3) Participants who simultaneously burdened caregiving responsibilities of other family members, 4) Paid caregiver. Drop out criteria is participants who fail to achieve attendance rate of 80% of ACT program in experimental group. Sample sized was determined guided by general recommendation for pilot study. We recruited participants who visit our clinic and public dementia care center. ACT intervention was conducted face to face in a quiet and private environment. All participants were given informed consent and this study obtained approval of Haeundae Paik Hospital institutional review board.

2) Intervention in experimental and control group

ACT was utilized based on research by published report, and a manual used in domestic research. ACT intervention was conducted weakly, with one-hour session each time for six weeks. Table 1 provides an overview of the ACT program. In the initial session, participants were introduced to the ACT program, its structure, and efforts were made to enhance motivation to participate. Sessions 2 and 3 emphasized experiential willingness and cognitive defusion. During these sessions, participants explored factors that hinder psychological well-being and discussed the methods they typically used to avoid distressing experiences. Moving on to sessions 4 and 5, the emphasis shifted towards emotional acceptance. Participants were guided to engage with their present experiences and become aware of themselves and their emotions. In sessions 6 and 7, the focus was on living a values-centered life. Participants were encouraged to discuss and apply leading a life centered around their values, detaching from situations and emotions, and dedicating themselves to what they value.

Table 1

Program of ACT (Acceptance and Commitment Therapy)
Session	Subject	Goal & Main Tasks
1	As you begin ACT	● Introduction to the Program ● Introduction to ACT ● Pre-Assessment
2	Issue of Control & Willingness to Experience	● Meditation for mindfulness ● The realization of avoidance concerning experiences and understanding how avoidance can lead to negative outcomes. ● Practice of willingness as an alternative
3	Cognitive defusion	● Meditation for mindfulness ● Distinguishing between direct experience and evaluative functioning, and practicing separating thoughts and feelings from facts through cognitive defusion ● Leaf meditation, verbalizing thoughts.
4	Acceptance & Contacting present experience	● Meditation for mindfulness ● Promoting healthy social distancing through a willingness to experience" ● Enhancing critical thinking ● Labeling experiences, Maintaining distance from thoughts and emotions
5	Self-dissociation Observing self	● Meditation for mindfulness ● Emphasizing that emotions or thoughts are not me and recognizing oneself as the context of thought ● Practice of observing oneself, Practice of self-concept journaling
6	Choosing values	● Meditation for mindfulness ● Assisting in clarifying committed actions ● Identifying obstacles to values ● Imagining a eulogy, Recording obstacles journal
7	Engaging in committed actions	● Meditation for mindfulness ● Helping one realize they can move towards their values despite obstacles ● Encouraging to engage in committed actions ● Welcoming greeting to obstacles, Analogy between a bus driver and passengers ● Post -Assessment

Participants in control group were given conventional educational program which is provided dementia care center in South Korea. All participants received one on one caregiver education with a doctor. And then, they were provided education and mental health resources and were instructed to revive the distributed materials at home themselves for six weeks.

3) Outcome measure

To assess effectiveness of the ACT intervention, validated scales were administered at baseline and immediately post-intervention. The depression was assessed using Beck Depression Inventory Ⅱ (BDI-Ⅱ was used for assessing depression [7]. The instrument consist of a total 21 items on a 3-point Likert scale and possible score range is from 0 to 63, with higher scores indicating higher levels of depression. The anxiety was evaluated using the Korean version of Beck anxiety Inventory (BAI)[8]. This yields a possible score range 0 to 63, where higher scores indicate higher level of anxiety. For estimating caregiver burden, we applied Short Zarit Burden Inventory, S-ZBI[9]. A higher score indicates a higher caregiver burden. To ACT, the degree of acceptance is a critical factor, we investigate the level of psychological acceptance using the Acceptance and Action Questionnaire-16 (AAQ-16)[10]. This questionnaire assesses the extent to which individuals willingly accept their thoughts and emotions while behaving in ways that are consistent with their values and goals. The possible score range is from 16 to 112, where higher scores indicate a greater degree of psychological acceptance.

4) Statistics

In each group, the Sphapiro-Wilt test was used for normality test. For the comparison between pretest and posttest within each group, paired t-test was applied if it is normal distribution, and Wilcoxon singed ranks test was used if it is non-normal distributed. To compare the differences of change of BAI, BDIⅡ, S-ZBI and between experimental and control group, ANCOVA was employed with demographic variable that showed significant differences between two groups as a covariate. Spearman Rank correlation analysis was used for investigating the correlation between the changes of clinical outcomes and AAQ-16. We also investigate the correlation between AAQ-16 and demographic factor including age, education level, disease severity of patient with dementia

The recruitment process is depicted in Fig. 1. 32 caregivers were recruited were assigned to experimental and control group. Three participants were withdrawn the consent. Two participants in experimental group were dropped out due to insufficient participation rate, and one participants with control group due to payed caregiving. Finally thirteen in experimental and thirteen participants in control group were analyzed. Retention rate across the study was 81%.

The average age is 60.69 and 7 were male among 26 participants. The baseline average of BDI-Ⅱ score is 17.00 ± 9.15 which indicate the mild depression state. The baseline average of BAI score is 18.00 ± 11.49 which is considered low anxiety [11]. On the other hand, the average of S-ZBI score is 23.96 ± 9.57 which indicate high caregiver burden. The baseline demographic data for the experimental and control groups were described in Table 2. The demographic data including age and education levels except sex were not different significantly between experimental and control group. Baseline clinical outcomes and disease severity of patients with dementia were not different between two groups.

Table 2

Demographic and baseline characteristics in participants and patients with dementia
	Experimental group (n = 13)	control group (n = 13)	p
Age	62.38 ± 10.64	60.00 ± 14.40	0.78
Sex	2/11	5/8	0.03
Education level	13.00 ± 2.08	13.15 ± 2.95	0.78
BAI	21.62 ± 13.39	14.38 ± 8.23	0.12
BDI	17.23 ± 7.83	16.77 ± 10.93	0.9
ZBI	27.54 ± 10.14	20.38 ± 7.73	0.06
AAQ	75.85 ± 12.68	71.31 ± 20.89	0.6
MMSE	15.77 ± 6.07	15.38 ± 5.31	0.87
GDS	4.85 ± 0.98	4.69 ± 0.86	0.68
Dementia
Alzheimer dz	7	8
Vascular dementia	4	2
Dementia with Lewy body	2	1
Frontotemoral dementia	0	2
Relationship
Spouse	6	7
Children	6	4
Grandchildren	0	1
Daughter in law	1	1

The results of primary outcomes are described in Table 3. Experimental group improved BDI-Ⅱ, BAI, S-ZBI score significantly after ACT intervention compared to baseline score. On the other hand, there is no significant change in all scales in control group compared to baseline. We compared the change of scales between intervention and control group. The changes of BDI-Ⅱ, BAI, ZBI and AAQ-16 also revealed significant different difference between intervention and control group.

Table 3
	Intervention group (n = 13)
	pre	post	p	pre	post	p	Intervention	control	p
BAI	21.62 ± 13.39	9.23 ± 5.43	0.00^1*	14.38 ± 8.23	12.77 ± 8.88	0.43²	12.38 ± 12.45	1.62 ± 7.17	0.01^3*
BDI-Ⅱ	17.23 ± 7.83	10.08 ± 12.61	0.00^1*	16.77 ± 10.63	16.46 ± 8.43	0.89¹	7.15 ± 6.24	-0.31 ± 7.77	0.02^3*
S-ZBI	27.54 ± 10.15	20.38 ± 8.59	0.03^1*	20.38 ± 7.77	25.25 ± 5.10	0.06¹	7.15 ± 8.78	-4.85 ± 8.62	0.00^3*
AAQ	65.00 ± 6.18	77.62 ± 6.64	0.00^1*	66.00 ± 8.89	65.92 ± 9.43	0.97	-12.52 ± 8.85	4.77 ± 20.67	001³
¹paired-t test
²Wilkoson ranked-rank test
³ANCOVA
*P values were derived from analysis of covariance adjusted for sex.

Spearman Rank correlation analysis revealed that the degree of acceptance and clinical outcomes for distress. The changes of BDI-Ⅱ between pre and post-test are significantly correlated with the changes of AAQ-16 (r=-0.44, p = 0.02), however, BAI and Z-BI did not (r=-0.33, p = 0.10 and r=-0.32, p = 0.10). (Fig. 2). Other demographic factor including age, education level of participants and disease severity of patients with dementia were not associated with the difference of AAQ-16.

The results of this pilot study revealed that ACT intervention improved depression, anxiety, and caregiver burden of CPWD. CBT, which is much reported for management of CPWD, focuses on modifying maladaptive thoughts and beliefs through cognitive reconstructing. Therefore, it brings about changes in emotions and behaviors [12]. In contrast, ACT emphasizes recognizing and accepting maladaptive thought and emotions that arise in difficult situations, moving away from experiential avoidance and negative thought[13]. Thus, while both therapies share a common cognitive approach that examines one’s cognition, emotion, behavior and physiological characteristics, they differ in their therapeutic approach within the cognitive processing. From the perspective of ACT, psychopathology is seen as psychological rigidity manifested as avoidance response due to the limiting nature of human language and negative cognition.[14] Therefore, the goal of ACT is the enhanced psychological flexibility which lead to experience their thought, emotion and physical sensation without unnecessary defense.

There have been few reports for investigating the effect of ACT in CPWD. Losada et al reported that ACT has a similar effect on depression, and superior effect on anxiety compared to CBT and control in caregivers of patients with dementia.[15] Paaler KA proved benefits of mindfulness program containing ACT in patients with dementia and family caregivers [16]. Fowler NR performed single arm study for CPWD. The results showed the feasibility and acceptable satisfaction with their telephone ACT [17]. A meta-analysis also proved that ACT has a moderate effect on anxiety and depression on CPWD [18]. Our results also revealed that ACT diminished caregiver burden as well as depression and anxiety consistent with previous reports. The previous reports often conducted CBT group counseling or remote counselling using telephone for dementia caregiver. In our study, 1:1 ACT individual counseling was performed, and it might be believed to have shown more remarkable effects compared to previous study.

This study targeted the caregivers of dementia patients exhibiting BPSD, with and average MMSE score of 15 and a GDS score of 4, indicating a severe dementia stage. Participants showed mild depressive mood and anxiety despite experiencing high caregiver burden. Previous research has reported than caregivers of severely demented patients often suffer from depression [19]. This can be attributed to the fact that the selection criteria for this study excluded patients who were already taking antidepressant medication. Nevertheless, the changes of AAQ-16 score was highly correlated with the changes of depressive mood which means that the participants who expanded psychological flexibility through ACT therapy and choose to accept their experience. The correlation between level of acceptance and anxiety, caregiver burden showed a tendency, but did not reach the statistical significance. This findings might due to small sample size and ceiling effect due to limited inclusion indicating a need for large prospective study.

There were several limitations of this study. First, small sample size is our major limitation. This is a pilot study to evaluate the feasibility of ACT in CPWD. Second, we did not perform randomization. Although there was differences in terms of sex between two groups, there were no statistical differences in all baseline outcomes. The larger, prospective, randomized trial should be performed to confirm the effect of ACT in caregivers in patients with dementia.

In conclusion, our study exhibited that ACT was effective intervention to family CPWD. Even in families with lower levels of depression and anxiety, the ACT intervention showed remarkable significant effect. Despite the trial of comprehensive services for dementia family, emotional support remain inadequate, and lacks a systematic and professional approach. Our study highlights the need for a new trend in counseling and emotional support of CPWD.

Data statement

The data that support the findings of this study provided supplementary information file.

Funding

This study was supported by the academic grant from Korean Dementia Society.

Author Contribution

Jiyoung Gwak: Conceptualization, Data curation, Methodology, Writing the original draft.Jinse Park: Writing- Review & editing the manuscript, Analysis and interpretation of result, Supervision, Funding acuisition

Acknowledgement

We extend our gratitude to the Gijang-gun Dementia Relief Center for their assistance in the participation of this research.

Data Availability

The data that support the findings of this study provided supplementary information file.

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No competing interests reported.

Data.xlsx

Effectiveness of Acceptance and Commitment Therapy for distressed family caregivers of patients with dementia: a case control study

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Abstract

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Introduction

Methods

Results

Discussion

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