Effectiveness of day care in supporting family caregivers of people with dementia: A systematic review

Maffioletti, Virgínia Lúcia Reis; Baptista, Maria Alice Tourinho; Santos, Raquel Luiza; Rodrigues, Valeska Marinho; Dourado, Marcia Cristina Nascimento

doi:10.1590/1980-57642018dn13-030003

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Dementia & Neuropsychologia

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Original Article • Dement. neuropsychol. 13 (3) • Jul-Sep 2019 • https://doi.org/10.1590/1980-57642018dn13-030003 copy

Effectiveness of day care in supporting family caregivers of people with dementia: A systematic review

EFICÁCIA DO CENTRO DIA NO APOIO A CUIDADORES FAMILIARES DE PESSOAS COM DEMÊNCIA: UMA REVISÃO SISTEMÁTICA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Day care (DC) provides a break in daily care as a support strategy for family caregivers (FC) of people with dementia (PwD).

Objective:

to analyze the support strategies used by the DC for FC, their methodological and theoretical models, as well as the respective benefits for FC burden, coping strategies and quality of life.

Methods:

a systematic review following the Prisma methodology was performed on PubMed, PsycInfo, Scopus and SciELO electronic databases in August, 2018. The search keywords were “day care”, “dementia” or Alzheimer disease, “caregiver”, “quality of life” and “psychological adaptation”.

Results:

twenty-one studies were included. No randomized controlled trials were found. The provision of education, counseling and support, access to information, the professionals' expertise and the quality of their relationship with DC users were highlighted by caregivers. Compared to standard programs centering on PwD, the integrated program focused on PwD and FC activities showed increased feelings of competence and self-confidence of FC to postpone institutionalization. Heterogeneity in the structure and organization of the DC programs, intervention strategies and theoretical basis was observed.

Conclusion:

Integrated programs are a promising approach that addresses the needs and demands of PwD and their FC in a multidimensional manner.

Key words:
day care; Alzheimer disease; caregiver; quality of life; psychological adaptation

Study	Objectives	Study design	Sample and setting	Assessment methods	Main results	MMAT- score
Qualitative studies
Rokstad et al.³⁶36 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409., 2017 Norway and Scotland	To explore and compare the experiences and outcomes of DC services designed for PwD as described by PwD and FC	Qualitative cross-national descriptive design	32 PwD-FC Dyads PwD N = 17 in Norway N = 19 in Scotland FC N = 17 in Norway N = 15 in Scotland	Qualitative interviews	FC Outcomes • Confidence in the staff, provided 'peace of mind' in the knowledge their relative was being well cared for • Benefit from a respite • In Scotland, FC felt they benefited from being able to stay and talk with staff. PwD Outcomes • Increased wellbeing • Increased social engagement • Improved functioning and mood • Improved relationships with FC • Overall satisfaction with the service.	****
Tretteteig³⁵35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5. et al., 2017 Norway	To provide an extended understanding of the situation of FC and examine to what extent DC can meet their need for support and respite	Cross-sectional Qualitative descriptive design	FC N =17	In-depth interviews	FC Outcomes • Relieves FC by meeting the PwD needs for social community, nutrition, physical activity, and structure and variety in everyday life • DC have a positive influence on the relationship between FC and the PwD • Led to a higher quality of time spent together and easier cooperation • Produced some hard feelings and challenging situations • DC gave the FC a feeling of freedom and increased the time available for their own needs, to be social and to work or do practical tasks undisturbed. • Provide the families with a sense of shared responsibility and relief while they are still active in their caregiving role. PwD Outcomes • DC reduces behavioural challenges • Contribute to the postponement of nursing home placement • This result depends on flexible opening hours, high quality of the DC program and regular cooperation with FC.	****
Liu et al.²³23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40., 2015 USA	To evaluate the magnitude of FC affective fluctuation and whether this is associated with caregivers' daily experiences, intervention, DC use that affects daily experiences by lowering exposure to care-related stressors, and with other caregiving characteristics	Cross-sectional Qualitative descriptive design	FC Users N = 173	Face-to-face interview; questionnaires; telephone interviews; Nonspecific Psychological Distress Scale; Daily Inventory of Stressful Events;	FC Outcomes • Changes the structure and routines of daily caregiving experiences • Provides temporary respite away from caregiving responsibilities • Relieves caregivers' exposure to potentially stressful behavior problems. • This recess prevents accumulation of daily negative affective reactions in both depression and anger. • It may help spouse or older caregivers or caregivers with lower education, and bring down their fluctuation in depression.	***
Zarit et al.²⁴24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.., 2014 USA	To examine the effects of use of DC by FC of PwD on daily stressors, affect, and health symptoms	Cross-sectional Qualitative descriptive design	FC Users N = 173	Daily telephone interviews; DRB; The Non-Specific Psychological Distress Scale; PANAS; ADL; IADL	FC Outcomes • Had lower exposure to care-related stressors on DC days, more positive experiences, more noncare stressors, lower anger and impact of noncare stressors on depressive symptoms.	****
Gústafsdóttir³⁷37 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 2014 Iceland	To explore the collaboration between families and staff in day-care units caring for elderly subjects suffering from dementia.	Longitudinal Qualitative Interpretive phenomenological study	FC N = 8	Interviews	FC Outcomes • All families found the services of specialized day-care units both useful and pleasant • This resource made everyday life much more manageable for all persons involved.	***
Phillipson et al.³⁹39 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34., 2012 Australia	To explore and understand DC use from the perspective of FC.	Longitudinal, qualitative	FC - N = 36 (29 users; 7 non-users); (25 spousal and 11 non-spousal).	Focus groups, semi-structured interviews, dyad interviews	FC Outcomes • They felt free to engage in other daily and social tasks, and to care for other family and friends. • They valued the opportunity to learn by observing team management strategies with PwD. The FC users had a more positive perception of DC than non-users. PwD Outcomes • The FC believes that PwD benefited from being engaged in positive occupation which enhanced their personhood or sense of self • Had gains from social interaction or mental stimulation. • The DC were perceived as improving the quality of life of the person with dementia.	***
de Jong et al.³²32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77., 2009 Netherlands	To study the needs and wishes of FC when providing skilled psychogeriatric DC.	Cross-sectional Qualitative descriptive design	N = 9 Dyads PwD / FC Co-residents N =4; Living alone N = 4 Nursing home N = 1	Semi-structured interviews and focus groups	FC Outcomes • The expertise of professionals and their relationship with the day-care users were considered important. • The FC need to know the structure and program of the DC • They expect the professionals to play a more active role in providing education, advice and support.	****
Quantitative non-randomised studies
Logsdon²²22 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. et al., 2016 USA	To evaluate whether MCWS improved quality of life, mood, behavior, or functional status for PwD and whether FC experienced decreased stress, burden, or depression, compared with control dyads	Longitudinal Quasi-experimental, control group design	187 PwD-FC dyads Group of users N = 162; Controls non-users N = 25	MMSE; QOL-AD; ADL; IADL; RMBPC; CES-D; Screen for Caregiver Burden; PSS.	FC Outcomes • The MCWS caregivers exhibited significantly less distress over behavior problems, memory and depressive problems, than comparison caregivers. PwD Outcomes • No significant differences were seen between MCWS and comparison dyads at 3 months. After 6 months, MCWS participants exhibited significantly fewer depressive behaviors and other behaviors problems than comparison participants.	****
Kim et al.²⁵25 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66., 2012 USA	To examine the effects of kin relationship on response to use of DC on feelings of burden, depressive symptoms, and positive affect for FC.	Longitudinal Quasi-experimental, control group design	FC N = 341 Users Group N = 182 (Wives = 67 + Daughters = 115) Controls non-users N = 159 (Wives = 64 + Daughters = 95)	Role overload; CES-D; PANAS; ADL; IADL; RMBP	FC Outcomes • Kin relationship affected the response to intervention • For depressive symptoms, both wives and daughters had lower scores over time compared to controls. • The wives and daughters had lower feelings of burden over time, but wives' scores dropped only to the level found among controls. • For positive affect, wives using DC showed a considerable decline over time.	***
Cho et al.²⁷27 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67., 2009 USA	To examine whether kin relationship affects the timing of nursing home placement for caregivers who enroll a relative into an DC program compared with caregivers not using DC.	Longitudinal Quasi-experimental, control group design	FC N = 371 Group users N = 174 Wives 76 + Daughters 98 Controls non-users N = 197 Wives = 65 + Daughters = 132	In-person and telephone interviews; IADL; ADL; RMBPC; Role captivity and Role overload Scales; SCL-90; CES-D.	FC Outcomes • The DC can serve as a stepping stone for institutionalization. For wives, institutionalization was associated with feelings of overworking wives and behavioral problems of husbands • For daughters, the effect of using DC was to delay institutionalization	***
Mossello et al.⁴⁰40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72., 2008 Italy	To evaluate the effects of DC on cognitive, functional and behavioral status of PwD and on psychological well-being of FC, compared with nonrandomly matched controls receiving usual home care (HC)	Longitudinal Quasi-experimental, control group design	60 Dyads PwD/FC Group users N = 30 Controls non-users N = 30	NPI; CBI; MMSE; ADL; IADL; BDI	FC Outcomes • Burden significantly decreased compared to controls • No significant difference in between-group depressive symptoms change PwD Outcomes • The behavioural and psychological symptoms significantly decreased; • Reduction in psychotropic drugs prescription, whereas this increased in FC. • No significant difference in cognitive and functional changes	****
Droes et al.³³33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24., 2006 Netherlands	To retest the hypothesis that integrated comprehensive family support in the MSCP is more effective for reducing feelings of burden of FC and positively influencing some potential determinants of feelings of burden, than non-integrated support, such as regular DC. Explored the potential effect of the MCSP on the emotional impact that behavioural and psychiatric problems of the PwD have on FC.	Longitudinal Quasi-experimental, control group design	FC N = 84 Group MCSP users N = 71 Controls Day-Care users - N = 13	GHQ; SCS; JCS; Social Support list; Services list; LS; NPI; ASEP; CSDD; Behaviour Observation Scale for Intramural Psychogeriatrics; PGCMS	FC Outcomes • After seven months, no effect was found in psychological and psychosomatic symptoms or in the determinants of burden. • The integrated approach proved more effective than regular DC for decreasing psychological and psychosomatic symptoms in lonely FC. • The majority of carers experienced less burden and more professional support. PwD Outcomes • After seven months, significantly fewer persons were institutionalized as compared to the controls patients.	***
Gitlin et al.²⁸28 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9., 2006 USA	To evaluate the short (3-month) and long-term (up to 12 months) effects of an innovative intervention, the Adult Day Services Plus (ADS Plus) program.	Longitudinal Quasi-experimental, control group design	N = 129 Dyads PwD/FC ADS Plus users N = 67 Controls DC users N = 62	Interviews; CES-D; ZBI; Memory and Problem Behaviors Scale; Perceived Change Index; REACH II	FC Outcomes • The ADS Plus Program provides evidence that DC is care which results in immediate and long-term clinically significant quality-of-life improvements for both the caregiver and impaired elder • Reduction in depressive symptoms • Increased confidence in managing troublesome behaviors • Enhanced overall perceived well-being	****
Droes et al.³⁴34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11, 2004 Netherlands	To compare whether the integrated support program (MCS) is more effective for reducing the feelings of burden of FC and positively influencing some determinants of burden experienced, such as behavioral changes, than the support offered by the regular DC.	Longitudinal Quasi-experimental, control group design	N = 55 Dyads PwD/FC Group MCS users N = 36 Controls DC users N = 19	CSQ; PGCMS; GHQ; LS; FCS; JCS; Social Support list; Services list; ASEP; BCRS; CSDD; Behaviour Observation Scale for Intramural Psychogeriatrics;	FC outcomes • There was no statistical indication that the MCS Program was more effective for reducing the feeling of overload of FC than the support offered by the regular DC • Participation in the program contributed to an increased sense of competence of FC and postponement of institutionalization.	***
Gaugler et al.³⁰30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62., 2003 USA	To determine whether DC use interacts with decreases in FC hours, to alleviate caregiver stress and negative mental health over time.	Longitudinal Quasi-experimental, control group design	FC N = 400 Group users N = 169 Controls non-users N = 231	In-person interviews; Role captivity; Role overload scale; CES-D; SCL-90; RMBPC, IADL, ADL	FC Outcomes The DC are potentially effective in restructuring caregiving time,providing FC with respite, when compared to non-users, thus leading to decreased feelings of exhaustion.	***
Zarit et al.³¹31 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77., 1998 USA	To evaluate the psychological benefits of DC for FC assisting a relative with dementia	Longitudinal Quasi-experimental, control group design	FC N = 324 Group users N =121 Controls non-users N = 203	CES-D; Role Captivity; Role Overload scales; Worry and strain; BSI; PANAS	FC Outcomes • The use of the day center significantly reduced overload, depression and anger compared to controls. PwD Outcomes • No decrease in behavioural problems.	***
Zank et al.⁴²42 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57., 2002 Germany	To evaluate the effects of DC on PwD and FC	Longitudinal Quasi-experimental, control group design	PwD N = 83 Group users N = 43; Controls non-users N = 40 FC N = 62 Group users N = 40 Control non-users N = 22	LSQ; PSS; Self-esteem instrument; MADRS; MMSE; NAI; ADAS; NAO; Family Conflict Scale; Job-Caregiving Conflict Scale; ZBI; CES-D; RMBPC; semi-structured interview	FC Outcomes • No change in subjective well-being and burden between the groups in the longitudinal follow-up • On a semi-structured interview, the FC of PwD in the treatment group reported substantial positive change due to use of DC • High levels of satisfaction were reported PwD Outcomes • An improvement or stabilization of the subjective wellbeing and dementia symptoms in the treatment group in comparison with the control group • Follow-up data showed a significant decline in health in the control group in comparison with the day care users	****
Quantitative descriptive
Kwok et al.³⁸38 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15., 2013 Hong Kong	To examine the effectiveness of a dementia-specific DC	Longitudinal Quantitative descriptive design	90 Dyads PwD / FC N = 90	ZBI; MMSE; CMAI; IADL; BI; CDR; MFAC; BBS; MNA, PWI-ID; BMI	FC Outcomes • Dementia-specific DC reduced caregiver burden. PwD Outcomes • Maintained cognitive function and quality of life • Self-care ability, mobility and behavioural problems did not improve.	***
Zarit, et al.²⁶26 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46., 2011 USA	To examine the daily assessment of FC on the impact of intervention and possible changes in the primary stressors associated with care, by comparing the days that the PwD were attended by the DC and the days they remained at home	Longitudinal Quantitative descriptive	FC - N = 121	Daily telephone interviews; DRB; in-home interview; MMSE; ADL; WRB	FC Outcomes • Total exposure to stressors and stress appraisals decreased significantly over time on • DC days compared with non-DC days. PwD Outcomes • Reduction in behavioral problems during the evenings was significant • Improved sleep immediately following DC use.	****
Mavall et al.⁴¹41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50., 2007 Sweden	To evaluate whether the DC is an effective way of resting for caregivers residing and not-residing with their relative with dementia.	Longitudinal Quantitative descriptive design	FC N =51 Co-resident group [CR] N= 29; Non-co-resident group [NCR] N = 22	CES-D; Likert Scale.	FC Outcomes • Experienced a rest period • Were less worried and had decrease in care-related stress after four months • Non-co-residing FC whose relative continued in DC had significantly less burden, role captivity and depression than non-co-residing controls	****
Higgins, et al.²⁹29 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9., 2005 USA	To evaluate whether a once-a-week activity-based DC program for dementia patients combined with 17 educational sessions for caregivers held at the same facility, over one year, increased quality of life (QOL), lowered levels of patient behavioral disturbance, and stimulated greater use of community-based resources	Longitudinal Quantitative descriptive design	Dyads PwD / FC Users - N = 21	MMSE; BRSD; QOL-AD; standardized questionnaire	FC Outcomes • Caregivers reported their own QOL as unchanged. PwD Outcomes • Cognitive function and behavioral symptoms worsened significantly Caregivers reported significant decrease in QOL for their loved ones, but patients reported essentially no change in QOL • The DC experience appeared to increase morale and decrease a sense of isolation for patients and caregivers alike.	***

Study	DC setting	Objectives of day care services	Design of interventions	Theoretical principles	Effectiveness indicators used
Rokstad et al.³⁶36 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409., 2017	Subsidy: Norwegian - DC is provided and regulated by the municipalities and run mainly by local authorities that must offer in-home nursing care and residential care. The service is free of charge if considered a health care service for the PwD. If defined as a respite service for FC, there is a subsidized payment for attendance. Scotland: DC is provided by statutory, private and third sectors organizations. There may also be some direct costs to attendees for lunch or transport. All social care services are regulated by the Care Inspectorate. Team: Norwegian - The staff comprise paid health and social care workers, but some DC include volunteers in the paid staff. Scotland - there is a mix of paid professional staff and volunteers Regularity: Not described	# To offer meaningful activities and social support and a safe environment to enhance coping and improve quality of life for users # DC should act as a respite service and possibly postpone the need for nursing home placement.	PwD: The day is structured with repeated routine centered on conversations, mealtimes, activities (singing, physical games and exercising, arts and crafts, word games, and quizzes) with an emphasis on fun and humor.	Not described	# Confidence in the staff # Increased social interaction, wellbeing, social engagement, improved function and mood, and relationships with caregivers # Quality is dependent on the way staff organized the service and engaged with people.
Tretteteig et al.³⁵35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5., 2017	Subsidy: Not described Regularity: for approximately 2 - 18 months, 2 - 5 days a week.	Not described	Not described	Not described
Logsdon²²22 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. et al., 2016	Subsidy: Not described Team: including social services, nursing, and occupational/speech therapy. Staffing ratio = 1:4 Regularity: A program operating at least 2 days a week, and at least 5 hours per day	# To facilitate continued care at home # To provide respite for the caregiver, as well as emotional support # To deliver health support for the PwD	FC: Involvement of the caregiver in care planning; Caregiver support, including information and referral services PwD: A program of specialized activities and exercise	Not described	# Better health, mood # Fewer behavioral problems # Better quality of life (QOL);
Liu et al.²³23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40., 2015.	Not described	Not described	Not described	Not described	Not described
Zarit et al.²⁴24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9., 2014	Not described	Not described	Not described	Not described
Gústafsdóttir³⁷37 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54, 2014	Not described	Not described	FC: Caregiver support groups. They talk regularly to the head of the DC or to the unit nurse and interact with everyone in the DC when they attend events such as travel or dance sessions.	Not described
Kwok et al.³⁸38 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15., 2013	Subsidy: A self-financed dementia-specific DC Regularity: Participants attended its respite service and also stayed in their own home at least 1 day per week.	# To alleviate caregivers' stress and burden # To maintain cognitive functioning, physical ability, daily functional ability, behavioural status, nutrition level, and quality of life of PwD.	FC: Supported by designated case managers PwD: Group training on memory, activities of daily living, reality orientation, and cognitive stimulation.	Not described	Not described
Kim et al.²⁵25 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66., 2012	Subsidy: Funded in part by a statewide subsidy available to family members caring for a PwD Regularity: two days per week or more	Not described	Not described	Not described	Not described
Phillipson et al³⁹39 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34., 2012	Not described	Not described	Not described	Not described	Not described
Zarit et al.²⁶26 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46., 2011	Regularity: three days a week, 6 hours on the program, not counting travel time	Not described	PwD: Daily routines, physical activities, social activities, cognitive stimulation	Not described	# Decreased frequency of behavioral problems # Reduced FC exposure to stress and its negative consequences
de Jong et al.³²32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77., 2009	Subsidy: the government covers the costs Team: multidisciplinary professional staff Regularity: two to four days each week, 7 hours a day Transportation: included	# To provide information at client level/cooperation Mutual familiarity # To promote trust and flexibility in schedule # To give information and advice # To offer specialized medical and paramedical care # To offer physical and therapeutic activities aimed at rehabilitating # To run individualized activities	PwD: Routinely provide systematic assessment, rehabilitation, education and support activities	Not described	# Identification of early warning of problems or changes in health, offering a guarantee of crisis intervention # Increased dignity and self-esteem # Offering of flexibility in relation to schedules by adjusting the service according to the conditions of each PwD # Interaction, communication, information and support offered by the team # Good team relationship with caregivers and users # Staff should inform FC about the experiences of PwD
Cho et al.²⁷27 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67., 2009	Subsidy: network of DC programs and subsidies provided to help families pay for it	Not described	Not described	Not described	Not described
Mossello et al.⁴⁰40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72., 2008;	Team: multi-professional team, including nurses and physiotherapist, supervised by a geriatrician Regularity: 2 to 6 days weekly for 8 hours a day	# To stimulate residual cognitive abilities # To reduce BPSD	FC: Informal counseling for caregivers PwD: individual care plans, based on geriatric multidimensional assessment of occupational and recreational activities Controls: Usual home care.	Not described	# Environmental management # Providing relief for caregivers and reducing their stress # Keeping patients close to their familiar environment # Decrease in behavioral changes
Mavall et al.⁴¹41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50., 2007	Not described	# To support FC # To provide a meaningful day # To delay institutionalization	Not described	Not described	# Decrease in time that FC spends caring and increase in time FC can dedicate to their other needs. # Decrease in depression and somatic problems of FC. # Improvement in psychological well-being of caregiver;
Droes et al.³³33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24., 2006	Regularity: FC: Ten informative meetings bi-weekly discussion group PwD: Three days a week Dyad: A monthly centre meeting A weekly consultation hour	# To support FC, improve their knowledge and sense of competence and support them emotionally and socially. # To offer some respite	FC: Participate in the discussion group whenever they feel the need to do so. PwD: Offer recreational and social activities for reality orientation training, reminiscence, validation, psychomotor therapy and music therapy. DYAD: Can utilize weekly consulting and participate in social festivities and excursions. Support and case management is provided by professional staff. A collaboration protocol regulates cooperation between the staff and the professional care and welfare services in the neighborhood involved with PwD. Controls: PwD participated in the regular DC. If necessary, medical care, physiotherapy or occupational therapy are also available. The FC is only marginally involved.	The adaptation coping model⁴⁰40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.^,⁴¹41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.; The model of determinants of experienced burden of carers of PwD	# Reduction of psychological and psychosomatic symptoms in carers who feel more lonely # Increase in sense of competence for FC of PwD who exhibit behavioral problems # Increase in satisfaction with FC coping strategies # Reduction of loneliness in carers older than 75. # Decrease in emotional impact that behavioural and psychiatric problems of the PwD have on the carer.
Gitlin et al.²⁸28 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9., 2006	Subsidy: Uses existing DC staff and resources Team: center director, family service provider, activity specialist, nurse, and program assistants, with a direct staff/elder ratio of 1:5. Regularity: FC received an average of 1 hour per month of contact with the service.	# ADS Plus integrates care management into regular DC to address the specific concerns and needs of FC and has the purpose of providing emotional support, counseling, education, and referral targeting the specific concerns identified.	FC: Meet face-to-face with the site service Director in order to: (a) identify areas of concern and needs; (b) develop a care plan for areas of difficulty; (c) implement an agreed-upon care plan with four components: counseling, education, referral, and periodic supportive contact with the service Director. Subsequently, the service Director meets with FC either face-to-face when their relative visits the center, or by telephone. Additionally, the service Director provides targeted education materials through mailings. The purpose of each follow-up contact is to provide emotional support, counseling, education, and specific referrals for concerns identified. PwD: Receive usual DC support and the ADS Plus Program for the caregivers. Controls: PwD use of DC; the FC have access to staff to obtain information as needed. The contact is generally not programmed or purposeful, nor is the structured care management service. Support and educational groups are occasionally offered.	The stress process model⁴²42 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57.	# Quality-of-life improvements for both the FC and PwD # Reduction in depressive symptoms # Increased confidence in managing troublesome behaviors # Enhanced overall perceived well-being.
Higgins, et al.²⁹29 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9., 2005	Subsidy: The University of Texas Southwestern Medical Center and the Greater Dallas Chapter of the Alzheimer's Association Team: volunteer staff Regularity: once a week for 6 hours a day	# To provide respite and education for FC. # To provide an inviting, comfortable, and stimulating environment for PwD	FC: Educational program for caregivers PwD: Use of overlearned skills in simple games and stimulation of recent memory, associative processes, and simple socially appropriate motor tasks	Not described	# Increased QOL in both PwD and FC # Lower levels of behavioral symptoms # Improvement in use of community resources # Improvement in educational experience for FC.
Dröes et al.³⁴34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11, 2004	Regularity: FC: Ten informative meetings and bi-weekly discussion group PwD: Three days a week and a weekly consultation hour Dyad: A monthly centre meeting	# To support FC, improve their knowledge and sense of competence and to support them emotionally and socially. # To offer some respite	FC: Informative meetings and long-term discussion group. PwD: Uses the DC activity club, which organizes creative recreational activities and participates in psychomotor therapy. A consultation hour organized, where PwD and FC can get personal advice. A meeting during which the dyad and professionals express their wishes concerning changes in the program. Controls: FC have incidental contacts with social worker and other staff members. PwD participated in the DC program.	The adaptation coping model⁴⁰40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.^,⁴¹41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.	# Reduction in the feelings of burden of FC; # Delaying admission in a nursing home # Positively influencing some potential determinants of burden.
Gaugler et al.³⁰30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62., 2003	Not described	Not described	Not described	Not described	Not described
Zank et al.⁴²42 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57., 2002	Subsidy: health insurance, care insurance, patients, or social welfare. Team: geriatric nurses, and untrained young men doing community work instead of military service. Transport: Provided Regularity: at least twice a week plus usual home-based community care 7 days per week, up to five times daily	# To enhance patients' well-being and competence # To reduce loneliness and depressive symptoms # To reduce burden placed on caregivers.	FC: Sometimes informative groups for caregivers are offered. PwD: DC plus usual home-based community care. The DC offer structured daily routine, individual training of residual competencies, new social contacts and constructive activities. The program consists of everyday life activities, games, individual training, and outings, tailored to the individual patient with his or her unique biography, specific weaknesses and strengths. Controls: PwD receiving only home-based care	Rehabilitation program based on clinical experience and gerontological knowledge	Improvement in emotional well-being and ADL of PwD. Reduction in primary stressors, the stress and burden of FC and increase in their free time; Provision of information about the disease; Reduction in family conflict and conflict between job demands and perceived caregiving demands.
Zarit et al.³¹31 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77., 1998	Regularity: 5 days a week for 7 hours per day. Many centers extend hours and a few have weekend hours to accommodate FC Transport: Provided	Not described	Not described	Not described	Not described

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