Current issues of ACP Journal Club are published in Annals of Internal Medicine


Support for caregivers delayed time to nursing home placement in Alzheimer disease

ACP J Club. 1997 May-Jun;126:67. doi:10.7326/ACPJC-1997-126-3-067

Source Citation

Mittelman MS, Ferris SH, Shulman E, Steinberg G, Levin B. A family intervention to delay nursing home placement of patients with Alzheimer disease. A randomized controlled trial. JAMA. 1996 Dec 4;276: 1725-31.



To determine the long-term effectiveness of counseling for caregivers of patients with Alzheimer disease (AD).


Randomized controlled trial with up to 8-years of follow-up.


Research center in New York, United States.


206 caregivers (58% women) who had spouses with AD living at home and had primary responsibility for their care. Patients or caregivers had to have ≥ 1 relative living in the metropolitan New York area and could not be participating in another caregiver counseling or support group.


Caregivers were allocated to an intervention group (n = 103) or a control group (n = 103). The intervention consisted of individual and family counseling sessions, weekly support group meetings, and continuous availability of counselors for helping caregivers deal with crises and the changing symptoms of the patients.

Main outcome measures

Time to nursing home placement of patients with AD and predictors of placement.

Main results

The time to placement in a nursing home was longer for patients whose caregivers received the intervention than for patients whose caregivers received the usual services (median time at home adjusted for caregiver sex 1203 d vs 874 d, 95% CI for the median 329-d difference 47 to 611, P = 0.02). Univariate intention-to-treat analysis showed that female caregivers were more likely to place their spouses in nursing homes than male caregivers (relative hazard [RH] 1.48, CI 1.03 to 2.14, P = 0.04). Other predictors of placement were increasing patient age (RH 1.33, CI 1.05 to 1.68, P = 0.02); severity of dementia (RH for severe dementia 25.6, CI 3.53 to 185, P = 0.001); increasing depression in the caregiver (RH 1.05 CI 1.02 to 1.07, P = 0.001); and increased negativity of the caregiver toward troublesome behavior of the patient (RH 1.11, CI 1.08 to 1.14, P < 0.001). Patients with incomes of U.S. $100 000 were 62% less likely to be placed in nursing homes than patients with incomes of $10 000. Cox proportional hazard models that included the explanatory variables showed reductions in risk for nursing home placement with mild dementia (RH 0.19, CI 0.05 to 0.82, P = 0.03) and moderate dementia (RH 0.43, CI 0.20 to 0.96, P = 0.04) but a trend toward increased risk for placement with severe dementia (RH 2.26, CI 0.97 to 5.27, P = 0.06).


A program of educational counseling, support, and as-needed advice to family caregivers was effective in delaying time to nursing home placement in patients with mild-to-moderate Alzheimer disease.

Source of funding: National Institute of Mental Health.

For article reprint: Dr. M.S. Mittelman, Aging and Dementia Research Center, New York University Medical Center, 550 First Avenue, THN 312C, New York, NY 10016, USA. FAX 212-263-6991.


The decision to institutionalize a family member with dementia may be costly both from a financial and a psychosocial standpoint. Approximately 30% of caregivers and patients adjust poorly to institutionalization (1).

The study by Mittelman and colleagues shows that an ongoing support program that involves structured and as-needed counseling plus referral to a support group can influence the timing of nursing home placement of patients with AD. This is done by reducing unnecessary placement in the mild-to-moderate stages of disease while promoting the necessary placement in the severe stages. Although the quality of life for caregivers was not assessed, a separate analysis (2) showed that the same intervention can slow the progression of caregiver depression. The intervention used advanced-degree counselors who would not ordinarily be available to most family caregivers. However, families commonly turn first to their doctor for help with managing a relative with dementia, and it is therefore incumbent on physicians to learn how to incorporate most of the counselors' activities (case management, caregiver training, and problem solving of troublesome behaviors) and to perform them directly or in collaboration with other appropriately trained health professionals (3).

Because of the limited efficacy of treatments for the underlying disorder, dementia management primarily entails ongoing attention to the needs and concerns of the caregiver as well as those of the patient (3). The increase in the prevalence of functional dependencies and behavioral disturbances during the course of the dementia necessitate periodic reassessments, which can be facilitated by such standardized questionnaires as the Neuropsychiatric Inventory (4).

Calvin H. Hirsch, MD
University of California, DavisSacramento, California, USA

Calvin H. Hirsch, MD
University of California, Davis
Sacramento, California, USA


1. Gold DP, Reis MF, Markiewicz D, Andres D. J Am Geriatr Soc. 1995;43:10-6.

2. Mittelman MS, Ferris SH, Shulman E, et al. Gerontologist. 1995;35:792-802.

3. Council on Scientific Affairs, American Medical Association. JAMA 1993;269:1282-4.

4. Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA. Neurology. 1994;44:2308-14.