The content, dissemination and effects of case management interventions for informal caregivers of older adults: A systematic review

Abstract

Objectives

To investigate and describe the content, dissemination and effects of case management interventions for informal caregivers of older adults, focusing on outcomes related to patients’ activities of daily living, nutrition assessment, pain measurement, depression, length of stay and to caregivers’ satisfaction and difficulties.

Design

This systematic review was based on the Preferred Reporting Items for Systematic. Reviews and Meta-Analysis of studies that evaluate healthcare interventions (PRISMA) statement.

Data sources

PubMed, CINAHL, and EMBASE were searched in September 2013 using a two-step search strategy combining an electronic search with a search in the reference lists. The search strategy was structured using the study inclusion criteria built on PICOS.

Review methods

Studies were reviewed by title, abstract and full-text by both authors. Duplicates and studies not meeting the inclusion criteria were excluded. Data was extracted from the eligible studies using narrative synthesis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was employed to rate the quality of the evidence.

Results

Seven studies (5 RCTs) including a total of 6956 patients over the age of 65 and their informal caregivers (spouses, family members, and close relatives) all in community-care settings were found eligible and included in the review. The assessment for risk of bias in the seven studies indicated variations in the study quality from very low (n = 4), to low (n = 1) and moderate (n = 2) due to lack of randomisation, blinding, transparency and not following intention to treat. A case management approach was claimed in four studies and the remaining three studies used a psycho-educational intervention with core components of case management consistent with the literature. Significant effects of case management interventions were seen on patients’ time to institutionalisation, municipal care costs and emotional health when informal caregivers were involved. A significant effect was also found on informal caregivers’ decrease in depressive symptoms over time.

Conclusion

Research of case management interventions for informal caregivers is very limited. This review identifies knowledge about case management as an intervention for informal caregivers to older patients, suggesting strengths and weaknesses for future interventions when informal caregivers are involved.

PROSPERO registration: CRD42014007462

Introduction

Informal caregivers, such as family and relatives, often have a great desire to be involved in patients’ care and treatment (Dreyer et al., 2009, Weman and Fagerberg, 2006). Studies show that informal caregivers play an important role in the care of their older family members by providing practical and emotional support before, during and after hospitalisation (Hertzberg et al., 2003, Lindhardt, 2007). However, health professionals can sometimes be reluctant to include informal caregivers in the care of older patients because of conflicting interests and lack of time (Berthelsen et al., 2014, Engström et al., 2011, Weman and Fagerberg, 2006), the nurses’ busy daily routines (Hertzberg et al., 2003) and striving to follow the standardised treatment programme (Berthelsen et al., 2014). An active involvement of informal caregivers in the care and treatment of their older family members can enhance the effect of treatment and well-being for the patient (Theiss et al., 2011) and these aspects become even more relevant to investigate in the future. Within the next 30 years there will be an estimated 25% increase in the number of over-65s in Denmark (Danish Statistics Database, 2011) and an estimated decrease of 7000 registered nurses employed in the public sector (The Danish Nursing Council, 2007). This is also an international challenge. The U.S. Department of Health and Human (2013) has estimated the US population aged 65+ to increase from 43 to 80 million people. However, the employment of nurses is estimated to increase with 19 percent between 2012 and 2022 (U.S. Department of Labor, 2014). The figures are similar in the UK where currently 14.7 million people are over 60 years with an expected rise to 20 million by 2030 (Age UK, 2014) and an estimated shortfall of nurses is estimated to 61.200 by 2050 (Randstad, 2014). At that point, informal caregivers will be an increasingly important resource to the patient as well as to the health professionals. Interventions aimed at involving relatives in older patients’ care trajectories to improve patient outcomes are therefore needed.

Involving informal caregivers by simply providing information is not sufficient, but combining this provision of information with case management seems to be a promising approach (Rosemann et al., 2007). Case management was developed in the USA to improve mental health issues in community care (Intagliata, 1982) and is defined as: “a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's holistic needs through communication and available resources to promote quality cost-effective outcomes” (www.cmsa.org.au/definition.html). In a review study of case management intervention for frail older persons, Hallberg and Kristensson (2004) stated that a comprehensive case management model should consist of the core components: outreach, client assessment, reassessment, case planning, referral to service providers, advocacy for client, direct casework, developing natural support systems, monitoring quality, public education and crisis intervention (Hallberg and Kristensson, 2004). Case management has been applied with success to patients in complex settings (Rosemann et al., 2007, Sandberg, 2013) and significant effects have been found on patients’ quality of life (Rosemann et al., 2007), depression (Gensichen et al., 2006), reducing length of stay (Dieterich et al., 2010), discharge (Lim et al., 2003), as a cost effective approach (Landi et al., 2001) and dependency in activities of daily living (ADL) (Eklund et al., 2013) referred to as an individuals’ daily self care activities. However, only a few studies include support and education for relatives through a family-oriented approach (Hallberg and Kristensson, 2004).

The rationale of this systematic review is to identify the evidence base of case management interventions for informal caregivers of older adults in order to develop future case management interventions for spouses’ involvement in older patients’ fast-track programmes during total hip replacement. Case management interventions are often considered complex because they comprise several components (Campbell et al., 2007) and include multiple groups targeted by the intervention and different behaviours of those delivering the intervention (Kirkevold et al., 2011). The dissemination and components with the best effects from this review will be used to develop an intervention of spouses’ involvement in older patients’ fast-track programmes during total hip replacement. Fast-track programmes are an effective way of reducing length of stay while optimising core procedures of surgical stress reduction, information, mobilisation, nutrition, and pain management (Kehlet and Søballe, 2010). To support the evidence base the core procedures from the fast-track programmes will serve as outcome measures according to patients’ activities of daily living, nutrition assessment and pain measurement, and additionally as outcomes related to patients’ depression, length of stay, and to spouses’ caregiver satisfaction and difficulties. The fast-track core procedure of information will be enhanced using case management intervention components.

The aim of the systematic review is therefore to investigate and describe the content, dissemination and effects of case management interventions on informal caregivers of older adults, focusing on outcomes related to patients’ activities of daily living, nutrition assessment, pain measurement, depression, length of stay, and to caregivers’ satisfaction and difficulties.