Effects of the Medicare Alzheimer's Disease Demonstration on caregiver burden and depression.

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STUDY QUESTION: Does improved access to community-based care reduce perceived burden and reported levels of depression among primary caregivers of people with dementia? DATA SOURCES: Baseline and periodic caregiver interviews with participants in the Medicare Alzheimer's Disease Demonstration. Client and caregiver attributes and caregiver outcomes such as depression and burden scores were among the measures. STUDY DESIGN: Applicants to the demonstration (all voluntary) were randomly assigned into treatment and control groups. Treatment group cases were eligible for case management and for up to $699 per month in community care benefits. (The actual monthly entitlement varied among the eight demonstration communities due to regional cost differences and inflation adjustments over the four-year demonstration period.) DATA COLLECTION: A total of 5,307 eligible individuals received a baseline assessment at the time of application to the demonstration and at least one semi-annual reassessment. Clients and their caregivers were periodically reassessed producing a total of 20,707 observations. PRINCIPAL FINDINGS: Persons in the treatment group had a high exposure to case management and a greater likelihood of community service use relative to those in the control group. Treatment group membership was associated with statistically significant, but very small reductions in caregiver burden (in four of eight sites) and depression (three of eight sites) over a 36-month tracking period. These findings are not sustained with all cases combined, or among a higher-resource demonstration model considered separately. CONCLUSIONS: Both the fact that these programmatic differences did not translate into substantial treatment group reductions in caregiver burden or depression, and the consistency of these findings with those of prior case management evaluations suggest the need to reformulate this programmatic intervention into areas not previously tested: 24-hour care, crisis intervention, coordination with primary care, or chronic disease management.

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