Managing Difficult Behaviors: A Standardized Intervention to Help Family Caregivers (STAR-C) :
An Evidence-Based Intervention for Alzheimer's and Dementia Care
STAR-Caregivers (STAR-C) is a standardized intervention to help family caregivers identify, reduce, and manage difficult behavioral symptoms of their relative with Alzheimer's disease. Behavioral symptoms are a major cause of family caregiver stress, burden, and depression. STAR-C decreases both the symptoms and the caregivers' related feelings of stress, burden, and depression.
STAR-C is based on the concept that behavioral symptoms in people with Alzheimer's disease who are living at home with a family caregiver can be addressed most effectively through training and support for the family caregiver. The components of the intervention were developed over many years by a team of researchers at the University of Washington . Most recently, the team wanted to test whether the intervention, which has been shown to have positive outcomes when implemented in a research environment, could be effectively implemented by non-research clinicians who work with older people in the community. Specifically, they wanted to find out whether community clinicians could deliver the standardized intervention in home-based counseling with families caregivers, and if so, whether the positive outcomes that were seen previously in research settings would be replicated.
The Star-C Intervention
The STAR-C intervention is delivered over a 6-month period by community clinicians with a master's degree or its equivalent in counseling, psychology, social work, or a related field and at least one year of clinical experience with older people. The clinicians are called “consultants” to emphasize that they provide expert training about behavioral symptom management for family caregivers who are the true experts about caring for their relative with Alzheimer's disease.
The consultant meets with a family caregiver in the caregiver's home once a week for eight weeks for about an hour. The STAR-C manual lays out a plan for each meeting. In the first meeting, the consultant provides information about behavioral symptoms and works with the family caregiver to identify three behavioral symptoms that are currently causing difficulty, describe the symptoms precisely, and rate how often they occur.
In the second and third meetings, the consultant teaches the caregiver the “ABC” approach to behavioral symptom change: that is, to identify A ntecedents or triggers that precede the B ehavioral symptom and observe C onsequences that follow the symptom. The consultant and caregiver then brainstorm strategies to modify identified antecedents and consequences with the objective of reducing behavioral symptoms. They also agree on a behavior change plan for the following week.
The remaining five meetings focus on how to communicate with a person with Alzheimer's disease, how to create pleasant events for the person, and other issues that concern the caregiver.
“Homework” is assigned between meetings, including reading materials and a diary the caregiver uses to record behavioral symptoms and the strategies he or she tried to reduce them.
After the in-home meetings, the consultant follows up with the caregiver through four monthly telephone calls. These calls are intended to help the caregiver develop strategies to address any new behavioral symptoms. They also help to reinforce the behavior change process the caregiver has learned in the preceding weeks and increase the likelihood that he or she will be able to use this process to avoid or reduce future behavioral symptoms.
Although the STAR-C intervention is standardized, consultants are encouraged to use their clinical judgment to modify the order of meeting topics in response to a caregiver's needs. The consultants are trained not to give advice but rather to try to build the family caregiver's skills and feeling of competence in identifying behavioral symptoms and strategies to address them.
Evidence for Effectiveness
STAR-C was tested in a rigorous, controlled study in which 95 people with Alzheimer's disease and their family caregivers were randomly assigned to either the STAR-C intervention or a control group that received no special services. Five consultants with master's degrees in counseling, psychology and social work and at least one-year of experience working with older adults were trained to provide the intervention. Results of the study show that the consultants were able to learn and deliver the content as intended.
Behavioral symptoms identified by the family caregivers in the STAR-C group in their first meeting with the care consultant included the following: shoving the caregiver, sundowning (afternoon agitation), withdrawing socially, refusing to go to adult day care, refusing to stop driving, wandering, inappropriate sexual behavior, and behavior that interferes with getting dressed, eating, shaving, bathing, and taking medications. After the eight in-home meetings, all the caregivers in the STAR-C group reported improvements in at least one of behavioral symptoms they had identified in the first meeting. Overall, improvements were reported in more than half of the identified symptoms. At the end of the study, after the monthly follow-up calls, STAR-C caregivers reported that their relative with Alzheimer's disease had significantly fewer behavioral symptoms than were reported by caregivers in the control group. STAR-C caregivers also ranked their family member's quality of life higher than did caregivers in the control group.
STAR-C caregivers showed statistically significant reductions in depression, burden, and reactivity to their relative's behavioral symptoms. Before the intervention, 43% of the STAR-C caregivers scored as clinically depressed compared with 34% of caregivers in the control. After the eight in-home meetings, only 29% of the STAR-C caregivers scored as depressed, compared with 37% of the control group caregivers. At the end of the study, STAR-C caregivers were significantly less likely than the control group to be depressed; they were less likely to report feelings of burden; and they had fewer problems with sleeping.
During this study, weekly supervision was provided for the consultants to assure that the intervention was delivered as intended. This amount of supervision is beyond what would be available in most community settings. The University of Washington research team suggests that future users of the intervention should reconsider how much supervision is truly needed.
Resources for Replication
The STAR-C manual provides detailed instructions for the consultants, family caregiver assignments, and handouts. The manual can be obtained from Linda Teri (see contact information below). The manuals are free while the supply lasts and then will be available for the cost of replication.
For more information about STAR-C or to obtain a STAR-C manual, contact Linda Teri, PhD, at the University of Washington , firstname.lastname@example.org or (206) 543-0715.
Logsdon RG, McCurry SM, and Teri L. STAR-Caregivers: A community-based approach for teaching family caregivers to use behavioral strategies to reduce affective disturbances in persons with dementia. Alzheimer's Care Quarterly . 2005:6(2):146-153.
Teri L, McCurry SM, Logsdon R, Gibbons LE. Training community consultants to help family members improve dementia care: A randomized controlled trial. Gerontologist. 2005;45(6):802-811.