Tele-Savvy: An Online Program for Dementia Caregivers

Abstract

Introduction:

This study examined the feasibility and efficacy of Tele-Savvy, an online version of the Savvy Caregiver Program, a psychoeducation program for caregivers caring for a person with dementia.

Methods:

A convenience sample of 22 caregivers from the Atlanta VA and 42 caregivers from 14 different states enrolled in Tele-Savvy. Pre- and post-program evaluations assessed caregiver burden, caregiver competency, and frequency of behavioral and psychological symptoms of dementia (BPSD).

Results:

Fifty-seven caregivers completed the 6-week Tele-Savvy program. Caregivers whose care recipients exhibited higher average BPSD frequency at baseline demonstrated significantly greater burden decreases post-program. Caregivers of care recipients in more advanced dementia stages demonstrated a significantly greater improvement in caregiver competence.

Discussion:

The results point to the feasibility of achieving significant results in caregivers’ well-being and care recipients’ BPSD with a fully online program. Tele-Savvy may be particularly efficacious for caregivers whose care recipients exhibit higher BPSD frequency and are in later dementia stages.

Introduction

Alzheimer’s disease (AD), an incurable progressive neurodegenerative disease, is the sixth leading mortality cause in the United States ¹ and a critical public health problem worldwide. ² Currently, 5.3 million Americans live with AD, the most common type of dementia (60%-80% of the cases). By 2050, this number may reach 16 million. ¹ Other dementia types, including vascular, mixed, frontotemporal dementia, and dementia with Lewy bodies, increase the current total number of persons living with dementia (PLWDs) up to 7 million. ³

Over 15 million informal unpaid caregivers, principally family members, provide the majority of care for PLWDs. ¹ Caregivers enable PLWDs to age in place—as preferred by most Americans. ⁴ For PLWDs, caregiver-assisted aging in place, compared to living in long-term care settings, translates to superior cognitive function, better performance of activities of daily living, enhanced social connectedness, and fewer depressive symptoms. ^5,6 Caregivers save the US health-care system at least US$217 billion annually (the combined cost of caregivers’ unpaid labor), but the adverse effects of caregiving on their mental and physical health increase their annual health-care costs by an estimated US$9.7 billion, and their caregiving responsibilities often reduce employment income. ¹ Further, caregivers frequently bear the out-of-pocket costs for the care that PLWDs require ⁷ ; care that caregivers often perceive as inadequate for dementia management. ⁸

Multiple in-person caregiver training and counseling programs have been developed. ^{9 –12} More recently, online interventions have been implemented. ^{13 –17} Online multicomponent programs that integrate information on dementia and caregiving approaches and communication with other caregivers are particularly effective, as opposed to solely didactic programs. ¹⁶ Online programs may be cost-effective ¹⁸ and allow caregivers’ participation without the need to find substitute care. Importantly, the online format may be increasingly available and accessible to dementia caregivers over the age of 65, since, as of 2012, 70% of Americans over the age of 65 used internet on a typical day. ¹⁹ Caregivers who use technology perceive several benefits of doing so, including saving time, simplifying caregiving logistics, improving care recipient’s sense of safety, increasing their own sense of being effective, and decreasing stress. ²⁰

The Tele-Savvy Caregiver Program ²¹ is an online adaptation of the evidence-based in-person Savvy Caregiver Program (SCP). ^12,22 Expert review of Tele-Savvy established its fidelity with, and in some aspects enhancements on, the SCP. ²¹ Tele-Savvy was developed and pilot tested in 2 phases where caregivers were affiliated with a single research institution with each phase. In the first phase (n = 22), preliminary pilot results demonstrated benefits for caregivers: decreases in caregiver burden (P < .05), depressive symptoms (P < .005), anxiety (P < .005), number of behavioral and psychological symptoms of dementia (BPSD) that occur at least once or more weekly (P < .05), and caregivers’ reaction, or upset, in relation to their persons’ BPSD (P < .05). ²¹ In the second phase (n = 42), caregivers were recruited nationwide. This article reports on the combined results (N = 64) of both phases of the pilot.

Methods

Intervention

The SCP’s main aim is to educate caregivers about dementia and strategies they may implement to create an environment for their persons that is calm, provide sufficient amount and quality of stimulation, prevent stimuli that result in problematic BPSD, and overall provide optimal quality of life for caregivers and PLWD despite the progressive deteriorating nature of dementia. It aims to instruct caregivers in the ways dementia affects their persons’ behavior and function and techniques caregivers may employ to engage their persons in activities in accordance with the person’s dementia stage and preferences. It likewise emphasizes approaches caregivers may take to decrease their burden and stress by enlisting support and understanding decision-making (e.g., when to take action and when to pause) intrinsic to dementia caregiving. ²² Like the SCP, Tele-Savvy emphasizes the development of knowledge, skills and outlook, and caregiving mastery as means to engage successfully in the “unexpected career” ²³ that caregivers have undertaken. The program, a structured, unified curriculum grounded in stress process theory, ²⁴ explicitly teaches caregivers to apply the basic nursing process model (Assess-Plan-Implement-Evaluate) ²⁵ to use the information they are learning about disease-produced losses in cognition, emotion, behavior, and performance to develop and implement caregiving strategies in guiding the daily life of their PLWD. Tele-Savvy also drew on other SCP adaptations ²⁶ and added material on self-care.

Over the course of 6 weeks, Tele-Savvy employed synchronous and asynchronous means to recreate, virtually, the time-limited intensity of the in-person SCP. To our knowledge, Tele-Savvy is unique among online programs in its attempt to simulate the in-person experience. The synchronous component consisted of weekly teleconferences in which instructors (K.H. and P.G.) led 75-minute groups of 4 to 8 caregivers. Consistent with the psychoeducational approach, ²⁷ each teleconference was dedicated to a key curriculum topic, presented in a lecture- and discussion-like style. Caregivers discussed the topic and they were encouraged to share about their week’s experience, including instances when they have applied Tele-Savvy-taught principles. This report and coaching element was essential to the development and strengthening of caregiver mastery. Communication between caregivers was encouraged, and instructors aimed to establish rapport with participants.

The asynchronous component was delivered through 5- to 15-minute-long videos on each of the 6 nonteleconference days, where the instructors presented a single educational message embedded in the curriculum. Each lesson was reinforced by expert commentary (by a physician, a nurse practitioner, etc.) or—in the majority of cases—was depicted in “telenovela” type vignettes in which actors (a PLWD and his wife or daughter as caregivers) portrayed scenes in clinical, home, and other settings to illustrate that lesson’s principles. Once a week, instructors and invited practitioners taught self-care (e.g., yoga, relaxation, and breathing techniques). Caregivers could watch and rewatch the videos at their convenience. Participants were provided with a manual and a workbook that complemented their learning and provided exercises to reinforce Tele-Savvy principles. Exercises included writing one’s thoughts and emotions that caregiver first experienced when he/she first learned about his/her person’s dementia diagnosis and classifying these thoughts and emotions as either positive or negative and powerful or powerless. Another exercise involved writing one’s decision-making process (under the guidance of the speaker for that day’s video) and illustrating one’s decision-making process in relation to one’s options, outcomes, values, and likelihoods (OOVL guide). ²⁸ One exercise involved drawing caregiver’s “village” where the person and the caregiver were depicted in the center and the dyad’s support systems were illustrated on the periphery. Caregivers were instructed to evaluate the degree to which their presumed support “anchors” were viable and necessary. For instance, if a relative/friend/group provided much needed support, a caregiver drew a bold line between the dyad and that relative. If, on the other hand, a caregiver had a group that did not provide meaningful help or even was detrimental to the dyad, the caregiver would erase the line between the dyad and that group. The goal of this exercise was to help the caregiver reevaluate his or her support systems and enlist support from those who were available and capable of providing meaningful help. Caregivers were encouraged to practice Tele-Savvy principles, and the synchronous coaching during the teleconferences reinforced and celebrated this, but instructors clarified that these practices were not mandatory so as to not add pressure to caregivers’ schedules.

Recruitment

Caregivers were recruited through referral at the research institutions where the study phases were conducted, ClinicalTrials.gov, Alzheimer’s Association, and another health-care company. Caregivers (age ≥ 18, English-speaking, with basic computer skills and internet access) were eligible if they identified themselves as primary caregivers of a PLWD, regardless of whether they coresided with their PLWD and whether their person lived in the community or in an assisted living facility. Caregivers were excluded if their person had dementia due to Parkinson's disease or stand-alone stroke (without preceding vascular disease, such as an isolated cerebrovascular event), based on the different pathogenesis of these conditions and, consequently, different disease manifestations compared to AD, vascular dementia, Lewy body disease, frontotemporal dementia, or mixed dementia (caregivers of persons living with these dementia types were included). Persons who did not have regular access to a computer/mobile device and internet access were excluded.

We did not restrict eligibility to a particular dementia type (except Parkinson's disease dementia or isolated stroke) or dementia stage (e.g., mild cognitive impairment, late stage). One reason for such wide inclusion criteria is reliance strictly on caregivers’ self-report of their person’s dementia diagnosis. Thus, we presumed that not every caregiver may know the exact dementia type their person has or be able to accurately estimate dementia stage. Second, Tele-Savvy curriculum was designed to be applicable to caregivers caring for a person with dementia regardless of PLWDs’ dementia type or stage or coresidence status between caregiver and PLWD. The parent in-person program, SCP, similarly did not exclude participants based on these criteria. ²¹ We acknowledge, however, that such wide inclusion criteria presented limitations (discussed in the Limitations section).

In the first phase, caregivers (n = 22) were provided with iPads with an internet connection. ²¹ In the second phase, caregivers owned a computer/mobile device (we did not provide them with an iPad or another device). If they did not have a webcam one was provided for the program duration to participate in weekly teleconferences. The pilot took place over 12 months. Efforts were made to recruit caregivers from as many different states as possible. The research team aimed to offer teleconference times that would suit the largest number of caregivers from different time zones and those who may be employed outside the home. Upon initial contact with a research assistant (personal “navigator,” assigned to each caregiver), caregivers were screened by telephone to determine eligibility. If eligible, a caregiver gave verbal consent and preprogram assessment, and Tele-Savvy orientation took place in-person (first phase) or via a videoconference (second phase).

Evaluation

Caregivers completed a baseline sociodemographic battery and a set of questionnaires at baseline and in post-assessment (the post-assessment was completed in a period ranging from immediately after the last teleconference up to approximately a month post-program). The following standardized, well-established measures were included in the assessments:

• Caregiver burden: Measured with the Zarit Burden Inventory-Short Form (12-item). ^29,30

• Depressive symptomatology: Measured with the Center for Epidemiological Studies Depression Scale, short form (CES-D 10). ^31,32

• Caregiver mastery: Measured with several subscales from Pearlin Caregiver Mastery Scale. ³³

• Behavioral and psychological symptoms of dementia and caregivers’ reaction: Measured with the Revised Memory and Behavior Problem Checklist. ³⁴

Additionally, participants answered post-video questions that asked them to assess their PLWD’s level of functioning; their answers were used to create a composite score representing the PLWD’s dementia stage.

Procedure

At enrollment, each participant was instructed by a “navigator” about technology use and teleconference participation. Participants were also mailed illustrated step-by-step written instructions for joining videoconferences.

Generic Gmail accounts (e.g., tscaregiver1234@gmail.com) created by “navigators” were provided to participants to maintain caregivers’ confidentiality and not to disclose caregivers’ personal e-mail addresses. Tonic Health ³⁵ sent an e-mail to each participant daily, providing a link to the daily video, as described by Griffiths and colleagues. ²¹ Participants opened their videos using a unique password that was recorded on the Tonic Health platform allowing the “navigators” to track whether caregivers watched the videos. If a “navigator” noted that caregivers did not log onto the Tonic Health platform for several days, the “navigator” contacted those participants offering assistance with technology. After multiple caregivers experienced difficulties or requested more detailed instructions on accessing daily videos, “navigators” developed a step-by-step illustrated print guide on accessing videos (similar to the print guide for joining videoconferences) and provided the guide to participants.

Data Analyses

Data analyses were conducted using SPSS software v.23. ³⁶ Comparison tests (independent t tests for continuous normally distributed measures, Mann-Whitney tests for nonnormally distributed measures, and χ² and Fisher exact tests for categorical measures) were run to test for differences between participants who completed the post-assessment and those who did not based on their demographics and baseline caregiver measures. Paired sample t test was used to test for significant changes from pre- to post-program on all caregiver outcome measures for participants who completed the study (had data at both time points). The changes in caregiver outcomes were tested for associations with the severity of the PLWDs’ dementia using correlation tests between the caregiver outcome changes scores and the average BPSD frequency and dementia stage scores, respectively. Significant associations are presented. For the significant changes in caregiving competence, mediation analysis was performed to test whether the improved caregiver competence at 6 weeks significantly mediated the association between baseline and 6-week scores for other significant caregiver outcome changes. Mediation analysis was performed using the PROCESS SPSS macro add-in. ³⁷

Results

Sample

Sixty-four participants from 14 states completed baseline assessment of whom 57 caregivers completed the program. Caregivers who discontinued their participation did so due to the death of their care recipients or schedule time conflicts; none discontinued due to technical difficulties. The participants’ characteristics are summarized in Table 1. The majority were women (91%), cared for their spouse (61%), and coresided with their PLWD (81%). Less than one-fourth were employed outside the home (23%). Most were educated above the high school level (59%). Caregivers were 63.3 (11.2) years old with PLWDs averaging 77.0 (8.7) years old. The 7 participants who discontinued participation were all female, caring for their parent or parent-in-law (71%), and employed outside the home (57%). They were 53.2 (6.1) years old with PLWDs averaging 73.4 (12.0) years old.

Table 1.

Baseline Sociodemographic Characteristics of 64 Caregivers.

Characteristic	Mean (SD) [Range]/N (%)
Age	63.3 (11.2) [36-86]
Care recipient age	77.0 (8.7) [56-97]
Caregiver gender (% female)	58 (91)
Education (% > HS)	38 (59)
Race (% African American)	21 (33)
PLWD
(% Spouse)	39 (61)
(% Parent or other relative)	25 (39)
Caregiver employed	15 (23)
Caregiver lives with the care recipient	52 (81)
Caregiver burden (ZBI-12)a	21.3 (8.8)
Depression (CES-D-10; 1 missing)b	9.7 (5.3)
Caregiver competence (Pearlin Caregiver Mastery; 1 missing)c	3.0 (0.6)
Number of BPSD occurring daily or more often (RMBPC)d	4.9 (3.6)
BPSD average frequency (RMBPC)e	1.7 (0.6)
Caregiver reaction to BPSD (RMBPC)f	2.4 (3.3)

Abbreviations: BPSD, behavioral and psychological symptoms of dementia; CES-D 10, Center for Epidemiologic Studies—Depression 10-item version; PLWD, persons living with dementia; RMBPC, Revised Memory and Behavior Problem Checklist; SD, standard deviation; ZBI-12, Zarit Burden Interview 12-item version.

^aCaregiver burden possible score range: 0 (no caregiver burden) to 48 (maximum caregiver burden).

^bCES-D 10 possible score range: 0 (no depressive symptoms) to 30 (maximum number of depressive symptoms).

^cCaregiver competence possible score range: 2 (minimum competence) to 8 (maximum competence).

^dNumber of BPSD occurring daily or more often possible score range: 0 to 24.

^eBPSD average frequency possible score range: 0 to 4 (0 = never occurred; 1 = not in the past week; 2 = 1-2 times in the past week; 3 = 3-6 times in the past week; 4 = daily or more often).

^fCaregiver reaction to BPSD possible score range: 0 (no reaction or upset) to 4 (extreme reaction or upset).

On average, CES-D 10 scores, 9.7 (5.3), were close to the cutoff score of ≥ 10, ³² with 26 (41%) of 64 caregivers scoring ≥ 10, indicating significant depressive symptoms. Compared to the 57 participants who completed the study, the 7 participants who did not were significantly younger (P = .011), employed (P = .047), experienced higher caregiver loss of self (P = .036; measured by the Pearlin Caregiver Mastery Scale ³³ ), and higher BPSD average frequency (P = .011).

Several associations in Caregiver Mastery subscale scores were observed. Spousal caregivers had significantly higher baseline depressive symptoms (P = .003) and significantly higher scores in 2 components of Caregiver Mastery—relational deprivation (intimate exchange [P = .010] and goals and activities [P = .028]), indicating that they were significantly more relationally deprived. Participants who lived with their care recipients had significantly higher baseline scores in caregiving competence (P = .007) and management of situation (P = .053; were more competent and better able to manage the situation). Caregivers who were employed outside the home had significantly higher baseline score in Management of Meaning—reduction of expectations (P = .007; were better able to reduce expectations). Finally, women had significantly higher baseline management of situation score (P = .015; managed the situation better).

Pre-Post Comparison of Dependent Measures

The comparisons between the baseline and post-program measures are summarized in Table 2 with all significant effect sizes reported. Significant decreases were observed in caregiver burden (P < .01), depressive symptoms (P < .05), number of BPSD that occurred daily or more often (P < .01), and average BPSD frequency (P < .05). Caregivers’ self-reported competence significantly increased after their program completion (P < .001). Caregivers’ upset, or distress, in relation to their persons’ BPSD increased after program completion, but not significantly (P = .304).

Table 2.

Measures Assessed Before and After the Tele-Savvy Program (n = 57).

	M (SD)		t Value	Cohen’s d a
Measure	Baseline	Post-program
Caregiver burden (ZBI-12)	21.0 (8.7)	18.3 (7.7)	3.3b	0.43
Depression (CES-D 10)	9.3 (5.1)	7.9 (5.3)	2.8b	0.37
Number of BPSD occurring daily or more often (RMBPC)	4.6 (3.4)	3.5 (3.1)	3.2b	0.42
BPSD average frequency (RMBPC)	1.6 (0.6)	1.5 (0.6)	2.4c	0.32
Caregiver reaction to BPSD (RMBPC)	2.4 (3.4)	3.4 (6.8)	−1.1
Caregiver competence (Pearlin)d	3.0 (0.6)	3.3 (0.5)	−4.6e	0.61

Abbreviations: BPSD, behavioral and psychological symptoms of dementia; CES-D-10, Center for Epidemiologic Studies—Depression 10-item version; RMBPC, Revised Memory and Behavior Problem Checklist; SD, standard deviation; ZBI-12, Zarit Burden Interview 12-item version.

^aCohen d effect sizes reported for significant changes.

^b P < .01.

^c P < .05.

^dData for 1 participant is missing for caregiver competence.

^e P < .001.

Caregivers who reported higher average baseline BPSD frequency in their care recipients exhibited greater decreases in caregiver burden (r = .301, P = .023) post-program. Additionally, dementia severity (higher dementia stage score) was significantly associated (r = .296, P = .039) with caregivers’ greater decreases in Caregiver Mastery—Loss of Self score post-program, indicating improved mastery—less loss of self within the situation.

Given the moderate-to-large improvement in caregiver competence (Cohen’s d = 0.61), it was tested as a potential mediator for the other significant improvements in caregiver burden, depressive symptoms, number of BPSD occurring daily or more often, and BPSD average frequency. Caregiver competence post-program was not significantly associated with baseline depressive symptoms, number of BPSD occurring daily or more often, and BPSD average frequency for participants who completed the study; thus, competence did not meet the first requirement for mediation. ³⁸ However, caregiving competence post-program was significantly associated with baseline caregiver burden and had a moderate-to-large mediating effect (standardized κ² = 0.16, 95% confidence interval [0.05-0.30]) between caregiver burden levels from baseline to post-program (Figure 1; effect sizes κ² = 0.01 considered small, κ² = 0.09 considered moderate, κ² = 0.25 considered large). ³⁹ When considering the added effect of participants who had higher caregiving competence post-program, the direct effect of caregiver burden pre-program to caregiver burden post-program is lessened, that is, higher caregiver competence post-program mediates the pre-to-post reductions in caregiver burden. Looking specifically at the third regression component of the mediation test, using stepwise linear regression and putting caregiver burden at baseline in block 1 followed by caregiver competence post-program in block 2, caregiver competence post-program accounted for 6% of the variance (P = .006) in caregiver burden post-program after adjusting for the caregiver burden at baseline (which accounted for 54% of the variance [P < .001]). These results suggest that greater improvements in caregiver competence increased the reductions in caregiver burden.

Figure 1.

Caregiver competence post-program mediating a significant reduction in caregiver burden from pre- to post-program (n = 57).

Discussion

This study tested the efficacy and feasibility of a dementia caregiver psychoeducational program, Tele-Savvy, that was delivered fully online over the course of 6 weeks. The program appears to have contributed to significant reductions in caregiver burden and depressive symptoms, a significant increase in caregiver competence, and significant reductions in the average number of BPSD and BPSD that occur daily or more. These results echo those from the in-person SCP and its precursor programs ^12,22,40 and are analogous to those in other interventions delivered fully or partly online. ^{14,21,40 –43} A nonsignificant increase in caregivers’ reaction (upset or distress) relative to their persons’ BPSD in Tele-Savvy may reflect either care recipients’ dementia progression, caregivers’ more attuned awareness of BPSD, or a combination of these factors.

The fact that caregivers’ depressive symptoms’ scores decreased significantly and that at baseline 41% indicated significant depressive symptoms highlight the efficacy of this program in terms of helping caregivers improve their mood. Numerous studies indicate that caregivers of individuals with dementia are at high risk of depression. ^{44 –46} Therefore, our results contribute to addressing an important concern in this population.

The study’s demonstration of the significant mediating effect of increased caregiving competence on significant reductions in caregiver burden reinforces Tele-Savvy’s grounding in the social cognitive theory, ⁴⁷ transactional stress and coping theory, ⁴⁸ Alzheimer’s caregiver’s stress model, ³³ and the psychoeducational foundation of the program. ²⁷ The program emphasizes acquisition of information to inform primary appraisal and the strengthening of secondary appraisal of enhanced caregiving mastery by developing and practicing evidence-based caregiving strategies taught by instructors and modeled by other caregivers who receive the same training.

Caregivers whose care recipients displayed higher average baseline BPSD frequency demonstrated greater reductions in caregiver burden post-program, and there was a significant reduction in BPSD frequency overall. This is salient since BPSD predict caregiver burden ⁴⁹ and PLWDs’ institutionalization. ⁵⁰

Caregivers whose care recipients were in more advanced dementia stages experienced a greater change in the Caregiver Mastery—Loss of Self Subscale Scores—an improvement in mastery. Tele-Savvy promotes learning about the progressive and irreversible nature of dementia and emphasizes the advantage of an attitude of clinical detachment that can be maintained in parallel with the emotional ties that a caregiver may feel toward his or her person. Attainment of this core psychoeducational objective may have helped caregivers improve their sense of self as a distinct individual apart from their role of a caregiver. Interaction with other caregivers in Tele-Savvy may also help them reevaluate their role of a caregiver and possibly experience less guilt associated with detachment from their person.

Several other findings are of note. White caregivers had significantly lower scores on several Caregiver Mastery subscales compared to nonwhite caregivers. This echoes findings of greater caregiver burden, depression, anxiety, and hostility among white compared to black caregivers of PLWDs. ⁵¹ Nonwhite caregivers’ care recipients were more advanced in dementia, which may agree with findings that ethnic minorities access health-care services later in dementia. ⁵²

The online format proved to be feasible and broadly applicable. No caregivers discontinued participation due to technical difficulties. The wide age range of caregivers who completed Tele-Savvy [36-86] underscores this format’s feasibility regardless of participants’ ages. Caregivers from 14 different states and with diverse backgrounds in terms of race, educational level, stage of illness of their PLWD, relationship to the PLWD, and other characteristics of caregiving situations completed Tele-Savvy. That 23% of completers were employed outside the home suggests that this format fits into various caregiving schedules, including those who may be in particular need of information and training due to their multiple responsibilities (e.g., “sandwich caregivers”). ¹ A considerable number of participants did not live with their care recipients yet they enrolled likely indicating a need for a resource like Tele-Savvy that is similar to those who coreside and arguably spend more caregiving hours with their PLWDs.

Nonetheless, differences in the samples of completers and noncompleters draw attention to the need to make Tele-Savvy more available for caregivers who are younger and are more likely to be employed outside the home. The fact that over half (57%) of noncompleters were employed outside the home (compared to 23% among completers) leads to the conclusion that Tele-Savvy’s format is less practical for caregivers working outside the home. A possible remedy for this is offering videoconferences during evenings or weekends, since videoconferences were the only synchronous program element and they were offered during business hours.

Implications

The online format of Tele-Savvy may be a viable tool to reach a greater number of caregivers who have internet access. Importantly, however, caregivers who may lack technological means, and thus may have much lower likelihood of learning about participation in similar programs, may have the greatest need for similar resources due to their lacking access to other online resources that dementia caregivers commonly use. ^20,53 This implies the importance of clinicians’ attention toward caregivers who may not be able to either participate in in-person interventions or access online resources. Finally, the online format appears to benefit caregivers indicating the potential advantages of wider adoption of this delivery mode.

Limitations

Although the findings point to the efficacy and feasibility of this program, they are based on a small convenience sample of caregivers who were either referred by health-care professionals or sought this opportunity themselves. Characteristics of the sample limit the results’ external validity. Our sample was heterogeneous not limited by person’s dementia type or stage or caregiver’s residence status (resides or does not reside with the PLWD). Furthermore, as reported in the qualitative exploration of participants’ experience, ⁵⁴ multiple caregivers indicated preference for a more tailored approach, such as strategies for early-stage versus late-stage dementia caregiving. Such recommendation prompts the development of analogous psychoeducational programs focused on various dementia stages. We likewise did not exclude caregivers according to their residence type (and, hence, amount of time they may spend fulfilling caregiving duties), which decreases the sample’s homogeneity and may decrease the study’s internal validity. The majority of caregivers, however, coresided with their persons (81%).

Additionally, this pilot effort employed no control group; thus, it was impossible to account for the positive effects caregivers may have received solely as a function of their participation in a group focused on their well-being. Caregivers who discontinued participation reported higher baseline Loss of Self Scores on the Caregiver Mastery Scale, and their care recipients had greater BPSD frequency. Caregivers who discontinued participation did so largely due to time conflicts with work; therefore, future programs should accommodate for these caregivers’ availability. Potentially, these caregivers may not have demonstrated similar positive results like the ones who completed the study.

Conclusion

Tele-Savvy demonstrated efficacy and feasibility in this pilot study. Significant results in caregiver well-being and PLWDs’ BPSD were obtained. Tele-Savvy provides a practical means to train dementia caregivers in a short amount of time, improving their psychological well-being and reducing their PLWDs’ BPSD. Given the insufficient availability of dementia education programs to caregivers ⁵⁵ and convenience and efficacy of the online format, this study gives an example of how similar interventions may be implemented and reach caregivers for whom in-person participation is impossible. Further research will involve conducting a randomized trial with a large sample to demonstrate this method’s efficacy on a larger scale and testing this program’s efficacy on a longer time frame due to the typically prolonged disease course and increasing amount of responsibility that dementia caregivers assume as their persons gradually lose their functional and cognitive abilities. Attention must be paid to recruiting caregivers who may not have other access to training and support, including access to health-care professionals who are knowledgeable of programs such as Tele-Savvy. The fact that caregivers successfully participate in programs using new technology (iPads) warrants the implementation of this approach despite apparent, but remediable, caregivers’ technological limitations.