Behavioral activation for improving sleep quality in family caregivers of people with dementia: a pilot randomized controlled trial

Abstract

Background: Sleep disturbance is a common phenomenon in family caregivers of people with dementia (PWD). It has a negative impact on caregivers themselves, care recipients, and society as a whole. Different non-pharmacological treatments, therefore, have been utilized to improve sleep quality and psychological health in family members who are caregivers of PWD. Among these treatments, behavioral activation (BA) shows promising potential in improving sleep quality; however, by now, evidence for the feasibility and efficacy of this treatment on sleep quality in family caregivers of PWD is limited. Aims and objectives: This study aims to develop and pilot test an evidence-based BA protocol for improving sleep quality in Chinese family caregivers of PWD. The objectives of this study are to (1) develop an evidence-based standard protocol for using BA to improve sleep quality for Chinese family caregivers of PWD; (2) determine the feasibility and acceptability of the newly developed BA protocol in Chinese family caregivers of PWD; and (3) preliminarily examine the effects of BA on sleep quality and psychological health in family caregivers of PWD. Methods: This study compromises two phases: 1) phase 1: development and refinement of the BA protocol, and 2) phase 2: feasibility assessment and preliminary examination of BA. For phase 1, a comprehensive literature review was conducted to identify relevant BA theories, principles, and related manuals to develop BA protocol. Semi-structured interviews were conducted to explore and understand Chinese family caregivers of PWD's perceptions and expectations of pleasant leisure activities and BA protocol. A draft BA protocol was also shown to the interviewers to comment. The BA protocol was revised based on the results of the interviews. For phase 2, a pilot 2-arm randomized controlled trial (RCT) was carried out to examine the feasibility, acceptability, and potential efficacy of the BA on sleep quality. The BA intervention involved eight weekly individual telephone-based sessions designed to teach caregivers specific BA techniques. Participants in the control group received usual care from communities, hospitals and clinics. Sleep quality, depression, leisure activity, relationship satisfaction, self-rated health, positive aspect of caregiving, and caregiving burden were assessed at baseline and post-intervention by blinded interviewers. Data were analyzed with Repeated Measures of ANOVA based on the intention-to-treat principle of all available data. After completing the pilot RCT, semi-structured interviews were conducted to explore the participants' experiences of participating in the BA intervention. Result: In phase 1 of this study, 20 family caregivers participated in the semi-structured interviews, and the BA intervention protocol was revised according to their comments. A total of 71 family caregivers of PWD (35 for the intervention group, and 36 for the control group) were recruited, and 59 participants (83.10%) completed the post-intervention outcome assessments. Compared with caregivers in the control group, caregivers in the intervention group displayed significantly greater improvement in sleep quality (F(1,69) = 6.32, p=0.014, Partial η2 = 0.084), leisure activities (F(1,69) = 15.89, p<0.001, Partial η2 = 0.218), as well as positive aspect of caregiving (F(1,69) = 6.53, p=0.013, Partial η2 = 0.086), and greater reduction in depression (F(1,69) = 7.53, p=0.008, Partial η2 = 0.098) and caregiving burden (F(1,69) = 6.93, p=0.010, Partial η2 = 0.091). The BA intervention protocol was found to be feasible for use, as the majority of participants (85.71%) from the intervention group followed the study protocol to complete the eight-week BA intervention. Nineteen participants took part in the post-intervention semi-structured interviews. Most of the interviewed participants were very satisfied with the intervention, and they could improve their sleep and psychological health by adopting BA intervention techniques. Conclusion: The current findings suggest that individual telephone-based BA intervention is feasible, acceptable, and effective for improving sleep quality as well as psychological health in family caregivers of PWD. Results contribute to the current literature by providing evidence for developing effective, accessible, sustainable BA intervention for family caregivers of PWD.