ORIGINAL ARTICLE
Cognitive Behavioral Group Intervention
for Alzheimer Caregivers
Serena Passoni, MSc,* Loretta Moroni, MSc,w Alessio Toraldo, PhD,z Manuela T. Mazzà, MSc,*
Giorgio Bertolotti, PhD,w Nicola Vanacore, MD, PhD,y and Gabriella Bottini, MD, PhD*z
Abstract: Long-term caregiving of patients with Alzheimer disease
(AD) frequently induces a relevant distress enhanced by inadequate
coping strategies. This study aimed to explore the impact of cog-
nitive and behavioral therapy (CBT) group intervention on AD
patients’ caregivers. In particular, reduction in caregivers’ global
care needs and in anxiety and depression has been investigated.
About 100 caregivers were divided into the following groups: CBT
group intervention, self-help manual, and control have been
enrolled in the study. CBT group intervention seems to be more
effective than the other 2 conditions in reducing caregivers’ anxiety.
Furthermore, only caregivers of the CBT group showed significant
needs related to reduction in care. The proposed treatment could be
the core of a more structured and systematic intervention for AD
patients’ caregivers in Italy.
Key Words: dementia, caregivers, cognitive-behavioral group
therapy
(Alzheimer Dis Assoc Disord 2014;28:275–282)
D ementia, a public health problem with relevant costs to
society, has major consequences for both patients and
relatives.1 People suffering from dementia are currently
over 35 million, although it is estimated that they will
double every 20 years to arrive at 115.4 million in 20502
(World Alzheimer Report, 2009), with a consequent sig-
nificant burden on health care services, although the most
relevant impact will be on the informal caregivers.
Informal cost provided by the family is often higher
than the formal one. A recent review reports an annual
median total care cost of h28,000 (year 2005 values) in
Europe.3 In Italy, the direct costs median value for each
patient (medical aids and visits, care services, drugs) is
h14,886, arriving to h60,905 if also considering the indirect
costs (working-time loss of patients and caregivers).4
Italy, compared with other European countries,
mainly relies on the informal care provided by the family,
depending on the coexistence of economic and sociocultural
factors.5 As a consequence, the number of Alzheimer dis-
ease (AD) patients living in residential homes is one of the
Received for publication December 24, 2012; accepted February 5,
2014.
From the *Cognitive Neuropsychology Center, Niguarda Ca’ Granda
Hospital, Milan; wPsychology Unit, Salvatore Maugeri Founda-
tion, IRCCS Tradate, Varese; yNational Centre for Epidemiology,
Surveillance and Health Promotion, National Institute of Health,
Rome; and zDepartment of Brain and Behavioural Sciences,
University of Pavia, Italy.
The authors declare no conflicts of interest.
Reprints: Serena Passoni, MSc, Cognitive Neuropsychology Center,
Niguarda Ca’ Granda Hospital, Piazza Ospedale Maggiore 3,
Milan 20162, Italy (e-mail: serena.passoni@gmail.com).
Copyright r 2014 by Lippincott Williams & Wilkins
Alzheimer Dis Assoc Disord  Volume 28, Number 3, July–September 2014
lowest in Europe, as 82.8% of those patients live with their
family.4 The prolonged care of patients with dementia
induces physical and psychological symptoms in caregivers
who become socially hidden patients themselves. This
syndrome together with wrong coping strategies may
develop affective disorders such as depression and
anxiety.6–9
Randomized controlled trials to define proper guide-
lines for dementia care demonstrate that when caregivers
are supported, patients’ severity symptoms reduce, emer-
gency care services are limited, and institutionalization is
delayed, with a potential reduction in the overall costs in
the time course.10–14
A recent review15 analyzing evidence-based psycho-
logical treatments for reducing distress and improving well-
being of caregivers of old relatives with cognitive or
physical impairment identified the following as effective
interventions: (1) Psychoeducational programs; (2) Multi-
component interventions (using a combination of at least 2
approaches, such as education, family meetings, and skill
building); and (3) Psychotherapy (cognitive behavior in
focus). The efficacy of a short (9 wk) cognitive-behavioral
intervention has also been shown.16
This cognitive-behavioral therapy (CBT) is very dif-
fuse in the United States. This kind of approach that must
be provided by a psychologist emphasizes on the relevance
of educational interventions to improve caregivers’ aware-
ness of their problems. This support requires individual
interview, written information, and educational meetings
with families with the same problem.17
This cognitive-behavioral approach grounds on the
hypothesis that, the more the disease knowledge, the better
the efficacy of the strategies in coping with problems caused
by the disease.
Recently, the need to implement psychosocial supports
to AD patients’ caregivers has also become urgent in
Europe.18
A number of Italian studies indicate the efficacy of
educational programs in reducing distressing symptoms in
caregivers of AD patients with relevant behavioral dis-
orders.19,20 Self-help groups, in particular, have been pro-
ven to improve the quality of life, reducing psychological
morbidity, and delaying patients institutionalization.21
Studies on CBT programs with Italian AD patients’
caregivers are still lacking.
We aim to evaluate the impact of a cognitive-behav-
ioral group intervention in reducing anxiety and depression
in these caregivers compared with a nontreated control
group. We also compared 2 approaches, a psychoeduca-
tional program, providing written information about the
disease and some suggestions concerning the control of
stress symptoms, and a cognitive-behavioral psychotherapy,
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Passoni et al Alzheimer Dis Assoc Disord
delivering the same written documentation associated with
group sessions conducted by a psychologist and a psycho-
therapist, both trained in the use of CBT techniques.
METHODS
Procedures
We patients with dementia and their caregivers were
recruited along 18 months at the Alzheimer Evaluation
Unit (Unità Valutazione Alzheimer: U.V.A.) of Niguarda
Ca’ Granda Hospital in Milan, where patients are moni-
tored every 6 months with a neurological and a neuro-
psychological assessment, according to the ministerial
project CRONOS (currently shared by the U.V.A. at
national level with the A.I.F.A. 85 note, the Italian Drugs
Agency).
The enrollment period lasted 18 months (from March
2010 to September 2011).
Inclusion criteria of patients were: (i) a diagnosis of AD
according to the Work Group on Dementia criteria
(National Institute of Neurological and Communicative
Disorders and Stroke, Alzheimer Disease and Related Dis-
orders Association Work Group: NINCDS-ADRDA),22
and (ii) the administration of acetylcholinesterase inhibitors
(AChEI) in a stable dose for at least 6 months.
Caregivers were excluded when (i) they had inadequate
educational level (conventionally stated as <3 y); (ii) were
not native Italian speakers; and (iii) were not related to the
patient (eg, institutional caregivers, friends, etc.). When >1
caregiver met these criteria, we selected the one who spent
most hours a day with the patient (principal caregiver).
Study Design
The study has been conducted as a clinical com-
parative trial. We planned to have 3 conditions: (i) care-
givers joining the CBT meetings (Group Treatment, GT
condition); (ii) caregivers only receiving our manual (Only
Manual, OM condition); and (iii) control caregivers (CO
condition). Owing to practical constraints posed by the
FIGURE 1. Flowchart of study design. AD indicates Alzheimer disease; CO, control; GT, group treatment; OM, only manual.
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hosting Institution (the U.V.A. of the Niguarda Ca’ Granda),
caregivers who did not join the CBT meetings (OM and CO
conditions) could just be evaluated 6 months apart (guidelines
of the CRONOS project). Routine CBT meetings, instead,
typically last for 3 months. Therefore, we could not randomize
caregivers in the 3 conditions by means of the awaiting-list
technique, because, to do so, we should have artificially pro-
longed awaiting lists to 6 months (which would have been a
reason for ethical concern, given that the possibility to join
CBT meetings is a routine service to improve the quality of
care of Niguarda Ca’ Granda, a public hospital). Therefore,
we could only randomize the CO versus OM conditions
between caregivers who did not join the CBT meetings.
Caregivers learned about the possibility to join CBT
meetings by means of a notice board and advertisements
shown in Hospital waiting rooms and in the Hospital
newspaper. In the 18-month period of data collection, 45
caregivers applied to attend the CBT meetings; 6 of them
were excluded as they did not meet the inclusion criteria (2
for the low educational level criterion and 4 as they were
not principal caregivers).
Another 63 caregivers were asked to participate in the
study during the scheduled visits of patients at the U.V.A.
After the psychological assessment, these 63 caregivers were
randomly assigned (by means of computer-generated ran-
dom numbers) to the OM and CO groups; 30 caregivers
entered the former, and 33 entered the latter group (Fig. 1).
These patients provide a written informed consent to par-
ticipate in the study.
 Caregivers of the Group Treatment (GT) condition were
further subdivided into closed groups of 7 to 10
participants, joining six 2-hour meetings every 15 days,
in an overall period of approximately 3 months. They
received the manual “Helping those who care” at the first
meeting and filled in the psychometric measures at the
baseline and at 6 months of follow-up.
 Caregivers of the Manual (OM) condition received the
same manual and filled in the psychometric measures at
the same above-mentioned times.
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Alzheimer Dis Assoc Disord  Volume 28, Number 3, July–September 2014
 Caregivers of the control (CO) condition did not receive
any additional treatment or informative material, but
filled in the psychometric measures as the above 2
groups.
All the AD patients followed up by the enrolled
caregivers were administered with a neurological and neu-
ropsychological evaluation at the beginning of the study.
Baseline and follow-up data are gathered by inde-
pendent and blinded interviewers for OM and CO groups.
Measures
Cognitive global functioning of patients was assessed
through the Mini-Mental State Examination (MMSE),23,24
a 30-point screening scale used to assess the severity of
cognitive impairment. The Italian cut-off for the Italian
population is 24/30.24
The autonomy in basic daily living activities [Instru-
mental Activities of Daily Living25 (IADL)] and in caring of
one’s own person [Activities of Daily Living26 (ADL)] have
been formally assessed as well. The physical ADL (range
score, 0 to 6) includes basic capacity demands for autonomy,
such as dressing, personal hygiene and grooming, bowel and
bladder management, and self-feeding. The IADL (range
score, 0 to 8) includes more complex skills needed to live
alone such as shopping, cooking, doing housework, doing the
laundry, using the phone, using transport, managing money,
and taking medications as prescribed.
The Anxiety and Depression Scale-Reduced Form
(AD-R) was also administered to assess caregivers’ psy-
chological status. This schedule has been validated for
patients in rehabilitation settings, consisting of 15 items
(range score, 0 to 15) of the Depression Questionnaire-
Reduced Form27,28 (QD-R) and 10 items (range score, 10 to
40) of the State Anxiety Inventory-Reduced Form29,30
(STAI-X3).
The Caregiver Need Assessment31 (CNA) has been
used to assess caregivers’ needs related to care. Such a scale
was built to investigate the needs related to the assistance
perceived by the caregiver of a patient with high level of
disability, and was statistically validated with a sample of
226 family caregivers (24.3% men) of 197 (50.8% men)
patients admitted in neuromotor rehabilitation depart-
ments following stroke, traumatic brain injury, lateral
amyotrophic sclerosis, Parkinson, or other diseases. The
questionnaire is composed of 17 items ranging on a 4-point
Likert scale (0 to 3). The overall score (range, 0 to 51)
estimates the perceived total needs related to informal care;
higher scores indicate higher needs. Needs can also be
analyzed with reference to 2 CNA subscales, each showing
good internal consistency: “Needs for emotional and social
support” (Cronbach a = 0.765) and “Needs for informa-
tion and communication” (Cronbach a = 0.742). Examples
of items from these 2 subscales are “I need a psychological
counseling (eg, for sorrows, troubles, or fears I am feeling)”
for the Needs for emotional and social support, and “I need
to easily contact the team which is nursing my relative” for
the Needs for information and communication.
The 2 subscales show a high test-retest reliability
(r = 0.942 and 0.965, respectively). Rossi et al32 observed a
positive correlation between the “Needs of emotional and
social support” CNA subscale and other questionnaires
measuring psychological well-being (STAI-X3,30 QD-R,27,28
and Family Strain questionnaire32), and between the “Needs
of information and communication” CNA subscale and the
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CBT Group Intervention for Alzheimer Caregivers
“Needs of knowledge around the illness” subscale of the
Family Strain Questionnaire.
“Helping Those Who Care” Manual
To develop the self-help handbook for caregivers, we
followed the structure of cognitive-behavioral manuals that
have been developed for other physical disorders, such as
stroke,33 or psychological disorders, such as depression.34 A
first draft of the manual was tested by a focus group of AD
patients’ caregivers who, after having read it, discussed on
the completeness of the contents and clarity of the concepts
expressed.
The result of the focus group lead to the production of
the final version of the manual “Helping those who care”
(42 pages long), which consists of the following sections:
Stages of Dementia, and Caregivers’ Problems
In this section, we addressed the potential stages of
evolution of dementia and provided an overview about the
main welfare problems that may arise at every stage of the
disease. A few sentences collected from the focus group, as
well as a story by the daughter of an AD patient are
included, with the purpose of communicating closeness and
empathy with the reader.
Advice for the Management of Everyday Life
In this section, useful and detrimental behaviors
toward the patients are discussed, with examples obtained
from the focus group. Appropriate communication modal-
ities are suggested, together with some tips to motivate and
help the patient to keep learning and practising residual
abilities (Skinner reinforcement theory). The suggestion is
finally provided to write a diary specifying the behaviors
that led to good results, as well as those that failed to ach-
ieve them. The purpose of the diary, in addition to teaching
a technique of self-monitoring, is to induce a critical view on
the specific relationship between caregiver and patient and
provide precious instructions for other caregivers.
Take Care of Themselves
This section addresses the caregivers’ needs. It stresses
the importance of taking care of oneself, and not only of the
patient, as the caregiver’s psychophysics health is a pre-
requisite for optimal caregiving. Information is provided
about how to recognize humoral dysphorias or depression
symptoms by means of self-monitoring, and how to fight
them (eg, by avoiding vicious circles triggered by negative
thoughts, and promoting distraction and enjoyable activ-
ities). The suggestion is made to program at least 1 pleasant
activity per day. Clues for managing stressful situations are
also provided: cognitive restructuring can help the reader to
recognize stressful situations that produce dysfunctional
thinking, such as catastrophic thoughts. Practical tips are
provided as to how to manage psychophysical overload (eg,
creating and maintaining a social network that is friendly
and supportive, practicing relaxation exercises), as well as a
set of guidelines to encourage proper sleep hygiene. The
reader is also encouraged to involve other people in the
care, both inside and outside the family.
Behavioral and Psychological Symptoms of Dementia
This section describes some of the major psychological
and behavioral disorders shown by the AD patients, such as
disorientation, depression, aggression, agitation, wandering,
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Passoni et al Alzheimer Dis Assoc Disord
insomnia, delusions, and hallucinations. Tips as to how to
manage each symptom are provided.
The Management of the Home Environment
This section provides directions to change the home
environment, guaranteeing safety and quiet, reducing the
perception of disability, respecting the dignity of the indi-
vidual, his/her privacy, and residual abilities.
Support for the Family
We list the care services available in the territory that
may serve as a relief for the family of a patient suffering
from AD, such as the day center, domiciliary assistance,
nursing homes, and rehabilitation clinics, which offer the
possibility of temporary relief. Caregivers are then shown
how to obtain disability declarations and carer’s allow-
ances. Access to critical Italian laws, regarding assistance,
social integration, and rights of people with severe dis-
abilities, is provided, as well as to other legal aspects con-
cerning the care. Addresses of some Italian Associations
aimed at AD patients and their caregivers are included, as
well as a series of in-depth readings for each section of the
manual.
The CBT Group Intervention
The group has been led by a psychologist and a cog-
nitive-behavioral psychotherapist, both trained in the neu-
ropsychology of cognitive decline.
The setting of the intervention was a quiet and com-
fortable room, appropriately lit, with some chairs arranged
circularly around a table, inside the U.V.A. of the hospital.
The method has been derived from CBT techniques
applicable in a group setting, starting with a psycho-
educational approach supported by the manual “Helping
those who care.” Thus, meetings were structured following
the different section of the manual, as described in the
previous section. Caregivers were asked to read the manual
at home, and then to share their opinions and questions
during the meetings. In these, general information about
the disease was given to stimulate and promote the care-
givers’ awareness of the patient’s level of damage. The focus
was initially set on the members’ daily problems related to
care: the direct confrontation between group members
promotes the sharing of their daily difficulties, and helps
them to use more effective behavioral models. The use of
self-observation diaries has been shown to be useful in
providing a common ground for discussion to detect dys-
functional thoughts and to monitor the caregivers’ coping
strategies and problem-solving abilities.
The identification and control of dysfunctional
thoughts, through cognitive restructuring techniques, was
useful to ameliorate caregivers’ coping strategies and
problem-solving abilities, and to detect mechanisms of self-
analysis necessary to increase their empowerment decision
in problematic situations with the patients.
Some practical tips such as the rise of a friendly and
supportive social network, practicing relaxation exercises,
or leisure suggestions are offered; indeed, such factors may
protect caregivers from cardiovascular risk in terms of
impaired endothelial function and catecholamine levels.35,36
Data Analysis
SPSS 17.0 was used for statistical analysis. The dif-
ferences between the 3 experimental groups in the socio-
demographic characteristics were evaluated by means of
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analysis of variance (ANOVA), when the required stat-
istical assumptions were met, and by means of the Kruskal-
Wallis test or the w2 test otherwise.
The differences in the psychometric measures between
the pretreatment and the posttreatment phase (after 6 mo)
were analyzed by means of ANOVA, with Time (pretreat-
ment vs. posttreatment) as a within-subjects factor and
Treatment (OM, GT, CO) as a between-subjects factor. If
significant main effects or interactions were found, appro-
priate comparisons between pretreatment and posttreat-
ment or between groups were carried out by means of
t tests. Given that potentially interesting effect sizes were
not known a priori, we could not compute a sample size on
grounds of power considerations. Hence, the number of
caregivers was not planned in advance.
RESULTS
Sample Characteristics
We recruited 102 patients (42 men and 60 women) with
a dementia status of AD, as assessed by the Alzheimer
Evaluation Unit (U.V.A.) of Niguarda Ca’ Granda Hos-
pital. Sociodemographic characteristics are reported
in Table 1.
The 3 groups did not differ significantly in any of the
following variables: sex, age, dementia severity at baseline
(MMSE corrected for Age), Activity of Daily Life scores
(ADL), the Instrumental ADL subscale (IADL), and
duration of dementia status.
We recruited only 1 family member per patient, the
primary caregiver (generally husband/wife, or son/daugh-
ter; in 1 case, a sister), reaching an overall number of 102
caregivers. Their characteristics are reported in Table 1.
The only differences between the 3 groups of caregivers
concern needs related to care as reported in the CNA ques-
tionnaire, both in the overall score (CNA-tot) and in each of
its 2 subscales (“needs of emotional and social support,”
CNA-1, and “needs of information and communication,”
CNA-2). The GT group had a higher CNA-tot score than
the other 2 groups (GT-OM: Mann-Whitney, z = 2.478,
P = 0.013; GT-CO: Mann-Whitney, z = 3.558, P < 0.001);
the OM and CO groups did not differ significantly. As for the
subscales, the same pattern was found for CNA1, whereas
significance was reached only by the GT-CO comparison on
the CNA-2 score.
We found no difference between the 3 caregiver groups
in terms of sex (w22 = 1.823, P = 0.402), kinship (w26 = 5.931,
P = 0.431), living situation (w22 = 1.182, P = 0.554), and
working status (w26 = 6.835, P = 0.336).
Effectiveness of the CBT Treatment
Effectiveness of the Treatment on CNA Score
ANOVA showed a significant Time Treatment
interaction on the score regarding the total CNA score
(F2,99 = 7.553, P = 0.001). The source of the interaction is
evident in Figure 2: caregivers who participated in the CBT
group treatment (GT group) showed a significant reduction
in the needs related to care (t38 = 4.392, P < 0.001),
whereas both the OM group (t29 = 1.511, P = 0.142) and
the control group (t32 = 1.669, P = 0.105) failed to show a
significant reduction, with the latter group, if anything,
showing an opposite trend (an increase of the needs with
time). Although both the GT and the OM groups showed
a larger reduction of needs than the control group did
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Alzheimer Dis Assoc Disord  Volume 28, Number 3, July–September 2014 CBT Group Intervention for Alzheimer Caregivers

TABLE 1. Characteristics of the Sample at Baseline

Group Treatment Only Manual Control (CO)
(GT) (N = 39) (OM) (N = 30) (N = 33) Statistics P
Patients
Sex
Male 20 11 11 w222.734 0.255
Female 19 19 22
Age 76.8 (7.1) 79.6 (6.7) 79.3 (7.8) F2,99 = 1.568 0.214
MMSE corrected 17.5 (6.6) 18.6 (6.3) 20.4 (4.2) Kruskal-Wallis 0.318
w22 = 2.288
ADL 4.4 (1.6) 4.1 (1.7) 4.3 (1.6) Kruskal-Wallis 0.76
w22 = 0.549
IADL 3.7 (2.4) 2.9 (2.1) 3.4 (2.3) Kruskal-Wallis 0.361
w22 = 2.038
Duration of dementia 31.2 (23.1) 34.6 (24.9) 39.4 (20.7) Kruskal-Wallis 0.344
status (mo) w22 = 2.135
Caregivers
Sex
Male 12 12 8 w22 = 1.823 0.402
Female 27 28 25
Age 58.9 (12.9) 56.5 (12.2) 60.1 (13.1) Kruskal-Wallis 0.334
w22 = 2.196
Resources
No aids 13 6 10 w22 = 1.36 0.507
Helped by 26 23 23
someone
Day center 0 1 0
CNA tot 38.0 (7.6) 32.8 (8.8) 27.9 (12.3) Kruskal-Wallis 0.001
w22 = 14.349
CNA-1 18.7 (4.3) 15.1 (5.5) 13.2 (7.5) Kruskal-Wallis 0.002
w22 = 12.299
CNA-2 19.3 (4.1) 17.7 (4.5) 14.7 (6.2) Kruskal-Wallis 0.003
w22 = 11.712
STAI-X3 (anxiety) 24.9 (6.3) 24.1 (6.1) 23.7 (6.6) Kruskal-Wallis 0.722
w22 = 0.65
QD-R (depression) 4.2 (2.8) 2.8 (3.0) 3.4 (2.8) Kruskal-Wallis 0.098
w22 = 4.638
Significant P-values are reported in bold.
ADL indicates Activities of Daily Living; CNA, Caregiver Need Assessment; IADL, Instrumental Activities of Daily Living;
MMSE, Mini-Mental State Examination; QD-R, Depression Questionnaire-Reduced Form; STAI-X3, State Anxiety Inventory-
Reduced Form.

(GT vs. CO: F1,70 = 8.872, P = 0.004; OM vs. CO:
F1,61 = 4.937, P = 0.03), the difference between the
improvement in the GT and OM groups failed to reach
significance (F1,67 = 1.814, P = 0.183).
We performed the same analysis on the CNA-1 and
CNA-2 scores separately, and obtained virtually identical
results and graphical profiles to those from CNA-tot. The
only discrepancy was that in CNA-2 (needs of information
and communication) the Treatment  Time interaction
while comparing the OM and CO groups fell short of sig-
nificance (F1,61 = 3.651, P = 0.061).
Effectiveness of the Treatment on STAI-X3 Score
The ANOVA on the caregiver’s level of anxiety
showed a Time Treatment interaction very close to sig-
nificance (F2,99 = 3.04, P = 0.052). Interesting profiles
emerge from such an interaction (Fig. 3): GT caregivers
were the only ones with a significant reduction in the anx-
iety level (GT: t38 = 3.276, P = 0.002); no such trend was
found in the other 2 groups (OM: t29 = 0.661, P = 0.514;
CO: t32 = 0.212, P = 0.833). The improvement was larger
in the GT than in the OM group (F1,67 = 2.848, 1-tailed
P = 0.048) or in the CO group (F1,70 = 5.511, 1-tailed
P = 0.011), but it was similar in the OM and CO groups
(F1,61 = 0.379, 1-tailed P = 0.27).
Effectiveness of the Treatment on QD-R Score
No significant Time Treatment interaction was
found regarding the caregiver’s mood (F2,99 = 0.784,
P = 0.459). Neither did we observe significant time changes
within groups, or differences between groups (Fig. 4).
DISCUSSION
Difficulties experienced by caregivers of AD patients
are widely reported in the literature.7,8,37 In this study, we
studied the effects of CBT on the reduction in the emotional
discomfort experienced by caregivers.
Perceived Needs
We found that caregivers in the full-treatment group
(GT), who joined the CBT meeting and also received a
manual, showed a reduction in the scores of perceived needs
(CNA); this reduction was smaller in the caregivers of the
“only manual” (OM) group, and turned, if anything, to an
increase of needs in the control (CO) group. The full-
treatment (GT) condition proved to be effective in reducing

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Passoni et al Alzheimer Dis Assoc Disord
FIGURE 2. Total CNA score (mean and standard error) at base-
line and after 6 months, in the 3 experimental conditions. CNA
indicates Caregiver Need Assessment; CO, control; GT, group
treatment; OM, only manual.
caregivers’ perceived needs, and would thus seem to be the
most suitable intervention to the purpose. However, in
addition, caregivers of the OM condition showed a reduc-
tion in perceived needs with respect to the CO group, and
the difference between the improvement in the full-treat-
ment group and the group who received only the manual
failed to reach significance. Nonetheless, whereas the
improvement in the GT group was 4.33 points, the OM
group showed half as large an effect (2.1 points): failure to
detect such a difference might be a matter of power in
samples with very large internal variability.
Therefore, we may assume that the crucial component
producing needs reduction is the availability of information
focused on the disease management, either provided by a
manual, or conveyed in group meetings sessions.
One interpretation problem might arise concerning the
initial levels of perceived needs, which were different in the
3 caregiver groups. Indeed, the CO and OM groups showed
a similar level of needs for both informational and
FIGURE 3. STAI-X3 (anxiety) score (mean and SE) in the
3 experimental groups across time (at baseline and after 6 mo).
CO indicates control; GT, group treatment; OM, only manual;
STAI-X3, State Anxiety Inventory-Reduced Form.
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FIGURE 4. QD-R (depression) score (mean and SE) in the 3
experimental groups across time (at baseline and after 6 mo). CO
indicates control; GT, group treatment; OM, only manual; QD-R,
Depression Questionnaire-Reduced Form.
emotional care, whereas GT caregivers presented with a
higher levels of needs with respect to the other 2 groups.
This result was expected by design, in that the GT group
joined the CBT meeting on voluntary basis, and a full
randomization was not possible because of practical con-
straints (see the “Study design” section). Clearly, caregivers
willing to attend the meetings were more aware of their
needs and their difficulties in the role. It is noteworthy that
that such initial difference does not seem to be due to the
various degree of mental deterioration of the patients: the
MMSE scores of the patients were comparable in both
groups. We therefore believe that these differences are
rather associated with the interindividual variability of the
caregivers’ personality profile, in line with previous
research.11
Despite such initial differences, and critically for the
purpose of our work, the GT group showed a relevant
reduction in the perceived level of needs after 6 months,
with respect to the CO group. Such a differential change
cannot be attributed to ceiling or floor effects, as mean
scores are very far from both (Fig. 2), and therefore the
inference that this interaction can be attributed to the dif-
ferent experimental conditions, and not (only) to the dif-
ferential initial motivation in the 2 groups can be derived.
One might argue that it is exactly motivation that induced a
decrease in the level of needs in the GT group; however, this
hypothesis is falsified by the results concerning the OM
group: although OM caregivers were as motivated as CO
caregivers (indeed OM and CO conditions were randomly
assigned), OM showed a change in CNA, which was not
shown by CO (see Fig. 2 and related text)—again, a result
consistent with the view that the content of the CBT, which
was faithfully reported in the manual, is critical for the
reduction in needs.
Anxiety
Group intervention seems to be effective in reducing
caregivers’ anxiety with a significant decrease in the GT
group only as the other groups remained stable in their
emotional distress index. The crucial variable in reducing
anxiety does not seem to be the availability of structured
information per se (as the OM group did not show such a
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Alzheimer Dis Assoc Disord  Volume 28, Number 3, July–September 2014
reduction)—rather the opportunity to participate in a
structured intervention based on a cognitive and behavioral
approach, and share care-related problems with other
caregivers during meetings, proved to be effective.
Depression
None of the 3 treatment groups have proven to be
helpful in alleviating depression. This result is consistent
with other studies demonstrating no evidence of improve-
ment in reducing emotional symptomatology,38,39 despite
the clear effectiveness of psychoeducational programs to
improve the knowledge of the disease and to reduce the
burden of care.19,40 As depression is very “rooted” in
caregivers, it is not responsive to too short intervention.
One might hypothesize that this emotional distress is
related to the resistance to accept a degenerative and irre-
versible disease causing such a marked and inevitable
change of his/her own beloved relative, whereas anxiety and
needs associating with care are more variable, modulated
by the coping level to manage the disease itself.
Possibly a longer intervention including individual
support, together with group psychotherapy, may be more
effective.
CONCLUSIONS
Although we are aware that randomized clinical trial
represents the gold standard in medicine to assess the
effectiveness of a treatment, and no statistical analysis
completely allows controlling the possible action of a
confounding factor, the current clinical practice situations
there have made it possible to conduct this study, as men-
tioned above.
In this context, structured information about disease
management, by means of a manual, seems to be effective in
reducing the overall level of perceived needs by caregivers;
in contrast, anxiety is only reduced when structured infor-
mation is coupled with group meetings, in which pro-
blems, doubts, and strategies can be shared and discussed
with the professional monitoring of cognitive-behavioral
psychologists.
These results indicate the need to extend a structured
and systematic intervention for AD patients’ caregivers in
Italy, possibly to be replicated in other health care contexts.
What the present study does not provide is a neuro-
psychological and functional follow-up of patients, and
thus we do not know whether and to what extent
improvement of the caregiving quality correlates with the
patients’ cognitive and functional level. Further studies are
needed to better define the role of CBT group intervention
in the long term.
ACKNOWLEDGMENT
The authors thank the AIAMC association, the Italian
Association for Analysis and Modification of Behavior and
Cognitive and Behavioral Therapy.
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