With the increase of the aged population, the prevalence of patient with dementia (PWD) in Korea is estimated around 127 million by 2030.1 The dementia care system in Korea had improved forward with the introduction of long-term care insurance, providing benefits and coverage of home-based caring and institutional care. Still, most individuals with dementia are cared by family members at home, primarily by spouses or adult children.2

The terms 'primary' or 'informal caregiver' has been used to depict a relative who takes on the principal role of taking care of the PWD at home. Informal caregivers (CG) are often required to provide years of care and to adapt to a continuously demanding situation. Their requirements of skills are: supervising daily tasks, coping with cognitive decline, managing behavioral problems, adapting to new social and economic circumstances, and making treatment decisions. The stress associated with caring for a family member with dementia is often severe, and is associated with a heightened risk of negative health consequences and unexpected death. Caregiving for PWD are also at risk of developing mental health problems such as depression and anxiety compared to caring for other disease.3 CG intervention programs have been developed to address these negative effects of caregiving using multicomponent approaches. More than 200 dementia caregiver interventions have been tested in randomized clinical trials; they were found to be efficacious.

Compared to significant progress in development and research in Europe and North America, the situation in Korea is difficult. There is no hospital-based systematized intervention program, and there are no randomized controlled trials (RCT) to prove its efficacy. To overcome these issues and develop systematized multicomponent CG intervention program (for dementia clinic based RCT), the recent updates of CG intervention programs will be reviewed.

In the preparation of this review, literature search in Pubmed (between 2010–2016) was performed, combining the key words of 'dementia', 'caregiver', 'intervention', 'randomized', and 'program'. This review integrated many of meta-analysis and systematic reviews currently available.

The first assessment of RCT in support of CG was in the 1990s was conducted in an Australian hospital. The CG of mild to moderate dementia of Alzheimer's disease (AD) received a structured, residential 10-day structured training program, which started either immediately (immediate group) or with six months' delay (wait-list group). There were follow-ups and telephone conferences over 12 months. During the 8-years of follow-up, the patients whom CG received training stayed at home longer and tended to live longer than control patients.4

The following theoretical models were used for developing CG intervention program: the stress-coping model, the stress-management model and the cognitive behavioral therapy (CBT) model. In the stress-coping model, individuals with a stressor make two appraisals; the primary assessment is how stressful or threatening the situation is, and the secondary appraisal is the assessment of their ability to cope. Once achieved, they can employ their coping skills to new appraisals. These coping skills can include emotion-focused approaches, problem-focused strategies, and utilization of social support systems.5 In the stress-management model, treatment is focused on specific aspects associated with CG's stress, understanding of the patient's disease, improving management of abnormal behaviors, or using more informal and formal supports.6 The CBT is a cognitive reframing, focuses on CG's dysfunctional thoughts about PWD's behaviors and their performance in the caring role, making them better adapted to the situation.7 The CBT interventions are most structured and psycho-educational model. It targets skill training, teaching CG's to practice self-management.

At present, there is no accepted classification system. Developing a classification system for evidence-based treatments and care practices would involve selecting the categories and identifying factors in each category which may affect treatment and care practice outcomes. The intervention programs can be categorized into psychosocial interventions of caregiver education (multicomponent intervention, exercise training, case management, behavioral management training, skills training of individual or groups), psychosocial intervention of caregiver support (individual, group and combined individual/group supporting counseling), technology-based interventions and respite care.8

There are several dementia caregiver programs in Korea which were developed for public communities such as regional Center for Dementia, day-care center or welfare centers. These are Dementia Caregiver Support program from the Korean Association for Dementia, Cognitive-behavioral therapy program22 and multimodal psychoeducational programs (Table 2).23 Additionally, the Rosalynn Carter Institute for Caregiving Korea established in 2010, provides specialized caregiver educational programs. Nevertheless, these programs are designed for group intervention in the public community setting, and no RCT evidence is available to prove the competence of the program.

A multicenter, randomized trial to assess efficacy of therapeutic intervention programs for decreasing CAREgiver burden in dementia caregiver (I-CARE) is being conducted in 9 hospital-based dementia clinic (Bobath Hospital, Pusan National University Hospital, Chuncheon Sacred Heart Hospital, Dongtan Sacred Heart Hospital, Ewha Womans University Mokdong Hospital, Hallym University Sacred Heart Hospital, Inha University Hospital, Myongji Hospital, and Seoul Asan Hospital). This clinical trial is funded by National Evidence-Based Healthcare Collaborating Agency. I-CARE is composed of 4 sessions: one group education delivered by physician and 3 individual sessions delivered by clinical neuropsychologist trained in psychotherapy (Fig. 1). It was designed to compose caregiver education (group education lecture with caregiver support), CBT (behavior management training), stress-coping (self-compassion and acceptance) and stress-management (skill management). First session of group education is focused on delivering information and free discussion for each caregiver. Individual sessions were focused on caregiver to 1) recognize and understand behavioral problem of PWD, 2) self-appraisal of their effort and how to overcome stress, and 3) simple skill buildings that caregiver can do with PWD (Table 3). Primary outcome is improvement in Zaret's Burden Inventory and Philadelphia Geriatric Center for Moral Scale. Secondary outcome is any change in Caregiver-Administered Neuropsychiatric Inventory, Instrumental Activities of Daily Living, Geriatric Depression Scale, Acceptance & Action Questionnaire, Self-Compassion Scale and Positive Affect and Negative Affect scale. I-CARE RCT is currently ongoing, targeting 98 CG of AD (CG distress score ≥2) and expected to finalize end of 2016.

There has been emerging evidence in recent years demonstrating that interventions targeting the patient's basic support, external environment, physical, cognitive and psychosocial activity are effective. In addition to patient-centered approaches, the convincing evidence indicates the efficacy of caregiver-centered multicomponent interventions in the mild to moderate dementia stage. It decreases caregiver burden, increases positive emotion and even delays institutionalization. Eventually, a need for developing an integrative multicomponent intervention that brings cognitive, psychosocial and physical strategies for each stage of dementia (especially for mild to moderate dementia) adapted to the practical needs are paramount. If CG intervention could start in the early stage of disease, it may help CG in accepting and planning the future through developing. Also, an education of advanced dementia CG showed a reduction in agitation and anxiety in dementia and enhanced the end-of-life care (e.g., decisions on hospitalization, antibiotics or percutaneous endoscopic gastroscopy).24 Evidence from end-of-life studies, it prevented pathological mourning of caregiver after the patients' death.25 Hence, with this paramount evidence, dementia wards and memory clinics should integrate caregiver education and support activities into therapeutic CG intervention concepts.

To incorporate CG intervention program to practice, there are two main obstacles. The major problem is the lack of remuneration in the implementation of caregiver by national health insurances. The 2014 World Alzheimer's Report concluded that even with CG multicomponent interventions with proven its efficacy, no governments have invested in this intervention to scale-up provision throughout the dementia care system. The Korean Ministry of Health and Welfare announced that dementia caregiver program will be reimbursed in the mid of 2016, but no further administrative action is being taken. Another problem is, there should be more scientific proven CG intervention program in wide range of focus. Advancing translational efforts will require the greater investment of government funds, and thus inserting translation and widespread implementation from policy makers and service providers. Through this process, the principles shared by proven interventions will be identified, and the guidelines and best practices will emerge. Guidelines will be useful to service providers which typically require specialized training, fidelity monitoring, and on-going researcher involvement.26 Given only a few treatments available in an epidemic of dementia, attention to family CGs incorporating non-pharmacological treatment and CG intervention program into practice is a medical and public health imperative.