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Effectiveness of day care in supporting family caregivers of people with dementia: A systematic review

EFICÁCIA DO CENTRO DIA NO APOIO A CUIDADORES FAMILIARES DE PESSOAS COM DEMÊNCIA: UMA REVISÃO SISTEMÁTICA

ABSTRACT

Day care (DC) provides a break in daily care as a support strategy for family caregivers (FC) of people with dementia (PwD).

Objective:

to analyze the support strategies used by the DC for FC, their methodological and theoretical models, as well as the respective benefits for FC burden, coping strategies and quality of life.

Methods:

a systematic review following the Prisma methodology was performed on PubMed, PsycInfo, Scopus and SciELO electronic databases in August, 2018. The search keywords were “day care”, “dementia” or Alzheimer disease, “caregiver”, “quality of life” and “psychological adaptation”.

Results:

twenty-one studies were included. No randomized controlled trials were found. The provision of education, counseling and support, access to information, the professionals' expertise and the quality of their relationship with DC users were highlighted by caregivers. Compared to standard programs centering on PwD, the integrated program focused on PwD and FC activities showed increased feelings of competence and self-confidence of FC to postpone institutionalization. Heterogeneity in the structure and organization of the DC programs, intervention strategies and theoretical basis was observed.

Conclusion:

Integrated programs are a promising approach that addresses the needs and demands of PwD and their FC in a multidimensional manner.

Key words:
day care; Alzheimer disease; caregiver; quality of life; psychological adaptation

RESUMO

O centro-dia (CD) permite uma pausa no cuidado diário como estratégia de apoio aos cuidadores familiares (CF) das pessoas com demência (PcD).

Objetivo:

analisar as estratégias de suporte aos CF oferecidas pelos CD, seus modelos metodológicos e teóricos, bem como os respectivos benefícios sobre sua sobrecarga, estratégias de enfrentamento e qualidade de vida.

Métodos:

uma revisão sistemática utilizando a metodologia Prisma foi realizada nos bancos de dados eletrônicos PubMed, PsycInfo, Scopus e SciELO em agosto, 2018. As palavras chave da pesquisa foram “centro dia”, “demência” ou doença de Alzheimer, “cuidador”, “qualidade de vida” e “adaptação psicológica”.

Resultados:

vinte e um estudos foram incluídos. Não foram encontrados estudos randomizados. A oferta de educação, aconselhamento e apoio, o acesso a informações sobre a estrutura e o programa do CD, a expertise dos profissionais e a qualidade da relação destes com os usuários foram aspectos ressaltados pelos cuidadores. Comparados aos programas padrão centrados na PcD, estudos descrevendo o programa integrado, focado nas atividades para PcD e CF, mostraram um aumento no sentimento de competência e autoconfiança do CF e adiamento da institucionalização. Observou-se heterogeneidade na estrutura e organização dos programas de CD, nas estratégias de intervenção e nas bases teóricas.

Conclusão:

programas integrados são uma abordagem promissora que atende às necessidades e demandas das PcD e seus CF de forma multidimensional.

Palavras-chave:
centro-dia; demência; doença de Alzheimer; cuidador; qualidade de vida; adaptação psicológica

By 2030, there is set to be an exponential increase in the costs of caring for people with dementia (PwD) worldwide that will burden social and health services, including long-term care systems.11 Prince M, Wimo A, Guerchet M, Ali GC, Wu Yutzu, Prina M. World Alzheimer Report 2015. The global impact of dementia: an analysis of prevalence, incidence, cost and trends. London: Alzheimer's Disease International; 2015.,22 Alzheimer's Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 (http://www.who.int/mental_health/publications/dementia_report_2012/en/, accessed 8 March 2017).
http://www.who.int/mental_health/publica...
The informal care offered by the family represents a high economic cost, as it compromises the available time of the family caregiver (FC) for formal work, family and social activities.22 Alzheimer's Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 (http://www.who.int/mental_health/publications/dementia_report_2012/en/, accessed 8 March 2017).
http://www.who.int/mental_health/publica...
,33 The Technical Report of European Collaboration on Dementia (Eurocode) (2006-2008). www.alzheimer-europe.org and www.dementia-in-europe.eu
www.alzheimer-europe.org...
For families, the financial impact is significant, considering the costs of medical care, treatment, in addition to formal and informal care.33 The Technical Report of European Collaboration on Dementia (Eurocode) (2006-2008). www.alzheimer-europe.org and www.dementia-in-europe.eu
www.alzheimer-europe.org...
Economic analysis takes into account the cost/benefit of informal care to provide policymakers with information guiding sustainable actions and care plans which support FC.22 Alzheimer's Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 (http://www.who.int/mental_health/publications/dementia_report_2012/en/, accessed 8 March 2017).
http://www.who.int/mental_health/publica...
,33 The Technical Report of European Collaboration on Dementia (Eurocode) (2006-2008). www.alzheimer-europe.org and www.dementia-in-europe.eu
www.alzheimer-europe.org...

In the last twenty years, day care (DC) has been studied as an important health technology in the configuration of support strategies for PwD and their FC.44 Bartfay E, Bartfay WJ. Quality-of-Life Outcomes Among Alzheimer's Disease Family Caregivers Following Community-Based Intervention. West J Nurs Res. 2013;35(1):98-116.

5 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88.

6 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review.

7 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62.

8 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63.
-99 Colvez A, Joel ME, Ponton-Sanchez A, Royer AC. 2002. Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union. Health Policy 2002;60(3):219-33. Proposed as a service model that provides a friendly environment and care for PwD, while the FC have a break that decreases their exposure to primary stressors, the DC seeks to reduce the burden of care44 Bartfay E, Bartfay WJ. Quality-of-Life Outcomes Among Alzheimer's Disease Family Caregivers Following Community-Based Intervention. West J Nurs Res. 2013;35(1):98-116.

5 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88.

6 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review.

7 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62.

8 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63.
-99 Colvez A, Joel ME, Ponton-Sanchez A, Royer AC. 2002. Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union. Health Policy 2002;60(3):219-33. and improve the quality of life of the dyad. Studies comparing different community-based temporary care strategies suggest that this care model is the most economical one.1010 Santos RL, Souza MFB, Brasil D, Dourado M. Group interventions focused on the burden of caregivers of patients with dementia: A systematic review. Rev Psiq Clin. 2011;38(4):161-7.

The complexity of the situation experienced by FC, in most cases, generates a burden that compromises their physical and psychological health, impacting their availability for care and can induce early institutionalization of PwD.1111 Pot A. Caregivers' perspectives. A longitudinal study on the psychological distress of informal caregivers of demented elderly. Academic thesis: Vrije Universiteit, Amsterdam; 1996.

12 Kramer BJ, Vitalino PP. Coping: a review of the theoretical frameworks and the measures used among caregivers of individuals with dementia. J Gerontol Social Work. 1994;23:15-174.
-1313 Lezak MD. Living with the characterologically altered brain-injured patient. J Clin Psychiatry. 1978;39:592-8. Moreover, the FC burden is worsened by their physical limitations, psychological and psychosomatic complaints, emotional aspects such as anger, fear, guilt, depression,88 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63.,1414 Zarit SH, Stephens MA, Townsend A, Greene R, Femia EE. Give day care a chance to be effective: A commentary. J Gerontol B Psychol Sci Soc Sci. 2003;58(3):P195-6; discussion P197-9.,1515 Femia EE, Zarit SH, Stephens MA, Greene R. Impact of adult day services on behavioral and psychological symptoms of dementia. Gerontologist. 2007;47(6):775-88. feelings of dissatisfaction with life and loneliness, doubts about their competence and the effectiveness of their coping strategies. The presence of secondary stressors, such as financial difficulties, the conciliation of care with other family and professional demands, social isolation,55 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88.,66 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review. and lack of information on the course and prognosis of dementia, about care and management strategies, as well as the need to adapt to the environment, are also factors that may influence caregiver burden.77 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62.

Beneficial outcomes have been described for FC who participate in DC, such as decreased stress,1414 Zarit SH, Stephens MA, Townsend A, Greene R, Femia EE. Give day care a chance to be effective: A commentary. J Gerontol B Psychol Sci Soc Sci. 2003;58(3):P195-6; discussion P197-9. depression,1414 Zarit SH, Stephens MA, Townsend A, Greene R, Femia EE. Give day care a chance to be effective: A commentary. J Gerontol B Psychol Sci Soc Sci. 2003;58(3):P195-6; discussion P197-9. anger,1515 Femia EE, Zarit SH, Stephens MA, Greene R. Impact of adult day services on behavioral and psychological symptoms of dementia. Gerontologist. 2007;47(6):775-88. more positive daily experiences,1616 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The effects of adult day services on family caregivers' daily stress, affect, and health: Outcomes from the daily stress and health (DaSH) study. Gerontologist. 2014;54(4):570-9. and overall improvement in health and well-being.55 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88.,88 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63. Tretteteig et al.,77 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62. in a recent integrative review, concluded that DC provide a sense of security and relief for FC, reduce burden and increase motivation for care. Vandepitte et al.,55 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88. in a review on the effectiveness of temporary care in supporting FC, observed a decrease in the FC burden and behavioral problems of the PwD. However, DC attendance did not delay institutionalization. Fields et al.88 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63. suggest that, given the diversity of service settings and the different models of support offered to caregivers, it is difficult to discern the benefits of reducing FC exposure to primary stressors of those associated with the specific interventions, such as psychosocial and psychoeducational interventions, or individual counseling. This lack of standardization of services makes research in this area a heterogeneous field, while also limits the interpretation of results and their replication.88 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63.,1717 Tarrant S. 2010 Next Steps Think Tank: Adult day services. Retrieved from http://www.ageandcommunity.org/products.attachment/2010adultdaythinktank2667/2010AdultDayThinkTank.pdf
http://www.ageandcommunity.org/products....
In addition, the caregiver approaches offered by DC,88 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63. include psychosocial and psychoeducational interventions, individual counseling and occasional meetings, but most of the studies do not present the theoretical assumptions that underlie this type of technology.77 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62.,88 Fields NL, Anderson KA, Dabelko-Schoeny H. The effectiveness and adult day services for older adults: A review of the literature from 2000 to 2011. J Appl Gerontol. 2014;33(2):130-63.

In view of this, the present review aims to analyze the intervention models for FC that make up the settings of the DC, considering their methodological and theoretical models, as well as the respective benefits for FC burden, coping strategies and quality of life.

METHODS

This systematic review used the methodology suggested by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)1818 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. criteria. The search was performed according to the following PICOS:1919 Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. Diretrizes Metodológicas: elaboração de revisões sistemáticas e metanálise de estudos observacionais e comparativos sobre fatores de risco e prognóstico/Ministério da Saúde, Secretaria de Ciência, Tecnologia e Insumos Estratégicos, Departamento de Ciência e Tecnologia. - Brasília: Ministério da Saúde; 2014:132.

P caregivers of people with dementia;

I day care;

C caregivers assisted by outpatient programs, caregivers without interventions, patients and caregivers without interventions;

O stress, burden, quality of life, coping skills and postponement of institutionalization;

S cross-sectional, longitudinal, randomized, non-randomized and case-control studies.

The literature search was performed on August 2018, using PubMed, SciELO, PsycINFO and Scopus databases. Studies published from 1998 and 2017 were included. The search keywords included the following MeSH terms: “day care” [MeSH} or (care day) or (partial hospitalization) and “dementia” [MeSH] or Alzheimer disease [MeSH] or (Alzheimer's disease) or (Alzheimer type dementia) and “caregiver” [MeSH] or (family caregiver) or (carers) and “quality of life” [MeSH] or (Health related quality of life) and “adaptation, psychological” [MeSH] or (coping behavior) or (coping skills). A manual search was also performed by revising the reference of all papers selected. The inclusion criteria were: 1. cross-sectional or longitudinal studies, 2. randomized or nonrandomized, 3. with or without a control group, 4. studies on day care for people with dementia with caregiver outcomes, 5. reports written in English or Portuguese.

The exclusion criteria were: 1. Participants with other pathologies; 2. Other community or outpatient care settings; 3. Evaluation of specific therapeutics (medications, physical exercise, occupational therapy etc.); 4. Evaluation of instruments; 5. Literature reviews; 6. Other languages; 7. Studies without full text; 8. Outcomes focused on the PWD; 9. Books, dissertations and theses; 10. Public health policies and epidemiological studies.

Study selection

The articles were evaluated using the quality score metrics proposed by the Mixed Methods Assessment (MMAT),2020 Pluye P, Robert E, Cargo M, Bartlett G, O'Cathain A, Griffiths F, et al. (2011). Proposal: A mixed methods appraisal tool for systematic mixed studies reviews. Department of Family Medicine, McGill University, Montreal, Canada. Retrieved on [date] from http://mixedmethodsappraisaltoolpublic.pbworks.com. Archived by WebCite® at http://www.webcitation.org/5tTRTc9yJ
http://mixedmethodsappraisaltoolpublic.p...
,2121 Pace R, Pluye P, Bartlett G, Macaulay AC, Salsberg J, Jagosh J, Seller R.Testing the reliability and efficiency of the pilot Mixed Methods Appraisal. Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud. 2012;49(1):47-53. a tool for the qualitative evaluation of empirical studies that used qualitative, quantitative or mixed methods. The MMAT establishes corresponding criteria for each research method and scores are rated from 1 to 4, considering the description of each stage of method implementation, using descriptors such as *, **, ***, and ****.

Two authors (VLRM and MCND) screened titles and abstracts to identify eligible papers. We excluded all studies that clearly did not meet all inclusion criteria or that met at least one of the exclusion criteria. Subsequently, two authors (VLRM and MATB) independently reviewed the full publications of the remaining papers and held consensus meetings to discuss any disagreement and to reach a consensus about inclusion. When necessary, a third co-author of this paper (RLS) clarified study eligibility.

The articles were reviewed considering the research procedures and the configuration of DC, the program, its objectives, therapeutic proposals and theoretical basis.

RESULTS

The initial database searches retrieved 587 articles; 82 were found on PsycINFO, 301 on Scopus, 202 were identified on PubMed and 2 on SciELO. All the authors reviewed the selected documents to reach a consensus.

After duplicates were removed (n=274), 299 studies not meeting inclusion criteria were excluded, and fourteen studies were selected for inclusion in this systematic review. Seven further studies were identified by manually searching the references in the selected articles. Twenty-one papers had been selected by the end of this search process (Figure 1). A flow diagram of the study selection process is depicted in Figure 1.

Figure 1
Flow of information through the different phases of the systematic review.

Methodological aspects

Place. Ten out of the twenty-one studies were conducted in the USA,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.

23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.

25 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.

26 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.

27 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.

28 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.

29 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.

30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.
-3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77. three in the Netherlands,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 one in Norway,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5. one in Norway and Scotland,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. one in Iceland,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 one in Hong Kong,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. one in Australia,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. one in Italy,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. one in Sweden4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. and one in Germany.4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. No articles on DC in Latin America were found.

Sample. Nineteen studies included FC of both genders, 2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.

23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.
-2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.

29 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.

30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.

31 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.

32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.

34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.

36 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.

37 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54

38 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.

39 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.

40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.

41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.
-4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. predominantly women, while two included females only,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67. Regarding the type of FC relationship with the PwD, fifteen studies included spouses, children and others,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.

23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.
-2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.

32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.

34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.

36 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.

37 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54

38 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.
-3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. two included only wives and daughters,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67. whereas four studies did not specify the kinship.2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. All articles reported that people were diagnosed with dementia, without specifying the causes.

Study design. No randomized controlled trials were found. Six descriptive qualitative studies2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. and a longitudinal phenomenological interpretative study3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 were found. Of the six studies, two were longitudinal3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. and four cross-sectional.2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5. These studies collected reports from caregivers to understand their needs for support and respite, and the role of Day Care in improving the relationship of care, health status and quality of life of the dyad. Ten non-randomized quantitative longitudinal studies with control-group design 2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. and four descriptive quantitative studies2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. were also found. Seven articles evaluated a group of DC user's caregivers comparing them with non-users' family control groups.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. Three articles evaluated a group of DC user's caregivers that participated in a special family support program in association with the care provided to PwD via integrated approaches, while control group caregivers participated in the care offered by a standard DC setting which offered activities to PwD only.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

Caregivers' outcomes. In the study by de Jong et al.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77. the needs and expectations expressed by the FC regarding the assistance offered by the DC emphasized the importance given to the provision of education, counseling and support, access to information about the structure and program of the DC, as well as the professionals' expertise and the quality of their relationship with users. Phillipson et al.3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. found that the opportunity to learn care strategies through the observation of professionals and the opportunity to engage in other daily and social tasks were valued by caregivers. These aspects contributed to a more positive perception of DC among FC users than non-users.

Seventeen studies observed a reduction in time spent on care activities and in exposure to primary stressors,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.

23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.

25 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.
-2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.

29 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.

30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.
-3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.

34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.
-3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.

39 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.

40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.
-4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. reduced feelings of burden,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. worry,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. anger,2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.
-2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77. affective fluctuation and depression,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.

23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.
-2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77. psychological/psychosomatic complaints,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. and loneliness.2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9. Increased feelings of competence2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 and freedom,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5. strengthening of coping strategies,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 improved health status and greater psychological well-being2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. were also reported. The FC exhibited significantly less distress over behavioral problems of the PwD2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. and less stress associated with their own non-fulfilment of life expectations.3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. Having a break increased the positive experiences and free time to stay with other family members or friends,2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. increased morale2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9. and social activity,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. and benefited the relationship between the dyad3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. and easier cooperation.3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.

Mossello et al.4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. found no significant between-group difference in depressive symptoms change. Similarly, Zank et al.4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. found no differences in well-being or burden on standard measures, but, in a semi-structured interview, FC reported substantial positive change promoted by the use of DC.

Kwork et al.3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. reported that PwD did not improve their capacity for self-care and mobility. Higgins et al.2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9. reported that FC observed no changes in their own quality of life or that of PwD, and reported worsening of cognitive function and behavioral symptoms among PwD.

The observation of improvement in self-esteem and well-being, quality of life and health status, associated with increased social stimulation of the PwD resulted in a secondary benefit for FC health and quality of life.2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.

37 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54

38 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.

39 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.

40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.

41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.
-4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. FC also reported that participating in the DC promoted a sense of kinship2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67. and maintained the PwD cognitively,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. functionally and physically active.3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. There were also improvements in behavior and sleep changes in the PwD immediately after the use of DC,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46. and lower use of psychotropic drugs.4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.

A delay in institutionalization was associated with improved health of the dyad and in their quality of relationships.2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. Cho et al.2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67. observed that, for the wives, DC helped in accepting the possibility of separation, especially in the presence of behavioral problems.

Gústafsdóttir3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 observed that the DC reinforced family ties, crucial to continue home care, and contributed to the contentment of life of the whole family.

The last benefit of the DC for the FC was the sharing of care with professionals, the information exchange and reflection on the case, and proposing care strategies.3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. DC helped FC to develop a different perspective on the illness, as well as on its course, allowing a more respectful relationship regarding the individuality of the PwD.3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54

The three articles that studied the benefits of an integrated approach compared to standard care offered to PwD only, observed a significant decrease in FC suffering over PwD behavioral problems,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 increased feelings of competence, self-confidence and coping strategies to avoid problem situations and postponement of PwD institutionalization.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 The families enrolled in the program used more DC than families receiving standard care.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9. Nevertheless, it was not effective for reducing the determinants of feeling of burden.3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

The characteristics of the selected studies are shown in Table 1.

Table 1
Characteristics of studies selected.

Configuration of day care

Sources of subsidy. Different sources of subsidy for DC were reported. Rokstad et al.3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. stated that in Norway, when a DC is considered a health care service for the PwD, it is regulated and subsidized by the municipalities. If it is defined as a respite for the FC there is a subsidized payment for attendance. In Scotland, the DC is provided by statutory, private, and third sector organizations and regulated by the Care Inspectorate. The Dutch skilled DC facilities are part of the nursing home organization, and are subsidized and legislated by the government.3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 In Germany, these services are paid for by health insurance, care insurance, patients, or social welfare.4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. In New Jersey (USA), the statewide network of adult DC is provided in part by the Department of Health and Senior Services for FC with low and moderate income.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77. One study was financed by the U.S. Administration on Aging Alzheimer's Disease Demonstration Grants to States funds and state matching funds.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. Three studies were conducted in DC funded by private sector and third sector or self-funded partnerships without subsidies or legislation by the government.2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. Eleven articles did not state whether the DC was funded by an institution or whether it was paid for by the users.2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.

Structure. Twelve articles provided no information about the structure of the DC.2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.
-2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.

36 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.

37 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54

38 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.
-3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. Nine studies presented information on the regimen of use of the DC, which varied from one to five times a week and from 4 to 8 hours daily.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.

32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. Regarding the competence of the team, only six studies reported having a multi-professional staff,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. which included social assistants,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. nurses,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. occupational therapist and speech therapist,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. physiotherapist and geriatrician,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. Director of center, family service provider, activities specialist,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9. and three reported having the participation of volunteers.2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57.

Program. Eleven studies did not describe the activities offered.2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.
-2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. Two studies reported recreational activities, social interaction and meals.3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. In addition to these activities, seven studies also included psychosocial activities, activities of daily living, cognitive stimulation, physical and psychomotor activity, and music therapy.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57.

Twelve articles made no mention of whether the DC offered caregiver support programs.2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.

25 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.

26 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.
-2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.

31 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.
-3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. Caregivers were supported by designated case managers in one study,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. informal counseling was provided in another,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. two studies offered educational program for caregivers,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. and one offered caregiver support groups.3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 Logsdon et al.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. described the Memory Care and Wellness Services (MCWS) program. This program provides specialized activities and exercise for PwD. The FC are involved in planning care for PWD and receive support and information, including referral services.

Drões et al.3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 evaluated whether an integrated program offered to the dyad would positively influence some potential determinants of burden. In the program, the PwD participated in social activities, recreation and rehabilitation. Simultaneously, the FC received emotional and social support based on a psychosocial diagnosis. The program included ten educational groups, a biweekly support group. PwD and FC participated in a weekly counseling meeting and a monthly meeting with all staff in which they discussed possible adjustments to the treatment program.

Gitlin et al.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9. studied Adult Day Services Plus (ADS Plus), a special support program for FC focused on user needs. FC were interviewed at the beginning of treatment, after three months and at one year. The FC received advice, information and educational materials through periodic personal contact or by telephone. At the same time, the PwD regularly participated in the DC program of activities.

Objectives and therapeutic proposals. The DC proposes to offer significant activities,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. a safe environment, as well as social, emotional and health support2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. for the PwD. Some programs offer rehabilitation care,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77. recreational activities,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. and motor and cognitive stimulation.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. They propose to improve their coping strategies3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. and quality of life,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. maintain cognitive functioning, physical ability, functional capacity.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. behavioral status, nutritional status.3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. as well as promote a sense of kinship2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9. and well-being.4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. The DC programs also serve as a respite service for FC.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. The program objectives are to alleviate FC stress and burden,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. improve their knowledge about the disease2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24. and sense of competence related to the caregiving tasks,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24. to give them emotional and social support,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. offer counseling,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9. facilitate continued care at home2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. and postpone the need for institutionalization.3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.

Theoretical basis. Only four studies reported the theoretical basis of the support program offered to FC. Drões et al.3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 cited the Meeting Centres Support Program (MCSP), with a theoretical framework based on the adaptation coping model4343 Droes RM. In Beweging; over psychosociale hulpverlening aan demente ouderen. [Moving; on psychosocial care for elderly people with dementia.] Nijkerk: Intro.1991.,4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. and the model of determinants of experienced burden. The models consider negative social circumstances as determinants of burden. Gitlin et al.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9. stated that the ADS Plus was based on the Pearlin et al.4646 Clare L. Rehabilitation for people living with dementia: A practical framework of positive support. PLoS Med. 2017;14(3):e1002245. stress process model. The program targets the primary stressors of caregiving: behavior problems of the PwD and the physical, mental, and social health of the FC. The approach was used to support positive intrapsychic factors (such as the perception of competence and rewards of caregiving), as well as to introduce positive coping strategies (such as problem solving) in order to mediate objective stressors of caregiving. Zank et al.4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. only reported that the DC units studied offered a rehabilitation program based on clinical experience and gerontological knowledge.

The structure, objectives and theoretical basis of the DC are depicted in Table 2.

Table 2
Characteristics of day care in studies selected.

DISCUSSION

Historically, the DC, as a strategy for supporting FC, was originally intended to offer a break in caregiving tasks, and to maintain or improve the health and quality of life of the PwD-FC dyad. This concept of service was inspired by studies on the burden and coping strategies of family caregivers and the impact on their quality of life.22 Alzheimer's Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 (http://www.who.int/mental_health/publications/dementia_report_2012/en/, accessed 8 March 2017).
http://www.who.int/mental_health/publica...

3 The Technical Report of European Collaboration on Dementia (Eurocode) (2006-2008). www.alzheimer-europe.org and www.dementia-in-europe.eu
www.alzheimer-europe.org...

4 Bartfay E, Bartfay WJ. Quality-of-Life Outcomes Among Alzheimer's Disease Family Caregivers Following Community-Based Intervention. West J Nurs Res. 2013;35(1):98-116.

5 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88.

6 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review.
-77 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62.,99 Colvez A, Joel ME, Ponton-Sanchez A, Royer AC. 2002. Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union. Health Policy 2002;60(3):219-33. Currently, DC are also considered a fundamental community-based technology for health care, which aim to offer all interventions to promote health, prevent and treat, improve rehabilitation and long-term care.44 Bartfay E, Bartfay WJ. Quality-of-Life Outcomes Among Alzheimer's Disease Family Caregivers Following Community-Based Intervention. West J Nurs Res. 2013;35(1):98-116.

5 Vandepitte S, Noortgate NVD, Putman K, Verhaeghe S, Verdonck C, Annemans L. Effectiveness of respite care in supporting informal caregivers of persons with dementia: a systematic review. Int J Geriatr Psychiatry 2016;31:1277-88.
-66 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.

The need for support, together with the benefits outlined, has justified investment from different actors, such as governments, statutory, third sector organizations, health insurance and assistance, universities, private institutions and families.2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.

32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. Logsdon et al.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25. reported that DC is the least expensive alternative for providing rest, emotional and health support to PwD, when compared to a non-medical home health intervention, home care or home nursing care. Although there is some evidence of the effectiveness of DC, the heterogeneity in service settings, activity schedules and staff, do not allow solid cost-effectiveness conclusions.22 Alzheimer's Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 (http://www.who.int/mental_health/publications/dementia_report_2012/en/, accessed 8 March 2017).
http://www.who.int/mental_health/publica...
,66 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review.,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. This factor also contributes to limitations in funding and availability of these programs.22 Alzheimer's Disease International and WHO. Dementia: a public health priority. Geneva: World Health Organization; 2012 (http://www.who.int/mental_health/publications/dementia_report_2012/en/, accessed 8 March 2017).
http://www.who.int/mental_health/publica...
,66 Mason A, Weatherly H, Spilsbury K, Arksey H, Golder S, Adamson J, et al. A systematic review of the effectiveness and cost-effectiveness of different models of community-based respite care for frail older people and their carers. Health Technol Assess. 2007;11(15):1-157, iii. Review.,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80.

Quantitative approaches with controls to evaluate the impact of this care2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. and qualitative studies, to ascertain the expectations, needs and beliefs3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. and level of satisfaction3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. of the FC were implemented. No randomized studies were found, and some studies questioned the validity of this type of design due to ethical concerns with the impact of non-access to treatment for the controls in the case of longitudinal studies.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,4545 Pearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: An overview of concepts and their measures. Gerontologist. 1990;30:583-94.

There was methodological heterogeneity in the characteristics of the FC samples and in the assessments used. This diversity hinders comparison among studies and their outcomes. For example, case studies with controls compared the days of DC treatment to the days when the PwD was cared for at home,2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.,2424 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77. FC of PwD users were compared to non-users,2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. while others only interviewed FC of DC users.3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. Despite the great diversity of methods, sample sizes, measuring instruments and interviews, most of the studies reported similar positive results with DC use.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.

23 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.

25 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.

26 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.

27 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.

28 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.

29 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.

30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.

31 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.

32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.

34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.

36 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.
-3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.

40 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.

41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.
-4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. The same heterogeneity was also evident in the configuration of the intervention regarding three aspects: the structure and organization of the DC programs, the design, and the theoretical basis.

Structure and organization

Attendance frequency varied from one to five times a week and the number of hours from four to eight hours per day.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.

30 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.

31 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.

32 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50. This variability possibly influences the results presented in the studies. Research on the needs and expectations of FC has identified an important demand for flexibility of the DC in relation to available days and times, and the possibility of a regular or intermittent frequency,77 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres for people with dementia on family caregivers: an integrative review of the literature. Aging Ment Health. 2016;20(5):450-62.,99 Colvez A, Joel ME, Ponton-Sanchez A, Royer AC. 2002. Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union. Health Policy 2002;60(3):219-33.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. numbering among the factors determining users' level of satisfaction. These aspects involve accommodating possible changes in the daily needs and schedules of FC. This flexibility has a considerable influence on the levels of burden and quality of life of the dyad.33 The Technical Report of European Collaboration on Dementia (Eurocode) (2006-2008). www.alzheimer-europe.org and www.dementia-in-europe.eu
www.alzheimer-europe.org...
,99 Colvez A, Joel ME, Ponton-Sanchez A, Royer AC. 2002. Health status and work burden of Alzheimer patients' informal caregivers: comparisons of five different care programs in the European Union. Health Policy 2002;60(3):219-33.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.

Intervention design

The diversity of the intervention designs impacts the results of the studies.3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5. Some studies did not describe the activities offered, mainly because they aimed to investigate the benefit of the break from care for the FC.2323 Liu Y, Kim K, Almeida DM, Zarit SH. Daily Fluctuation in Negative Affect for Family Caregivers of Individuals With Dementia. Health Psychology. 2015;34(7):729-40.

24 Zarit SH, Kim K, Femia EE, Almeida DM, Klein LC. The Effects of Adult Day Services on Family Caregivers' Daily Stress, Affect, and Health: Outcomes From the Daily Stress and Health (DaSH) Study. Gerontologist. 2014;54(4):570-9.
-2525 Kim K, Zarit SH, Femia EE, Savla J. Kin relationship of caregivers and people with dementia: stress and response to intervention. Int J Geriatr Psychiatry. 2012;27:59-66.,2727 Cho S, Zarit SH, Chiriboga DA. Wives and daughters: the differential role of day care use in the nursing home placement of cognitively impaired family members. Gerontologist. 2009;49:57-67.,3030 Gaugler JE, Jarrott SE, Zarit SH, Stephens MA, Townsend A, Greene R. Adult day service use and reductions in caregiving hours: Effects on stress and psychological wellbeing for dementia caregivers. Int J Geriatr Psychiatry. 2003;18(1):55-62.,3131 Zarit SH, Stephens MA, Townsend A, Greene R. Stress reduction for family caregivers: effects of adult day care use. J Gerontol B Psychol Sci Soc Sci. 1998;53:S267-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34.,4141 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.Among the programs described, some offered activities for PwD only,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. while others included activities for the dyad.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.

41 Mavall L, Thorslund M. Does day care also provide care for the caregiver? Arch Gerontol Geriatr. 2007;45:137-50.
-4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57.

The two approaches, including the caregivers in the service or otherwise, identified different protocols of activities aimed at PwD. Programs of recreational activities with an emphasis on socialization and well-being,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. and others that included both motor and cognitive stimulation plus rehabilitation.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.
-3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. The results showed that the provision of physical, cognitive and social stimuli positively impacted well-being and health in general, sleep quality, functioning and cognitive readiness, even in participants with reduced cognitive capacity.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. These studies reinforce the premise that lack of activity contributes to the emergence of PwD neuropsychiatric symptoms.4646 Clare L. Rehabilitation for people living with dementia: A practical framework of positive support. PLoS Med. 2017;14(3):e1002245.

47 Woods B, Aguirre E, Spector A E, Orrell M. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev. 2012;(2):CD005562.

48 Thuné-Boyle IC, Iliffe S, Cerga-Pashoja A, Lowery D, Warner J. The effect of exercise on behavioral and psychological symptoms of dementia: towards a research agenda. Int Psychogeriatr. 2012;24(7):1046-57.

49 Behrer L. Cognitive plasticity in older adults: effects of cognitive training and physical exercise. Ann N Y Acad Sci. 2015;1337:1-6.
-5050 Clare L, Linden DE, Woods RT, Whitaker R, Evans SJ, Parkinson CH, et al. Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer disease: a single-blind randomized controlled trial of clinical efficacy. Am J Geriatr Psychiatry. 2010;18(10):928-39. Conversely, a multimodal program of cognitive and physical rehabilitation can improve socialization mood and also reduce caregiver burden.4646 Clare L. Rehabilitation for people living with dementia: A practical framework of positive support. PLoS Med. 2017;14(3):e1002245.

47 Woods B, Aguirre E, Spector A E, Orrell M. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev. 2012;(2):CD005562.

48 Thuné-Boyle IC, Iliffe S, Cerga-Pashoja A, Lowery D, Warner J. The effect of exercise on behavioral and psychological symptoms of dementia: towards a research agenda. Int Psychogeriatr. 2012;24(7):1046-57.

49 Behrer L. Cognitive plasticity in older adults: effects of cognitive training and physical exercise. Ann N Y Acad Sci. 2015;1337:1-6.
-5050 Clare L, Linden DE, Woods RT, Whitaker R, Evans SJ, Parkinson CH, et al. Goal-oriented cognitive rehabilitation for people with early-stage Alzheimer disease: a single-blind randomized controlled trial of clinical efficacy. Am J Geriatr Psychiatry. 2010;18(10):928-39.

The results concerning the impact of activities on behavioral changes were contradictory. Zarit et al.2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46. and Mossello et al.4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. observed a significant reduction in behavioral changes, leading to an improvement in sleep in users on days of DC use,2626 Zarit SH, Kim K, Femia EE, Almeida DM, Savla J, Molenaar PC. Effects of adult day care on daily stress of caregivers: a within-person approach. J Gerontol B Psychol Sci Soc Sci. 2011;66:538-46. along with a reduction in the prescription of psychotropic drugs, when compared with non-users of DC.4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. Kwok et al.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. on the other hand, observed no improvement. These disparities may be related to methodological differences and to intervention time. In any case, the improvements observed reduced the impact of primary stressors on FC and, as a secondary result, burden was reduced.3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. In turn, the certainty that the PwD would be protected in a friendly environment, involved in meaningful and stimulating activities, and would receive personalized attention adapted to their interests and levels of functionality, were relevant aspects for FC confidence in the service.3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.,3535 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.,3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,3939 Phillipson L, Jones SC. Use of day centers for respite by help-seeking caregivers of individuals with dementia. J Gerontol Nurs. 2012;38:24-34. Notably, the high degree of heterogeneity precluded analysis of the effect size of the studies.

Different approaches to FC were observed. In one study, the DC program offered informal counselling,4040 Mossello E, Caleri V, Razzi E, Di Bari M, Cantini C, Tonon E, et al. Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23:1066-72. but the model was not described. In some programs, the FC were only marginally involved in care.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. In others, the program included support interventions,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. such as educational programs2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,2929 Higgins M, Koch K, Hynan LS, Carr S, Byrnes K, Weiner MF. Impact of an activities-based adult dementia care program. Neuropsychiatr Dis Treat. 2005;1(2):165-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. and support groups,2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 both with the aim of improving FC sense of competence regarding the caregiving tasks. Some programs also offered social activities, such as parties and trips, during which the FC had the opportunity to interact in a fun way with their family member.3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54 In some services, the FC were supported by case managers or had regular meetings with staff.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. In such cases, FC, along with staff, analyzed needs, and developed a care plan to be implemented both at home and at the DC.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. Treatment follow-up occurred through face-to-face meetings or by telephone contact, in which FC expressed their observations, concerns and needs, received counseling and were informed about referral services.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11,3737 Gústafsdóttir M. The Family's Experience of Sharing the Care of a Person with Dementia with the Services in Specialized Day-Care Units. Dement Geriatr Cogn Disord. 2014;4:344-54,3838 Kwok T, Young D, Yip A, F Ho. Effectiveness of day care services for dementia patients and their caregivers Asian J Gerontol Geriatr 2013; 8:9-15. The way in which DC met the need for flexibility, support, information and sharing of responsibilities was positively highlighted by FC.2222 Logsdon RG, Pike KC, Korte L, Goehring C. Memory Care and Wellness Services: Efficacy of Specialized Dementia Care in Adult Day Services. Gerontologist. 2016;56(2):318-25.,2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3232 de Jong JD, Boersma F. Dutch psychogeriatric day-care centers: a qualitative study of the needs and wishes of carers. Int Psychogeriatr. 2009;21:268-77.

33 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.

34 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11

35 Tretteteig S, Vatne S, Rokstad AMM. The influence of day care centres designed for people with dementia on family caregivers - a qualitative study. BMC Geriatrics (2017) 17(1):5.
-3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409.,4242 Zank S, Schacke C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. J Gerontol B Psychol Sci Soc Sci. 2002; 57(4):P348-57. The studies suggested that this integrative approach better addresses the different needs of FC.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9.,3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 However, these results cannot be considered conclusive since they are similar to those observed in other non-integrative approaches. In addition, the heterogeneity observed in DC approaches hinders characterization of a gold standard for this kind of intervention.

Theoretical basis

With regard to theoretical background, the adaptation coping model adopted by the MCS was briefly described in the two articles by Drões et al.3333 Dröes RM, Meiland FJM, Schmitz MJ, van Tilburg W. Effect of the Meeting Centres Support Program on informal carers of people with dementia: Results from a multi-centre study. Aging Ment Health. 2006;10(2):112-24.,3434 Droes RM, Breebaart E, Meiland FJ, Van Tilburg W, Mellenbergh GJ. Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia. Aging Ment Health. 2004;8:201-11 This model provides a framework for explaining behavioral problems in PwD, based on the principle that people constantly strive for balance when confronted with changes in their existence.4343 Droes RM. In Beweging; over psychosociale hulpverlening aan demente ouderen. [Moving; on psychosocial care for elderly people with dementia.] Nijkerk: Intro.1991.,4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. The socioenvironmental, material and determinant factors of the disease are believed to interfere in the subjective evaluation of the PwD about their condition. Consequently, given the imbalance generated by the disease, the person has to carry out cognitive, social and emotional adaptive tasks. This adaptation implies a learning process and depends on the quality of interaction with the environment.4343 Droes RM. In Beweging; over psychosociale hulpverlening aan demente ouderen. [Moving; on psychosocial care for elderly people with dementia.] Nijkerk: Intro.1991.,4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. Therefore, the dyad are assisted in this complex process of adaptation that includes learning to deal with limitations and dependence, maintaining and establishing social relations, dealing with environmental aspects and prescribed treatments, preserving an emotional balance, a positive self-image and preparing for an uncertain future.4343 Droes RM. In Beweging; over psychosociale hulpverlening aan demente ouderen. [Moving; on psychosocial care for elderly people with dementia.] Nijkerk: Intro.1991.,4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. This theory offers an understanding of the PwD response to the illness and guides a stimulation program that facilitates the adaptive process and support that helps the FC understand the condition of the family member and to reflect on more effective care strategies. However, by focusing only on the aspects related to primary stressors, it disregards possible secondary stressors that interfere with the care relationship and contribute to the feeling of burden. The focus is on understanding the PwD experience, the consequences of the illness, and possible coping strategies.

The stress process model of Pearlin et al.4545 Pearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: An overview of concepts and their measures. Gerontologist. 1990;30:583-94. was cited by Gitlin et al.2828 Gitlin LN, Reever K, Dennis MP, Mathieu E, Hauck WW. Enhancing quality of life of families who use adult day services: Short- and longterm effects of the adult day services plus program. Gerontologist. 2006; 46(5):630-9. as the theoretical basis of ADS Plus. Firstly, this theory considers the difficulties and problems anchored directly in care as primary stressors. Secondly, the socioeconomic conditions, conflicts and tensions resulting from working, family relationships and social life, or intrapsychic tensions associated with the personality or decrease in the caregiver's self-concept were considered secondary stressors.4545 Pearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: An overview of concepts and their measures. Gerontologist. 1990;30:583-94. From this perspective, coping and social support can potentially influence multiple aspects throughout the stress process.4545 Pearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: An overview of concepts and their measures. Gerontologist. 1990;30:583-94. This theory offers a theoretical scope that allows a diagnosis and understanding of the situation of the FC, and proposes specific intervention strategies to support and improve the resources and conditions of care. The focus of the intervention was centered on FC experience and their resources for care.

The person-centered approach was cited as the recommended theoretical axis to guide the care model of the DC.3636 Rokstad M, McCabe L, Robertson JM, Strandenæs MG, Tretteteig S, Vatne S. Day care for people with dementia: A qualitative study comparing experiences from Norway and Scotland. Dementia (London). 2019;18(4):1393-409. This theory entails a theoretical principle underlying the different psychosocial models as it shifts the focus of the disease to the PwD and the way in which they experience their condition.

These approaches are offered as theoretical references for care delivery and are part of the set of psychosocial models used in the field of Psychogeriatrics.4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. In this field, the theories articulate three fundamental axes: the focus on the sick person and their experience, the focus on the caregiver and their experience, besides understanding of the disease and its consequences.4444 Finnema E, Drões R, Ribbe M, van Tilburg W. A Review of Psychosocial Models in Psychogeriatrics: Implications for Care and Research. Alzheimer Dis Assoc Disord. 2000;14(2):68-80. The approaches seek to understand the multidimensional aspects that contribute to the condition of the PwD and FC, considering their needs, suffering, resources, coping strategies and the impact of illness on the family relationship. The theories analyzed are not exclusive, as each focuses on fundamental aspects for the provision of dementia care. The development of further DC should include a theoretical framework in order to enable more consistent intervention.

Limitations

The possible influence of socioeconomic and cultural differences between the samples studied calls for caution in the interpretation of results. Likewise, the lack of standardization in the configuration of DC hampers comparison of results. In addition. the conception of DC as a rest service, restricts the understanding of its therapeutic role as a treatment and rehabilitation device for PwD, and a source of guidance and support for FC.

Most of the studies failed to describe the strategies of interaction, support and guidance for FC, and did not explain the theoretical framework that conceptually defines the services model and its therapeutic goals. The lack of a detailed description limits the interpretation of the congruence of results in relation to objectives proposed and intervention programs.

In conclusion, The reduction in daily exposure of the FC to primary stressors promoted a rest period and contributed to the continuity of the family living together with the PwD, delaying institutionalization. The DC appears to be a promising technology for reducing FC burden, thereby improving their health and quality of life.

Integrated programs that cater for the needs of the PwD and their FC represent a promising approach that meets their needs and demands in a multidimensional manner. The DC is a technology that aims to promote health, prevent disease and also provide treatment through interventions that minimize burden and enable long-term care. However, there is a lack of integrative approaches that articulate the contribution of different complementary theories and guide comprehensive and cost-effective intervention programs.

  • This study was conducted at the Center for Alzheimer’s Disease, Institute of Psychiatry, Universidade Federal do Rio de Janeiro, RJ, Brazil.

Acknowledgments. Marcia Cristina Nascimento Dourado is researcher 2 and received funding from the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

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Publication Dates

  • Publication in this collection
    23 Sept 2019
  • Date of issue
    Jul-Sep 2019

History

  • Received
    10 Jan 2019
  • Accepted
    01 July 2019
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