All of the dementia patients were enrolled from the 10 dementia counseling centers in Incheon, South Korea. In total, 301 elderly patients who were older than 60 years and had dementia as diagnosed by physicians in accordance with 10th revision of the International Statistical Classification of Diseases and Related Health Problems criteria were evaluated for the eligibility in our study.⁵ All of them had been taking choline esterase inhibitors and/or NMDA antagonists. In the screening interview, subjects with any of the following characteristics were excluded: admission to long-term care facilities, symptoms that were too severe to allow neuropsychological testing, and not providing written informed consent to participate in the study (both themselves and their family members). Finally, 132 elderly people with dementia were enrolled in the study. Healthy elderly caregivers older than 60 years were recruited from the Incheon Senior Resources Development Center and evaluated for medical illness by history-taking and the elderly who had the serious medical disease were excluded. Finally, 197 healthy elderly who were willing to participate in dementia care and the research program provided written informed consents to participate. The study protocol was approved by the Institutional Review Board of Gil Medical Center.

The main aim of this care program was to improve the cognitive function, quality of life, emotional state, and activities of daily living of dementia patients. A secondary aim was to improve the quality of life and self-esteem of the caregivers. The applied program included cognitive stimulation and general care.

The cognitive stimulation comprised reading a book or newspaper to patients or having them read the same, providing useful information, and participating in origami, painting, naming, communication practice, and a life review. The contents of the cognitive stimulation were selected based on previous cognitive stimulation studies.³⁶ The general care comprised assistance in taking pills, maintaining personal hygiene, providing emotional support, supporting social activities, performing physical activities (e.g., strolling and other forms of exercise), and singing.

An educational course taking 36 hours was provided to the caregivers, and they were supplied with a manual containing a comprehensive description of the care procedures. The total duration, frequency, and session duration of the program were 6 months, three times per week, and 4 hours per session, respectively. A health-care practitioner gave regular call once per month to ensure that all of the healthy elderly caretakers were providing the program correctly.

The included dementia patients and caregivers were evaluated at baseline and 6 months after implementing the program. In order to evaluate changes in the cognitive function of subjects, the Korean version of the Consortium to Establish a Registry for Alzheimer's disease Assessment Packet, 1st Edition (CERAD-K) and the Montreal Cognitive Assessment for Dementia were applied to all of the dementia patients by clinical psychologists.⁷⁸ These clinical psychologists were well trained in neuropsychological tests by certified clinical psychologists, and they had sufficient experience in applying these tests to dementia patients. The Functional Activities Questionnaire (FAQ),⁹ Disability Assessment for Dementia (DAD-K),¹⁰ and World Health Organization Quality of Life-Short Version (WHOQOL-BREF)¹¹ were used to evaluate cognitive function, activities of daily living, and quality of life in the dementia patients. The quality of life of the caregivers was evaluated using the WHOQOL-BREF.

Sociodemographic data were analyzed using the chi-square test for dichotomous variables and the independent t test for continuous variables. Since the Shapiro-Wilk test indicated that most of the scores for the neurocognitive tests, social functioning, and quality of life were not normally distributed, the nonparametric Wilcoxon's signed-rank test was used to compare these variables between before and after the intervention. The cutoff for statistical significance was set as p<0.05 (two tailed). All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows (SPSS, Chicago, IL, USA).

The sociodemographic data of the dementia patients and caregivers are listed in Table 1. There were 113 (85.6%) female and 19 (14.4%) male dementia patients, and they were aged 79.9±7.1 (mean±SD) years. Their duration of education was 7.2±3.6 years, and 62 (47.0%) of them had received no education. Sixty-one dementia patients were evaluated after participating in the care program for 6 months; this excluded those who had withdrawn their consent and who could not be evaluated for various other reasons including a lack of cooperation.

There were 169 (85.8%) female and 28 (14.2%) male caregivers, and they were aged 68.6±4.8 years. Their duration of education was 8.0±3.7 years. One hundred and six caregivers were evaluated after participating in the care program for 6 months; this excluded those who declined to be evaluated for several reasons, including withdrawal of consent.

The WHOQOL-BREF score was significantly higher for the caregivers (70.57±17.61) than for the dementia patients (52.88±7.63, p<0.001) at baseline, and it improved for the caregivers after 6 months (Z=-2.354, p=0.019) when applying the nonparametric Wilcoxon's signed-rank test, especially in the environmental domain (Z=-3.865, p=0.0001) (Table 3).