Geriatric Nursing 48 (2022) 203!

213

Contents lists available at ScienceDirect

Geriatric Nursing
journal homepage: www.gnjournal.com

eHealth interventions for the informal caregivers of people with

dementia: A systematic review of systematic reviews
Linh Khanh Bui, MSN, RNa,b, Myonghwa Park, PhD, RN, FAANa,*,
Thi-Thanh-Tinh Giap, PhD, RNa
a
Education and Research Center for Evidence Based Nursing Knowledge, College of Nursing, Chungnam National University, Daejeon, South Korea
b
Faculty of Nursing and Midwifery, Hanoi Medical University, Hanoi, Vietnam

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To systematically synthesize existing evidence on the implementation and effectiveness of
Received 24 July 2022 eHealth interventions for the informal caregivers of people with dementia.
Received in revised form 19 September 2022 Methods: A systematic review of systematic reviews was conducted following the Cochrane methodological
Accepted 21 September 2022
recommendations. Data were searched from MEDLINE/Ovid, Embase, CINAHL, Web of Science, Cochrane
Available online 21 October 2022
Library, and PsycInfo. Methodological quality was appraised independently using the AMSTAR 2.
Results: Nineteen reviews were included. The methodological quality of reviews varied from high to critically
Keywords:
low. The eHealth interventions provided multiple components covering informative, psychoeducation, com-
Dementia
Informal caregivers
munication, psychotherapeutic, and psychosocial support. Interventions were delivered via the Internet, tel-
Telemedicine ephones, and combined technologies. The evidence varied, but was generally positive regarding depression,
eHealth anxiety, caregiver burden, stress, self-efficacy, knowledge, and skill improvements. No evidence was found
Systematic review on the coping competence of caregivers.
Conclusions: eHealth interventions are widely applied and benefit informal caregivers, but still lacking high
methodological quality. More rigorous research is necessary to produce robust evidence for this changing
field.
© 2022 Elsevier Inc. All rights reserved.

Introduction
According to the World Alzheimer Report 2021, more than 55 mil-
lion people live with dementia worldwide, which is estimated to
increase 78 million by 2030 and over 131 million by 2050.1 A new
case of dementia is reported every 3.2 seconds. Dementia is one of
the leading causes of disability and is a condition with significant bur-
den among older adults worldwide, and also has one of the highest
caring costs in many economies.2
Most people with dementia live in the community,3 and are
mostly taken care of by spouses, adult children, and relatives.4 They
known as informal caregivers who provide uncompensated care to
those need assistance in illness or disability. Informal caregivers play
an important role in dementia care and are mostly responsible for a
large amount of care required for their loved ones with dementia.5,6
Because of the complex and continuous care conditions, caregivers
often experience a greater burden7 and more depression and stress
*Corresponding author at: Education and Research Center for Evidence Based Nurs-
ing Knowledge, College of Nursing, Chungnam National University, 266 Munhwa-ro,
Jung-gu, Daejeon 35015, Republic of Korea.
E-mail address: mhpark@cnu.ac.kr (M. Park).
than their peers of other chronic diseases.8 They also have to deal
with financial hardship and have a lower quality of life.6 Providing
appropriate support for caregivers of dementia patients does not
only beneficial caregivers themselves but also positively impacts peo-
ple with dementia. Positive improvements of the emotional out-
comes and quality of life of caregivers could lead to better care for
people with dementia, thus delaying their institutionalization.9
In the context of digital transformation, technology has a huge
impact on many aspects of life. In health care, an explosion of tech-
nology interventions could be seen that provide innovative means
for the delivery of diagnosis and caring. In dementia care, eHealth
interventions are becoming a preferable, widely applied option to
support informal caregivers due to their greater accessibility, cost-
effectiveness, and capability for personalization.10-12 eHealth is
defined as “the use of information and communication technologies
for health”.13 eHealth interventions have demonstrated positive
impacts on caregivers, addressing issues such as anxiety, stress, and
depressive symptoms, while increasing their self-efficacy and
improving their quality of life.14
The number of systematic reviews and meta-analyses on eHealth
interventions for informal caregivers of people with dementia has
been significantly increased.15 There is a huge amount of information

https://doi.org/10.1016/j.gerinurse.2022.09.015
0197-4572/$ ! see front matter © 2022 Elsevier Inc. All rights reserved.
204 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
from numerous studies available for people interested in this field.
However, heterogeneous results regarding the implementation and
effectiveness of interventions may be confusing. New methods have
emerged that collect the best available evidence to provide a broad
picture of the topic. A systematic review of systematic reviews is one
of these approaches, which aims to synthesize the evidence from sys-
tematic reviews using a comprehensive and systematic method.16
While systematic review of primary research focuses on specific
research questions within a broader field, a systematic review of sys-
tematic reviews focuses on lumping information across reviews and
finding commonalities between them to generate findings for a
broader question.17 The upside of a systematic review of systematic
reviews is providing an accessible summary of evidence that supports
broader decision-making in terms of clinical and policy.16,17
The dementia literature includes several systematic reviews of
systematic reviews conducted to determine the efficacy of nonphar-
macological18 and psychosocial12 interventions for caregivers. Those
reviews focused on various caregiver interventions from psychosocial
and therapeutic interventions, information, and training to technol-
ogy-based interventions. eHealth interventions have not yet been
discussed in detail due to the diverse range of delivery formats18 and
methodological quality of existing reviews.12 There has been only
one broad review determining factors influencing the implementa-
tion of eHealth interventions for the caregivers of people with
dementia.15 While systematic reviews of systematic reviews have
been published summarizing the evidence of eHealth interventions
in somatic diseases,19 or in reducing social isolation among older
adults,20 no previous review aimed to synthesize the evidence from
systematic reviews regarding eHealth intervention types and their
effects on the specific context of support for informal caregivers.
Technology-based applications are steadily growing,21 and it is bene-
ficial to provide an overall picture on which types of eHealth inter-
vention are available and their effects on the caregivers of people
with dementia.
This systematic review of systematic reviews aims to appraise and
synthesize the evidence from published systematic reviews on the
implementations and efficacies of eHealth interventions on support-
ing the informal caregivers of people with dementia, identifying
research gaps, and providing suggestions for future studies.
Material and methods
Design
This was a systematic review of systematic reviews. The protocol
of the review was registered on the PROSPERO database (registration
number CRD42021254334).
Inclusion and exclusion criteria
The inclusion and exclusion criteria were based on the PICOS (Par-
ticipant, Intervention, Comparison, Outcomes, and Study design). The
participants were the informal caregivers of people with dementia.
Interventions were related to eHealth components that were (1)
delivered via information and communication technologies such as
the Internet, telephone, web-based applications, and mobile applica-
tions, and (2) mostly directed at support for informal caregivers.
Comparisons were made with direct, face-to-face, and usual-care
interventions. The outcomes on the effects of interventions on care-
givers such as depression, caregiver burden, anxiety, stress, self-effi-
cacy, coping competence, and quality of life. Only systematic reviews
and/or meta-analyses of randomized controlled trials (RCTs) were
included. Articles were restricted to those written in English for prac-
ticality, but the abstracts of non-English papers were quickly
screened to ensure that no relevant papers were excluded. The
restriction to peer-reviewed journals was to ensure that the included
studies were of high quality.
Search strategy
Six databases (MEDLINE/Ovid, CINAHL, PsycInfo, Embase,
Cochrane Library, and Web of Science) were comprehensively
searched from 1994 to November 11, 2021. Additional promising
articles were identified by screening the reference lists of included
reviews. Search keywords included four main categories: (1) demen-
tia, (2) informal caregivers, (3) eHealth, and (4) systematic reviews
and meta-analyses. The full search process can be found in Supple-
mental Table 1.
Selection process
One reviewer screened titles and abstracts to select potential
reviews and exclude irrelevant reviews. The full texts of all potential
reviews were retrieved and assessed for eligibility. During the selec-
tion process, any reviews that did not clearly fulfill the inclusion cri-
teria were included and discussed with an expert in systematic
reviews and the eHealth field, who also checked the list of included
reviews and made final decisions about selection.
Overlap
The overlap occurring within included reviews was calculated
using the corrected covered area (CCA) to quantify the degree of
overlap between studies.22 The amount of overlap could range from
0!100, with values of 0!5, 6!10, 11!15, and >15 considered to
indicate slight, moderate, high, and very high overlap, respectively. A
citation matrix with nonoverlapped primary publications and indi-
vidual reviews was formulated, and primary studies were checked
for duplicates in each review.
Quality assessment
Two reviewers independently assessed the methodological qual-
ity of systematic reviews using the AMSTAR 2 checklist.23 This check-
list consists of 16 items with responses of “yes” for a positive result,
“partial yes” for a partial adherence, and “no” if no information was
provided. Individual items are not combined to obtain an overall
score, but critical domains (items 2, 4, 7, 9, 11, 13, and 15) were con-
sidered to determine overall confidence. The methodological quality
was rated as high, moderate, low, or critically low. Any divergence
between reviewers was resolved by discussion and consultation with
a third person. The results indicated that there was good interrater
reliability between the two assessors.
Data extraction
Descriptive characteristics and relevant outcomes (intervention
types, delivery formats, and effectiveness to caregivers) were
extracted. Included reviews were separately extracted by two inde-
pendent reviewers, with the results indicating no significant discrep-
ancies between the two reviewers. A more-experienced reviewer
audited the extracted data.
Data synthesis
Due to the heterogeneity of study approaches, outcomes, and
finding interpretations, quantitative syntheses were impossible. The
findings were tabulated and developed narrative summaries. Find-
ings were grouped where possible according to intervention types,
delivery formats, and effects on informal caregivers.
 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
Results
Characteristics of included reviews
Fig. 1 shows a flow chart of the study selection. The database
searches yielded 1,684 records. After screening, 71 full texts were
retrieved and reviewed. 19 systematic reviews and meta-analyses
(11 systematic reviews [57.9%]24-34 and 8 meta-analyses [42.1%]35-42)
were included. Supplemental Table 2 lists the excluded studies. Eight
reviews included RCTs only (42.1%), and eleven (57.9%) included both
RCTs and non-RCTs (mostly quasi-experimental, pretest-posttest,
and cohort studies). Table 1 lists the characteristics of the included
reviews.
The number of primary publications ranged from 3 to 34 across
the reviews, and 97 nonoverlapping primary articles published dur-
ing 1990!2019 were identified. Based on the formula used by Pieper
et al. to calculate the degree of overlap,22 the CCA in this review was
10.3%, which was considered a moderate overlap. A detailed matrix
of the primary publications contained within included reviews is pro-
vided in Supplemental Tables 3 and 4.
Methodological quality
The methodological quality of reviews ranged from high to criti-
cally low. The detail of quality assessment using the AMSTAR 2 are
provided in Supplemental Table 5. Only two reviews were of high
quality,25,37 five reviews were of moderate quality,38-42 and the
remaining reviews were of low or critically low quality. Fig. 2 shows
Fig. 1. PRISMA flowchart describes the search process.
205
the number of meta-analyses and systematic reviews that satisfied
the AMSTAR 2 checklist.
Intervention types and their efficacies
A wide range of eHealth interventions with various delivery for-
mats and contents were covered in the 19 included reviews (Table 2).
They were provided though the Internet, telephones, and a combina-
tion of the Internet and telephones with supplemental modes. Inter-
ventions were classified into five main groups: (1) informative
interventions, (2) psychoeducation, (3) psychotherapeutic interven-
tions, (4) psychosocial support, and (5) communication. All except
two reviews covered multicomponent interventions that blended
multiple different approaches: one was focused on the effectiveness
of counseling via the telephone,39 and the other on technology-based
cognitive behavioral therapy.40 Fig. 3 illustrates the specific outcomes
and the various reviews reporting them.
Internet-based interventions
The Internet was the main delivery format for the various care-
giver interventions in seven reviews.24,26,31,36,38,41,42 Informal care-
givers could access information sources related to knowledge on
dementia and caregiving issues, and other supportive sources via
websites,24,31,38,41,42 forums,24,31 or video conferences.31 They identi-
fied online training workshops and educational programs through e-
learning platforms, online courses, or watching videos created by
healthcare professionals.24,26,31,36,38,42 Online materials and training
modules conveyed knowledge on diseases and caregiving issues,
206 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
Table 1
Characteristics of included reviews.
No First author, year, Review method Searching (Number of
country databases), databases, searching
time limitation
1 Boots, 2014, Netherlands Systematic review (5) PubMed, CINAHL, PsycINFO,
Cochrane Library, Web of Sci-
ence (1988-2013)
2 Deeken, 2019, Germany Meta-analysis (3) PubMed PsysINFO Cochrane
Library (up to 2018)
3 Díaz, 2014, Brazil Systematic review (9) CINAHL, PubMed, CENTRAL,
PSYCRITIQUES, ProQuest,
IBECS and LILACS, ISI Web
Knowledge, Science Direct,
Scopus (1995-2013)
4 Egan, 2018, UK Systematic review (6) PubMed, ISI Web of Science,
Cochrane, PsycINFO, CINAHL,
EMBASE (up to 2016)
5 Etxeberria, 2021, Spain Systematic review and (5) PubMed, CINAHL, PsycINFO,
meta-analysis Cochrane Library, Web of Sci-
ence, (2014-2018)
6 Godwin, 2013, US Systematic review (3) Medline, PsycINFO, EBSCO
(1990-2012)
7 Gonza
!lez-Fraile, 2021, Systematic review and (6) MEDLINE, ALOIS, PsycINFO,
Spain meta-analysis Embase, CINAHL, LILACS (up
to 2020)
8 Jackson, 2016, Australia Systematic review (8) MEDLINE, PsycINFO, Embase, 22 (RCTs and NRSIs)
CINAHL, Web of Science, Age-
line, Scopus, Cochrane Library
(2013-2014)
9 Leng, 2020, China Systematic review and (6) PubMed, Web of Science,
meta-analysis CINAHL, Embase, PsycINFO,
Cochrane Library (to 2020)
10 Lins, 2014, Germany Systematic review and (7) MEDLINE, Embase, CINAHL,
meta-analysis PsycINF, LILACS, ALOIS, CEN-
TRAL (Not stated)
11 Lucero, 2019, US Systematic review (4) PubMed, CINAHL, Web of
Science, PsycINFO (to 2017)
12 McKechnie, 2014, UK Systematic review (3) PsycINFO, MEDLINE, CINAHL 14 (6 RCTs, 8 NRSIs)
(2012-2020)
13 Parra-Vidales, 2017, Spain Systematic review (5) PubMed, PsycINFO, Scopus,
SciELO, Psicodoc (2010-2015)
14 Powell, 2008, UK Systematic review (5) MEDLINE, Embase, CINAHL,
PsycINFO, AMED (to 2007)
15 Ruggiano, 2018, US Systematic review (6) MEDLINE, CINAHL, ASSIA,
Social Service Abstracts, Psy-
cINFO, Social Work Abstracts
(no restriction of publication)
16 Scott, 2016, Australia Systematic review and (4) PsycINFO, Cochrane Reviews, 4 (2 RCTs, 2 waitlist
meta-analysis Scopus, MEDLINE (from 1995)
17 Thompson, 2007, UK Systematic review and (24) MEDLINE, Cochrane, Psy-
meta-analysis cINFO, Embase, CINAHL, ISTP,
SIGLE, INSIDE, Dissertation
Abstract, Aslib Index to The-
ses, Alzheimer Society,
ADEAR, South Australia Net-
work for Resea rch on Ageing,
YS Dept of Veterans Affair
Cooperative Studies, NIH,
GlaxoSmithKline, Schering
Health Care Ltd, MRC,
National Research Register,
Hong Kong Health Services
Research Fund, NHS, LILACS
Number of included Quality criteria Number of participants
studies
12 (3 RCTs; 9 NRSIs) Cochrane criteria; > 1370 ranging from 11
(1995-2013) Oxford Centre for Evi- to 700
dence-based Medi-
cine guidelines
33 RCTs (1990-2018) Cochrane criteria 3313 ranging from 11 to
299 mean age 62, from
46 to 71
3 RCTs (2004-2013) JBI-MAStARI criteria 115 ranging from 42 to
71
8 RCTs (1995-2015) Cochrane for risk of bias 962 ranging from 11 to
GRADE (if meta-anal- 299
ysis were feasible)
10 (8 RCTs and 2 NRSIs) Downs and Black Qual- 1016 ranging from 40 to
(2014-2018) ity Checklist 245 mean age from 53
to 70 predominantly
female
8 (4 unique RCTs) NA 2192 ranging from 26 to
(1995-2007) 1222 mean age from
46.9 to 69 predomi-
nantly female
26 RCTs (1995-2020) Cochrane criteria 2367 ranging 40 to 110
mean age 63 (from 51
to 72 years) predomi-
nantly female (72%)
Cochrane criteria 3244 ranging from 14 to
(1998-2015) 994
17 RCTs (1995-2019) Cochrane criteria 2202 ranging from 25 to
547
11(9 RCTs and 2 quali- Cochrane criteria mean age 60 to 71
tative studies) (1999-
2008)
12 RCTs (1995-2015) Quality Assessment 1453 ranging 32 to 250
Tool for Quantitative predominately female
Studies
Downs and Black Qual- 2947 ranging from 18 to
(2003-2011) ity Checklist 329
7 NRSIs (2010-2015) NA 402 ranging from 11 to
150
15 (RCTs and NRSIs) NA 560 ranging from 21 to
(1995-2006) 148
30 (21 RCTs, 9 NRSIs) Johns Hopkins Nursing 2927 ranging from 5 to
(1990-2016) Evidence Based Prac- 299
tice: Model and
Guidelines
Cochrane criteria 505 ranging from 33 to
control trial) (2000- 299 mean age 57 pre-
2005) dominately female
4 (RCTs and NRSIs) Cochrane criteria, CRD NA
(1990-2003) Only guideline
findings related to
eHealth interventions
were included
(continued)
 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213 207

Table 1 (Continued)

No First author, year, Review method Searching (Number of Number of included Quality criteria Number of participants
country databases), databases, searching studies
time limitation

18 Waller, 2017, Australia Systematic review (4) MEDLINE, Embase, CINAHL, 34 (1 cluster RCT, 30 EPOC criteria 3294 ranging from 11 to
Cochrane (1990-2016) RCTs, 4 NRSIs) (1990- 299
2016)
19 Zhao, 2019, China Meta-analysis (5) PubMed, Excerpta Medica 6 RCTs (2005-2015) Cochrane criteria 815 ranging from 49 to
database, Ovid MEDLINE, 299 mean age
Cochrane (to 2018) 58.66 years predomi-
nantly female

how to improve skills for coping with caregiving demands, and on
self-care for caregivers. Behavioral relaxation training and cognitive
behavioral therapy were also delivered using computer networks
and Internet platforms.26,38 Informal caregivers could share their
experiences with peers through private and anonymous forums to
find support.42 Internet-based interventions were divided into those
comprising a single component (i.e., providing information or psy-
choeducation) and multiple components (i.e., providing two or more
support types).42
Four of seven reviews included meta-analyses.36,38,41,42 Internet-
based interventions indicated benefits in improving
depression,24,31,36,38,42 with generally small pooled effect sizes from
!0.23 to !0.21.36,38,42 Improvements in anxiety26,31,38,42 and stress38
were recorded in several reviews, also with significantly small pooled
effect sizes. The current reviews failed to find supportive evidence for
online interventions in reducing caregiver burden.24,26,36,38,42 Coping
competence was reported as an outcome in several
reviews,24,26,31,38,42 but no positive evidence was recorded. Likewise,
no significant improvement was found in caregiver reactions to
behavioral symptoms.38
Getting support by interacting with other caregivers in similar sit-
uations improved the self-efficacy of caregivers.24 Self-efficacy
reportedly improved26,31,38 with a small effect size after receiving
web-based interventions. No evidence was found for improving the
quality of life.24,26,31,38,42
Telephone-based interventions
One systematic review25 and one meta-analysis39 summarized
the evidence on telephone-based interventions. Telephones were
used to provide psychoeducation25 and counseling39 to informal
caregivers. Compared with usual care or the same interventions
delivered face to face at home, interventions provided via telephone
had a significantly smaller effect on caregiver burden.39 Telephone
counseling was effective for reducing depression, with a small effect
size (standardized mean difference=0.32, 95% CI=0.01!0.63).25
Meanwhile, there were no clear positive effects of counseling via the
telephone on reducing anxiety and stress for caregivers.39
Combined interventions
Ten reviews reported evidence from combined interventions.27-30,
32-35, 37,40
The most common combination of delivery formats was the
Internet with telephones, and additional supplementary modes such
as DVDs and videos. Positive outcomes regarding reductions in
depression and caregiver burden, and improvements in self-efficacy

Fig. 2. a. Number of meta-analyses satisfied AMSTAR II criteria (8 meta-analyses) 2b. Number of systematic reviews satisfied AMSTAR II criteria (11 systematic reviews) Criteria no
11a, 11b, 12, 15 were excluded because these only were applied for meta-analyses 1-Using PICO framework in research questions and inclusion criteria; 2-prior protocol; 3-selec-
tion of designs; 4-comprehensive search strategy; 5-duplicate study selection; 6-duplicate study extraction; 7-justify exclusion; 8-detail of included studies; 9a-risk of bias assess-
ment of reviews only including RCTs; 9b-risk of bias assessment of reviews including both RCTs and NRSIs; 10-funding sources; 11a-appropriate methods for meta-analysis of
reviews only including RCTs; 11b-appropriate methods for meta-analysis of reviews including both RCTs and NRSIs; 12-potential impact of risk of bias in meta-analysis; 13-inter-
pretation of risk of bias; 14-explain heterogeneity; 15-publication bias in meta-analysis; 16-conflicts of interest.
208
Table 2
Key findings of included reviews.
Reviews Intervention description
Information Psychoeducation Communication Psycho-therapeutic Psychosocial support mixed results !
Internet-based
interventions
Boots 2014 Websites provide informa- x x
tion, caregiving strategies;
additional support via
emails
Egan 2018 Online training and support
programs provide psycho-
education, therapeutic
interventions such as
relaxation and cognitive
reframing, arranging help
and support through text,
video, forum,
videoconferencing.
Etxeberria 2021 Psychoeducation provides
information, cognitive-
behavioral strategies and
skills and interact with
professionals and care-
givers via online forums,
social media
Leng 2020 Web-based multimedia x x
interventions aimed at
knowledge, skills training,
information and commu-
nication. Psycho-therapeu-
tic interventions and
various support were pro-
vided via the Internet and
internet-enabled devices.
Parra-Vidales 2017 Informative interventions, x x
cognitive training, and
support from peer and/or
healthcare professionals
were provided via web-
sites including video chat
Thompson 2007 Computer interventions pro- x
vide information and
support
Zhao 2019 Information, psychoeduca- x x
tion programs were pro-
vided though the Internet.
Sharing with peers via pri-
vate forum or finding
other psychological sup-
port online.
Telephone-based
interventions
Díaz 2014 Telephone provided psycho- x
education aim to improve
caregiver’s knowledge,
teaching them to deal with
stressors by providing
L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
Intervention type Effectiveness of intervention
# decrease " increase $
! no evidence
(-) number of primary studies
x x # depression (2) " self-effi-
cacy (4) " sense of compe-
tence (2) " decision
making (1) $ burden (4) !
! quality of life (1) !
! cop-
ing skills (1) !! social iso-
lation (1) !! stress
management of technolo-
gies (1)
x x x # anxiety (2), stress (3) "
knowledge skills (3) " self-
efficacy (1) $ depression
(4) !! burden (3) ! ! quality
of life (3) !
! coping (2)
x x # depression (5) [g: -0.213
(-0.401; -0.025)] $ burden
(5) [g: 0.044 (-0.215;
0.303)] $ anxiety (2) [g:
-0.245 (-0.601; 0.111)] $
competence (3) [g: 0.035
(-0.285;0.354)]
x x # depression (11) [SMD:
-0.21 (-0.31; -0.1)] # per-
ceived stress (7) [SMD:
-0.4 (-0.55; -0.24)] # anxi-
ety (3) [SMD: -0.33 (-0.51;
-0.16)] " self-efficacy (2)
[SMD: 0.19 (0.05; -0.33)]
$ burden (10) [SMD: -0.04
(-0.34; 0.27)]
$ reactions to behavioral
symptoms (4) [SMD: -0.11
(-0.27; 0.06)] ! ! coping
competence (7) [SMD:
0.11 (-0.05; 0.27)] ! ! qual-
ity of life (3) [SMD: 0.15
(-0.14; 0.44)]
x # depression (1) # anxiety
(1) # stress (1) " self-effi-
cacy (3) " acquired compe-
tence (2) " knowledge of
disease (2) " functional
autonomy (27) ! ! quality
of life (2) !! coping skills
(1) !! self-efficacy (1)
x - depression (3) [WMD: 0.62
(-1.98;3.22)]
x # depression (4) [SMD: -0.23
(-0.38; -0.07)] # anxiety
(2) [SMD: -0.32 (-0.5;
-0.14)] !! stress/distress
(2) !! coping (2) ! ! burden
(3) !! quality of life (3)
x # burden (2) ! ! physical
health outcomes (1) !!
distress (1)
(continued)
 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
Table 2 (Continued)
Reviews Intervention description
Information Psychoeducation Communication Psycho-therapeutic Psychosocial support mixed results !
information, resources,
and services
Lins 2014 Counseling was provided via
telephone
Combined
interventions
Deeken 2019 - Telephone support group x x
with professionals, a peer
telephone network; treat-
ment for behavioral activa-
tion, psychoeducation,
coping strategies - Web-
based via online platform,
apps, internet course,
web-based programs to
provide psychoeducation,
contact with other care-
givers - Combined inter-
ventions for call,
conferences, and informa-
tion, therapeutic and
psychoeducation
Gonza
!lez-Fraile 2021 Information, training and x x
support were provided by
telephone and internet
Godwin 2013 Computer, telephone net- x x
work provides informa-
tion, communication
features, counseling and
psychosocial support
through text, video
Jackson 2016
Intervention type
x 1. Telephone counselling
x x
x x
x x x x
209
Effectiveness of intervention
# decrease " increase $
! no evidence
(-) number of primary studies
(6) # depression (3) [SMD:
0.32 (0.01; 0.63)] $ bur-
den (4) [SMD: 0.45 (0.01,
0.90)] $ social support (2)
[SMD: 0.25(-0.24;0.73)] ! !
self-efficacy (3) !! distress
(1) !! quality of life (1) !
!
satisfaction (1)
2. Telephone combined
with video (1) !! depres-
sion (1) !! anxiety (1) !!
satisfaction (1)
3. Telephone combined
with video and a work-
book (2) # depression (2)
$ self-efficacy (2) ! ! bur-
den (1) !! distress (1)
x # depression (24) [SMD: -0.2
(-0.31; -0.1)] # burden (22)
[SMD: -0.13 (-0.24; -0.02)]
x 1. interventions versus
usual treatment, waiting
list or attention control !
! caregiver burden (9)
[SMD: -0.06 (-0.35;0.23)]
!! depression (8) [SMD:
-0.05(-0.22;0.12)] ! !
health related quality of
life (2) [SMD: 0.1
(-0.13;0.32)] !! knowledge
and skills (4) [SMD: 0.2
(-0.1; 0.5)]
2. interventions versus
information only # bur-
den (9) [SMD: -0.24 (-0.51;
0.04)] # caregiver depres-
sive symptoms (11) [SMD:
-0.25 (-0.43; -0.06)] $
knowledge and skills (2)
[SMD: 0.18 (-0.29; 0.65)] !
! caregiver health related
quality of life (2) [SMD:
-0.03 (-0.28;0.21)]
# depression (5) # anxiety
(2) # burden (2) " self-effi-
cacy (1) " intention to seek
help (1) " perceptions of
positive aspects of caregiv-
ing (1) " decision making
confidence (2) $ strain (2)
!! social support
(continued)
210
Table 2 (Continued)
Reviews Intervention description
Information Psychoeducation Communication Psycho-therapeutic Psychosocial support mixed results !
Psychoeducation, psycho-
therapy, and support were
provided through tele-
phone, internet and com-
bined use of telephone
with the Internet
Lucero 2019 Psychosocial interventions, x
educational modules, sup-
port, information, commu-
nication features were
delivered via telephone,
video, and computer-
based interventions
McKechnie 2014 Psychoeducation, profes-
sional therapy and sup-
port, peer support was
provided via internet pro-
gram, computer-telephone
system, and a DVD
program
Powell 2008 Networked technologies x x
such as computer-tele-
phone integration system,
web-based programs,
video conferencing forum
provide information, train-
ing sections, support
Ruggiano 2018 ’Psycho-social support, psy-
choeducation, therapy and
monitoring mental and
physical health were pro-
vided via telephone, web-
based interventions,
video-based conferencing
and networking, video-
phones interventions
Scott 2016 Cognitive-behavioral therapy
delivering via the Internet,
DVD, and video
Waller 2017 Psychoeducation, skill train- x
ings, psychotherapeutic,
and support among peers
and health care professio-
nals were delivered by
computer only, telephone
and combined computer-
telephone systems
SMD: standardized mean difference; WMD: weighted mean difference; g: Hedges’ g
L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
Intervention type
x x
x x
x x
x x
Effectiveness of intervention
# decrease " increase $
! no evidence
(-) number of primary studies
1. Telephone (13) # burden
(5) # stress (3) # depres-
sion (3) " self-efficacy (3)
2. Internet (5) # depression
(2) # anxiety (1) # stress
(1) # bother (1) " quality of
life (2)
3. Telephone and internet
combined delivery (4) #
depression (2) # burden
(2) # anxiety (1) # bother
(1)
x x 1. Telephone-based (6) #
burden (1) # depression
(2)
2. Video-based (4) # depres-
sion (1) # anxiety (1) #
stress (1) " satisfaction (1)
" physical activity (1) "
self-efficacy (1)
3. Computer-based (2) #
stress (1) " decision mak-
ing (1) !! social isolation
(2)
x # anxiety (2) # burden/stress
(9) " self-efficacy (1) $
social support (3) $
depression (7) $ positive
aspects of caring (2)
x # stress (2) " self-efficacy (2)
" decision confidence (4)
$ depression (10) $ bur-
den (7)
x # depression (5) # anxiety
(2) " social support (2) $
self-efficacy $ caregiving
skills
x # depression (4) [SMD: -0.27
(-0.02; -0.52)]
x x 1. Computer-based (10) #
burden (2) # stress (2) #
depression (3) " knowl-
edge (2) " positive aspects
of caregiving (3) " quality
of life (1)
2. Telephone-based (15) "
goal attainment (1) " man-
aging memory and behav-
ior (2) $ burden (4),
depression (6) !! social
support (7) !! self-efficacy
(7) !! health and self-care
outcomes (7)
3. Multi-modal interven-
tions (9) $ burden $
depression
 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
Fig. 3. Number of reviews reported caregiver’s outcomes.
were found when combining the Internet and telephones compared
to using independently.28 Interventions delivered through combined
formats like telephones and the Internet,29 telephones and
videos,26,30,32,34 and Internet with DVD and video37 were beneficial
in reducing depression among caregivers,27,35 with generally small
pooled effect sizes. Compared with solely providing information to
caregivers, a combination of information, training, and support
through telephones and the Internet improved depressive symptoms
among caregivers, but this difference was not significant compared
with usual care or waiting lists.37 Small but statistically significant
pooled effect sizes were reported for the caregiver burden after pro-
viding multicomponent interventions through telephones, online
platforms, and mobile applications.29,30 Five reviews found beneficial
effects in reducing stress after completing a multicomponent inter-
vention through the Internet,32 telephones,27,30,35 or a computer-
telephone system.26,36,38,42
Positive evidence for self-efficacy improvements among care-
givers was found in several reviews.28-30 Only two reviews found
positive improvements in the quality of life of caregivers.28,34 There
was no clear evidence for increased knowledge and/or improved
skills among caregivers after receiving multicomponent interven-
tions through combined technology formats.33,37
Discussion
This review provides a comprehensive summary of which types of
eHealth interventions currently support the informal caregivers of
people with dementia and their efficacies.
Intervention types
Most reviews included more than one intervention type, which
challenges the synthesis of the effectiveness of specific eHealth inter-
ventions. Current systematic reviews did not describe the nature of
interventions but covered a wide range of interventions when inter-
preting results. Among included reviews, only one reviews divided
internet, telephone and combined supports into four sub-categories
including: supportive, psychotherapeutic, psychoeducational, and
multicomponent.28 Another review made a distinction between psy-
cho-educational and psychosocial intervention in the protocol, but
211
they failed to process when interpreting the result because primary
studies were considered terms describing intervention as synonyms
and did not make a clear distinction.25
The lack of a clear and consistent intervention classification across
both primary studies and systematic reviews may contribute to the
inconsistency in the evidence. Disseminating and translating the
research findings as well as facilitating future studies about the effec-
tiveness of different caregiver interventions require a consensus on
transparency and consistency of the intervention classifications.
Using a comprehensive framework for reporting interventions might
yield a consistent intervention classification across the literature. The
main themes of a previous study on classifying caregiver interven-
tions for people with dementia could be referred to as a reporting
framework for future reviews.43 According to that study, authors
should report dementia caregiver interventions following “content of
the intervention, delivery method, source of delivery, standardized
versus tailored content, structure, intensity, and intended
audience”.43
The delivery methods of interventions
There was a tendency of combining various technology formats
and devices to create a platform delivering interventions. The Inter-
net took a substantial role in creating the environment for providing
interventions dementia care.15 The asynchronous delivery formats
which were combined technology were more beneficial than the syn-
chronous delivery format with a single mode of technology in
improving psychosocial outcomes among dementia caregivers.28,35
Some existing evidence supported the better effectiveness and
helpfulness of multicomponent programs to single component
interventions.24,36 Additionally, technology is rapidly changing, mod-
ern technologies are developing and applied to make our lives faster
and easier. The use of low-tech delivery means such as DVDs in some
of the systematic reviews are becoming redundant since these tech-
nologies are not commonly used. Future reviews should be focused
more on modern delivery formats which help up to date the evi-
dence.
Effectiveness of eHealth interventions
Promising evidence for the effects of eHealth interventions among
the informal caregivers was found. The most common reported out-
comes for caregivers were depression, caregiver burden, anxiety,
stress, and self-efficacy. The findings for reducing depression and
anxiety were consistent across the included reviews, whereas those
on effectiveness toward caregiver burden, stress, self-efficacy, and
knowledge or skill improvements were somewhat mixed but gener-
ally positive. The pooled effect sizes of the included meta-analyses
were quite small. Meanwhile, there was relatively little evidence for
the efficacy of eHealth interventions on the quality of life and positive
benefits in coping competence.
Compared with outcomes related to the negative aspects of car-
ing, there was a lower frequency of outcomes reported regarding the
positive aspects of caring. It was interesting that whether caring for
people with dementia require specific knowledge and skills; and
enhancing knowledge and improving caring skills were priorities of
various studies but only 2 reviews included in this overview were
looking to increase knowledge or improve skills of caregivers.33,37
Meanwhile, caregiving-specific outcomes focused on the negative
aspects of caregiver wellbeing such as depression and burden still
receive the most attention in studies of interventions for the demen-
tia caregivers.35 However, the positive aspects of caregiving are also
important, such as self-efficacy, feelings of dependency, satisfaction,
fulfillment, and relationship bonding with family members and infor-
mal caregivers.44 Focusing on the understanding of the impacts of
212 L.K. Bui et al. / Geriatric Nursing 48 (2022) 203!213
positive caregiving aspects may be a crucial research direction. Future
studies should develop interventions promoting outcomes related to
the positive aspects of dementia care and measurements of positive
outcomes. This will preface the paradigm shift from “reducing stress”
to “optimizing positive experience”.44
Limitations
Several limitations of this review should be mentioned. Firstly,
only peer-reviewed, English language articles were included, which
may have increased the likelihood of not identifying relevant studies.
However, we performed searches without the English restriction,
and all non-English studies were screened to ensure that no potential
reviews were excluded. Secondly, significant variability existed in
intervention contents, delivery formats, and outcome measures; low
methodological quality were common issues for the included
reviews. This may restrict the number and validity of conclusions
that could be drawn about the effectiveness of interventions. Finally,
overlap is a critical consideration when conducting a systematic
review of systematic reviews.22 The present review noticed a moder-
ate overlap between the available reviews. Even though different
studies covering similar topics may apply different approaches, the
overlap might still lead to duplicate evidence or different interpreta-
tions of findings among studies. Readers should keep this issue in
mind when considering the current results.
Conclusions
The number of systematic reviews and meta-analyses on eHealth
intervention supporting the informal caregivers of people with
dementia has been increased markedly. eHealth interventions have
been widely implemented and significantly advanced, but no reviews
have focused solely on this intervention type. The present review has
provided evidence for the common components and efficacies of
eHealth interventions for the informal caregivers of people with
dementia. The findings among the reviews indicate that interven-
tions based on communication and information technology can
potentially support dementia caregivers. Due to the limitation of the
low methodological quality of the currently available systematic
reviews, more high-quality evidence is required to develop clear and
robust recommendations for eHealth interventions for the informal
caregivers of people with dementia.
Protocol registration
Registration number CRD42021254334 on the PROSPERO data-
base.
Funding sources
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
Declaration of Interest
The authors declare that there is no conflict of interest
Acknowledgements
The authors thank Myong Ock Jang and Huyn Ju Seo for their valu-
able comments during this review.
Supplementary materials
Supplementary material associated with this article can be found
in the online version at doi:10.1016/j.gerinurse.2022.09.015.
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