Effects and cost-effectiveness of an internet-based intervention for family caregivers of patients with dementiamethods of a personalized exercise program.

  1. Madruga Vicente, Miguel
  2. Guerrero, José Luís González
  3. Domínguez, Paloma Rohlfs
  4. Fuertes, Narcis Gusi
Journal of sport and health research

ISSN: 1989-6239

Year of publication: 2023

Issue Title: Enero-Abril

Volume: 15

Issue: 1

Type: Article

DOI: 10.58727/JSHR.86294 DIALNET GOOGLE SCHOLAR lock_openOpen access editor

More publications in: Journal of sport and health research


Objectives: Internet-based interventions may represent an efficacious supporting alternative for those family caregivers who are often limited to do physical exercise regularly due to lack of time and/or they reside away from conventional facilities, especially those who live in remote rural locations. This study aims to describe comprehensively a new methodology for a randomized controlled trial that will evaluate the efficacy and cost-effectiveness of a personalized Internet-based physical exercise intervention to improve the fitness and health-related quality of life of female family caregivers of relatives with dementia. Methods: The intervention will include three Internet-based 1-hour-long physical exercise sessions per week during 3 months; it will be supervised by a personal trainer, and it will be performed at the caregiver’s home by using online interaction in real-time. Results: The expected outcomes will be: (1) feasibility and adherence to the intervention; (2) positive effects on fitness and health-related quality of life; (3) lower risk of depression; (4) decrease in subjective burden and (5) reduction of other psychological symptoms. Analyses will also include the evaluation of the cost-effectiveness of the intervention. Discussion: This personalized intervention is a support strategy to overcome the constraints that the caregivers usually have to face when it comes to participating in a physical exercise program. This intervention might thus be a feasible and appropriate proposal to alleviate the physical and psychological impacts that arise from their role as primary caregiver, and might be an innovative cost-effective assistance intervention for this population. Conclusion: The present intervention might provide policymakers with potential solutions to promote the implementation of Internet-based care services at regional and national level, lessen caregivers’ demands for face-to-face health-care resources.

Bibliographic References

  • Alanne, S., Roine, R. P., Rasanen, P., Vainiola, T., & Sintonen, H. (2015). Estimating the minimum important change in the 15D scores. Qual Life Res, 24(3), 599-606. doi:10.1007/s11136-014- 0787-4
  • Alonso, J., Prieto, L., & Anto, J. M. (1995). [The Spanish version of the SF-36 Health Survey (the SF-36 health questionnaire): an instrument for measuring clinical results]. Med Clin (Barc), 104(20), 771-776.
  • Alzheimer's Association. (2020). 2020 Alzheimer's disease facts and figures. Alzheimers Dementia. doi:10.1002/alz.12068
  • Alzheimer's Disease International. (2016). World Alzheimer Report 2016. Improving healthcare for people living with dementia: coverage, Quality and costs now and in the future (A. s. D. International Ed.). London: Alzheimer's Disease International.
  • Arthur, P. B., Gitlin, L. N., Kairalla, J. A., & Mann, W. C. (2018). Relationship between the number of behavioral symptoms in dementia and caregiver distress: what is the tipping point? Int Psychogeriatr, 30(8), 1099-1107. doi:10.1017/S104161021700237X
  • Avargues-Navarro, M., Borda-Mas, M., CamposPuente, A., Pérez-San-Gregorio, M., MartínRodríguez, A., & Sánchez-Martín, M. (2020). Caring for Family Members With Alzheimer’s and Burnout Syndrome: Impairment of the Health of Housewives. Frontiers in Psychology, 11(576), 1-14. doi:10.3389/fpsyg.2020.00576
  • Badia, X., Lara, N., & Roset , M. (2004). Quality of life, time commiment and burden perceived by the principal informal caregiver of Alzheimer's patients. Rev. de At. Primaria, 34(4), 170-177. doi:https://doi.org/10.1016/S0212- 6567(04)78904-0
  • Badia, X., Roset, M., Monserrat, S., Herdman, M., & Segura, A. (1999). The Spanish version of EuroQol: description and uses. Med Clin (Barc), 112(Supl 1), 79-85.
  • Bartfay, E., & Bartfay, W. J. (2013). Quality-of-life outcomes among Alzheimer's disease family caregivers following community-based intervention. West J Nurs Res, 35(1), 98-116. doi:10.1177/0193945911400763
  • Bauer, R., Koepke, F., Sterzinger, L., & Spiessl, H. (2012). Burden, rewards, and coping--the ups and downs of caregivers of people with mental illness. J Nerv Ment Dis, 200(11), 928-934. doi:10.1097/NMD.0b013e31827189b1
  • Birkenhäger-Gillesse, E., Kollen, B., Zuidema, S., & Achterberg, W. (2018). The “more at home with dementia” program: a randomized controlled study protocol to determine how caregiver training affects the well-being of patients and caregivers. BMC Geriatr, 18, 252-259. doi:doi: 10.1186/s12877-018-0948- 3
  • Blom, M. M., Bosmans, J. E., Cuijpers, P., Zarit, S. H., & Pot, A. M. (2013). Effectiveness and cost-effectiveness of an internet intervention for family caregivers of people with dementia: design of a randomized controlled trial. BMC Psychiatry, 13, 17. doi:10.1186/1471-244X-13-17
  • Blom, M. M., Zarit, S. H., Groot Zwaaftink, R. B., Cuijpers, P., & Pot, A. M. (2015). Effectiveness of an Internet intervention for family caregivers of people with dementia: results of a randomized controlled trial. PLoS One, 10(2), e0116622. doi:10.1371/journal.pone.0116622
  • Bramboeck, V., Moeller, K., Marksteiner, J., & Kaufmann, L. (2020). Loneliness and Burden Perceived by Family Caregivers of Patients With Alzheimer Disease. Am J Alzheimers Dis Other Demen, 35, 1533317520917788. doi:10.1177/1533317520917788
  • Castro, C., Wilcox, S., O'Sullivan, P., Baumann, K., & King, A. C. (2002). An exercise program for women who are caring for relatives with dementia. Psychosom Med, 64(3), 458-468.
  • Castro, C., Wilcox, S., O’Sullivan, P., Baumann, K., & King, A. (2002). An exercise program for women who are caring for relatives with dementia. Psychosomatic Medicine, 64, 458- 468.
  • CEAFA, & Sanitas, F. (2016). El cuidador en España. Contexto actual y perspectivas de futuro. Propuestas de intervención. Retrieved from Pamplona Barcelona:
  • Chan, W. C., Lautenschlager, N., Dow, B., Ma, S. L., Wong, C. S., & Lam, L. C. (2016). A homebased exercise intervention for caregivers of persons with dementia: study protocol for a randomised controlled trial. Trials, 17(1), 460. doi:10.1186/s13063-016-1582-z
  • Chiao, C. Y., Wu, H. S., & Hsiao, C. Y. (2015). Caregiver burden for informal caregivers of patients with dementia: A systematic review. Int Nurs Rev, 62(3), 340-350. doi:10.1111/inr.12194
  • Cohen, J. (1992). A power primer. Psychol Bull, 112(1), 155-159. doi:10.1037//0033- 2909.112.1.155
  • Collins, L. G., & Swartz, K. (2011). Caregiver care. Am Fam Physician, 83(11), 1309-1317.
  • Cooper, C., Selwood, A., Blanchard, M., & Livingston, G. (2010). Abusive behaviour experienced by family carers from people with dementia: the CARD (caring for relatives with dementia) study. J Neurol Neurosurg Psychiatry, 81(6), 592-596.
  • Covinsky, K., Kahana, E., Chin, M., Palmer, R., Fortinsky, R., & Landefeld, C. (1999). Depressive symptoms and 3-year mortality in older hospitalized medical patients. Ann Intern Med, 130(7), 563-569.
  • Cristancho-Lacroix, V., Kerherve, H., de Rotrou, J., Rouquette, A., Legouverneur, G., & Rigaud, A. S. (2013). Evaluating the efficacy of a web-based program (diapason) for informal caregivers of patients with Alzheimer's disease: protocol for a randomized clinical trial. JMIR Res Protoc, 2(2), e55. doi:10.2196/resprot.2978
  • Csuka, M., & McCarty, D. J. (1985). Simple method for measurement of lower extremity muscle strength. Am J Med, 78(1), 77-81.
  • Cuthbert, C. A., King-Shier, K. M., Ruether, J. D., Tapp, D. M., Wytsma-Fisher, K., Fung, T. S., & Culos-Reed, S. N. (2018). The Effects of Exercise on Physical and Psychological Outcomes in Cancer Caregivers: Results From the RECHARGE Randomized Controlled Trial. Ann Behav Med, 52(8), 645-661. doi:10.1093/abm/kax040
  • Dawood, S. (2016). Caregiver Burden, Quality of Life and Vulnerability Towards Psychopathology in Caregivers of Patients with Dementia/Alzheimer's Disease. J Coll Physicians Surg Pak, 26(11), 892-895. doi:2471
  • Del Rio Lozano, M., Garcia-Calvente, M. D. M., Calle-Romero, J., Machon-Sobrado, M., & Larranaga-Padilla, I. (2017). Health-related quality of life in Spanish informal caregivers: gender differences and support received. Qual Life Res, 26(12), 3227-3238. doi:10.1007/s11136-017-1678-2
  • Delgado, E., Suárez, O., De Dios, R., Valdespino, I., Sousa, Y., & Braña, G. (2014). Características y factores relacionados con sobrecarga en una muestra de cuidadores principales de pacientes ancianos con demencia. SEMERGEN, 40(2), 8.
  • Derogatis, L. R. (1977). SCL-90-R, Administration, Scoring and Procedures Manual I for the Revised Version of the SCL-90. Baltimore: Johns Hopkins University Press.
  • Domingues, N. S., Verreault, P., & Hudon, C. (2018). Reducing Burden for Caregivers of Older Adults With Mild Cognitive Impairment: A Systematic Review. Am J Alzheimers Dis Other Demen, 33(7), 401-414. doi:10.1177/1533317518788151
  • Erol, R., Brooker, D., & Peel, E. (2015). Women and Dementia: a global research review. Project Report. Alzheimer's Disease International (ADI), London
  • Eysenbach, G. (2001). What is e-health? J Med Internet Res, 3(2), E20. doi:10.2196/jmir.3.2.e20
  • Farran, C. J., Etkin, C. D., Eisenstein, A., Paun, O., Rajan, K. B., Sweet, C. M., . . . Evans, D. A. (2016). Effect of Moderate to Vigorous Physical Activity Intervention on Improving Dementia Family Caregiver Physical Function: A Randomized Controlled Trial. J Alzheimers Dis Parkinsonism, 6(4). doi:10.4172/2161-0460.1000253
  • Farran, C. J., Paun, O., Cothran, F., Etkin, C. D., Rajan, K. B., Eisenstein, A., & Navaie, M. (2016). Impact of an Individualized Physical Activity Intervention on Improving Mental Health Outcomes in Family Caregivers of Persons with Dementia: A Randomized Controlled Trial. AIMS Med Sci, 3(1), 15-31. doi:10.3934/medsci.2016.1.15
  • Feast, A., Orrell, M., Russell, I., Charlesworth, G., & Moniz-Cook, E. (2017). The contribution of caregiver psychosocial factors to distress associated with behavioural and psychological symptoms in dementia. Int J Geriatr Psychiatry, 32(1), 76-85. doi:10.1002/gps.4447
  • Fenwick, E., & Byford, S. (2005). A guide to costeffectiveness acceptability curves. Br J Psychiatry, 187, 106-108. doi:10.1192/bjp.187.2.106
  • Flores, N., Jenaro, C., Moro, L., & Tomsa, R. (2014). Salud y calidad de vida de cuidadores familiares y profesionales de personas mayores dependientes: estudio comparativo. European Journalof Investigation in Health, Psychology and Education, 4, 79-88. doi:https://doi.org/10.30552/ejihpe.v4i2.73
  • Franco, C., Sola, M., & Justo, E. (2010). Reducing psychological discomfort and overload in Alzheimer's family caregivers through a mindfulness mediation program. Rev. Esp. Geriatr Gerontol, 45(5), 252-258. doi:10.1016/j.regg.2010.03.006
  • Fredman, L., Bertrand, R., Martire, L., Hochberg, M., & Harris, E. (2006). Leisure-time and overall physical activity in older women caregivers and non-caregivers from the Caregiver-SOF study. Preventive Medicine, 43, 226-229.
  • Fredman, L., Bertrand, R., Martire, L., Hochberg, M., Harris, E. (2006). Leisure-time and overall physical activity in older women caregivers and non-caregivers from the Caregiver-SOF study. Preventive Medicine, 43, 226-229.
  • Garzón-Maldonado, F., Gutiérrez-Bedmar, M., García-Casares, N., Pérez-Errázquin, F., Gallardo-Tur, A., & Martínez-Valle, M. (2016). Calidad de vida relacionada con la salud en cuidadores de pacientes con enfermedad de Alzheimer. Neurologia, 32(8), 508-515. doi:http://dx.doi.org/10.1016/j.nrl.2016.02.02 3
  • Gaugler, J., & Kane, R. (2015). A perfect storm? The future of family caregiving. Family caregiving in the new normal. San Diego: Elsevier.
  • Godwin, K. M., Mills, W. L., Anderson, J. A., & Kunik, M. E. (2013). Technology-driven interventions for caregivers of persons with dementia: a systematic review. Am J Alzheimers Dis Other Demen, 28(3), 216- 222. doi:10.1177/1533317513481091
  • Gonzalez de Rivera, J., Derogatis, L. R., De las Cuevas, C., Gracia, R., Rodríguez-Pulido, F., Henry-Benítez, M., & Monterrey, A. (1989). The Spanish version of the SCL-90-R. Normative data in the general population. Towson, MD, USA.
  • Gusi, N., Prieto, J., Madruga, M., Adsuar, J., González-Guerrero, J., & García Domínguez, J. (2009). Health-related quality of life and fitness differences between family caregivers of patient with dementia and noncaregivers. Medicine & Science in Sport & Exercise, 41(6), 1182-1187. doi:10.1249/MSS.0b013e3181951314
  • Gustaw, K., Beltowska, K., & Makara-Studzinska, M. (2008). [Dementive patients' caregivers-psychological aspect of their needs]. Przegl Lek, 65(6), 304-307.
  • Haines, K. J., Denehy, L., Skinner, E. H., Warrillow, S., & Berney, S. (2015). Psychosocial outcomes in informal caregivers of the critically ill: a systematic review. Crit Care Med, 43(5), 1112-1120. doi:10.1097/CCM.0000000000000865
  • Herdman, M., Badia, X., & Berra, S. (2001). EuroQol-5D: a simple alternative for measuring health-related quality of life in primary care. Aten Primaria, 28, 425-430.
  • Hill, K., Smith, R., Fearn, M., Rydberg, M., & Oliphant, R. (2007). Physical and psychological outcomes of a supported physical activity program for older carers. J Aging Phys Act, 15(3), 257-271.
  • Hirano, A., Suzuki, Y., Kuzuya, M., Onishi, J., Ban, N., & Umegaki, H. (2011). Influence of regular exercise on subjective sense of burden and physical symptoms in community-dwelling caregivers of dementia patients: a randomized controlled trial. Arch Gerontol Geriatr, 53(2), e158-163. doi:10.1016/j.archger.2010.08.004
  • Ho, S. C., Chan, A., Woo, J., Chong, P., & Sham, A. (2009). Impact of caregiving on health and quality of life: a comparative population based study of caregivers for elderly persons and non-caregivers. J Gerontol A Biol Sci Med Sci, 64(8), 873-879. doi:10.1093/gerona/glp034
  • Hopwood, J., Walker, N., McDonagh, L., Rait, G., Walters, K., Iliffe, S., . . . Davies, N. (2018). Internet-Based Interventions Aimed at Supporting Family Caregivers of People With Dementia: Systematic Review. J Med Internet Res, 20(6), e216. doi:10.2196/jmir.9548
  • Hunter, J., & Schmidt, F. (2004). Method of metaanalysis: Correcting error and bias in research findings (2nd ed): Sage.
  • Ito, T., Shirado, O., Suzuki, H., Takahashi, M., Kaneda, K., & Strax, T. E. (1996). Lumbar trunk muscle endurance testing: an inexpensive alternative to a machine for evaluation. Arch Phys Med Rehabil, 77(1), 75-79.
  • Izal, M., & Montorio, I. (1994). Evaluación del medio y del cuidador del demente. In T. Del Ser & J. Peña Casanova (Eds.), Evaluación neuropsicológica y funcional de la demencia (pp. 201-202). Barcelona: Prous Science.
  • Jackson, G., & Browne, D. (2017). Supporting carers of people with dementia: what is effective? BJPsych Advances, 23, 179-189.
  • King, A. C., Baumann, K., O'Sullivan, P., Wilcox, S., & Castro, C. (2002). Effects of moderateintensity exercise on physiological, behavioural and emotional responses to family caregiving: a randomized controlled trial. Journal of Gerontology, 57A(1), 26-36.
  • Lamotte, G., Shah, R. C., Lazarov, O., & Corcos, D. M. (2017). Exercise Training for Persons with Alzheimer's Disease and Caregivers: A Review of Dyadic Exercise Interventions. J Mot Behav, 49(4), 365-377. doi:10.1080/00222895.2016.1241739
  • Lavretsky, H., Epel, E. S., Siddarth, P., Nazarian, N., Cyr, N. S., Khalsa, D. S., . . . Irwin, M. R. (2013). A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity. Int J Geriatr Psychiatry, 28(1), 57-65. doi:10.1002/gps.3790
  • Lee, M., Ryoo, J. H., Crowder, J., Byon, H. D., & Wiiliams, I. C. (2020). A systematic review and meta-analysis on effective interventions for health-related quality of life among caregivers of people with dementia. J Adv Nurs, 76(2), 475-489. doi:10.1111/jan.14262
  • Lee, S., Colditz, G. A., Berkman, L. F., & Kawachi, I. (2003). Caregiving and risk of coronary heart disease in U.S. women: a prospective study. Am J Prev Med, 24(2), 113-119.
  • Loi, S. M., Dow, B., Ames, D., Moore, K., Hill, K., Russell, M., & Lautenschlager, N. (2014). Physical activity in caregivers: What are the psychological benefits? Arch Gerontol Geriatr, 59(2), 204-210. doi:10.1016/j.archger.2014.04.001
  • Lok, N., Lok, S., & Canbaz, M. (2017). The effect of physical activity on depressive symptoms and quality of life among elderly nursing home residents: Randomized controlled trial. Arch Gerontol Geriatr, 70, 92-98. doi:10.1016/j.archger.2017.01.008
  • Lowery, D., Cerga-Pashoja, A., Iliffe, S., ThuneBoyle, I., Griffin, M., Lee, J., . . . Warner, J. (2014). The effect of exercise on behavioural and psychological symptoms of dementia: the EVIDEM-E randomised controlled clinical trial. Int J Geriatr Psychiatry, 29(8), 819-827. doi:10.1002/gps.4062
  • Madruga, M., Gozalo, M., Prieto, J., Adsuar, J. C., & Gusi, N. (2020). Psychological Symptomatology in Informal Caregivers of Persons with Dementia: Influences on Health-Related Quality of Life. Int J Environ Res Public Health, 17(3). doi:10.3390/ijerph17031078
  • Madruga, M., Prieto, J., Rohlfs, P., & Gusi, N. (2020). Cost-Effectiveness and Effects of a Home-Based Exercise Intervention for Female Caregivers of Relatives with Dementia: Study Protocol for a Randomized Controlled Trial. Healthcare (Basel), 8(1). doi:10.3390/healthcare8010054
  • Mahmood, A., Blaizy, V., Verma, A., Stephen Sequeira, J., Saha, D., Ramachandran, S., . . . Solomon, J. M. (2019). Acceptability and Attitude towards a Mobile-Based Home Exercise Program among Stroke Survivors and Caregivers: A Cross-Sectional Study. Int J Telemed Appl, 2019, 5903106. doi:10.1155/2019/5903106
  • Mahoney, F. I., & Barthel, D. W. (1965). Functional Evaluation: The Barthel Index. Md State Med J, 14, 61-65.
  • Manca, A., Hawkins, N., & Sculpher, M. J. (2005). Estimating mean QALYs in trial-based costeffectiveness analysis: the importance of controlling for baseline utility. Health Econ, 14(5), 487-496. doi:10.1002/hec.944
  • Martin-Carrasco, M., Dominguez-Panchon, A. I., Gonzalez-Fraile, E., Munoz-Hermoso, P., Ballesteros, J., & Group, E. (2014). Effectiveness of a psychoeducational intervention group program in the reduction of the burden experienced by caregivers of patients with dementia: the EDUCA-II randomized trial. Alzheimer Dis Assoc Disord, 28(1), 79-87. doi:10.1097/WAD.0000000000000003
  • Martin, M., Salvado, I., Nadal, S., Miji, L., Rico, J., Lanz, P., & Taussing, M. (1996). Adaptation to our mean of caregiver burden scale of Zarit. Revista de Gerontología, 6(4), 338- 345.
  • Marziali, E., & Garcia, L. J. (2011). Dementia caregivers' responses to 2 Internet-based intervention programs. Am J Alzheimers Dis Other Demen, 26(1), 36-43. doi:10.1177/1533317510387586
  • Mollinedo, I., Lopez, A., & Cancela-Carral, J. M. (2019). The effects of different types of physical exercise on physical and cognitive function in frail institutionalized older adults with mild to moderate cognitive impairment. A randomized controlled trial. Arch Gerontol Geriatr, 83, 223-230. doi:10.1016/j.archger.2019.05.003
  • Nickel, F., Barth, J., & Kolominsky-Rabas, P. L. (2018). Health economic evaluations of nonpharmacological interventions for persons with dementia and their informal caregivers: a systematic review. BMC Geriatr, 18(1), 69. doi:10.1186/s12877-018-0751-1
  • Oja, P., & Tuxworth, B. (1995). Eurofit for Adults, Assessment of HealthRelated Fitness. Tampere Finland: UKK Institute for Health Promotion Research. p. 2.
  • Orgeta, V., & Miranda-Castillo, C. (2014). Does physical activity reduce burden in carers of people with dementia? A literature review. Int J Geriatr Psychiatry, 29(8), 771-783.
  • Pagan-Ortiz, M. E., Cortes, D. E., Rudloff, N., Weitzman, P., & Levkoff, S. (2014). Use of an online community to provide support to caregivers of people with dementia. J Gerontol Soc Work, 57(6-7), 694-709. doi:10.1080/01634372.2014.901998
  • Parra-Vidales, E., Soto-Perez, F., Perea-Bartolome, M. V., Franco-Martin, M. A., & MunozSanchez, J. L. (2017). Online interventions for caregivers of people with dementia: a systematic review. Actas Esp Psiquiatr, 45(3), 116-126.
  • Parra-Vidales, E., Soto-Pérez, F., Perez-Bartolomé, M. V., Franco-Martín, M. A., & MuñozSánchez, J. L. (2017). Intervenciones online para cuidadores de personas con demencia: revisión sistemática. Actas Españolas de Psiquiatría, 45(3), 116-126.
  • Pérez-Fuentes, M., Gázquez, J., Ruiz, M., & Molero, M. (2017). Inventory of overburden in Alzheimer's patient family caregiver with no specialized training. International Journal of Clinical and Health Psychology, 17, 56-64. doi:https://doi.org/10.1016/j.ijchp.2016.09.00 4
  • Pinquart, M., & Sorensen, S. (2003). Differences between caregivers and noncaregivers in psychological health and physical health: a meta-analysis. Psychol Aging, 18(2), 250- 267. doi:10.1037/0882-7974.18.2.250
  • Ploeg, J., Markle-Reid, M., Valaitis, R., McAiney, C., Duggleby, W., Bartholomew, A., & Sherifali, D. (2017). Web-Based Interventions to Improve Mental Health, General Caregiving Outcomes, and General Health for Informal Caregivers of Adults With Chronic Conditions Living in the Community: Rapid Evidence Review. J Med Internet Res, 19(7), e263. doi:10.2196/jmir.7564
  • Pot, A. M., Blom, M. M., & Willemse, B. M. (2015). Acceptability of a guided self-help Internet intervention for family caregivers: mastery over dementia. Int Psychogeriatr, 27(8), 1343-1354. doi:10.1017/S1041610215000034
  • Prince, M., Wimo, A., Guerchet, M., Ali, G., Y., W., & Prina, M. (2015). The Global Impact of Dementia. An analysis of prevalence, incidence, cost and trends. Retrieved from London: https://www.alzint.org/u/WorldAlzheimerReport2015.pdf
  • Rodriguez, F., ., Valenzuela, A., Gusi, N., Nacher, S., & Gallardo, I. (1998). Evaluation of the health-related fitness in adults (II): reliability, feasibility and reference norms by means of the AFISAL-INEFC. Apunts Educación Física y Deportes., 54, 54-65.
  • Sacristan, J., Oliva, J., Del Llano, J., Prieto, L., & Pinto, J. (2002). What is an efficient health technology in Spain? Gac Sanit, 16:, 334- 343.
  • Salazar, A., Murcia, L., & Solano , J. (2016). Evaluación e intervención de la sobrecarga del cuidador informal de adultos mayores dependientes: Revisión de artículos publicados entre 1997 – 2014. Archivos de Medicina, 16(1), 144-154.
  • Sevick, M. A., Dunn, A. L., Morrow, M. S., Marcus, B. H., Chen, G. J., & Blair, S. N. (2000). Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults: results of project ACTIVE. Am J Prev Med, 19(1), 1-8.
  • Sherifali, D., Ali, M. U., Ploeg, J., Markle-Reid, M., Valaitis, R., Bartholomew, A., . . . McAiney, C. (2018). Impact of Internet-Based Interventions on Caregiver Mental Health: Systematic Review and Meta-Analysis. J Med Internet Res, 20(7), e10668. doi:10.2196/10668
  • Shua-Haim, J. R., Haim, T., Shi, Y., Kuo, Y. H., & Smith, J. M. (2001). Depression among Alzheimer's caregivers: identifying risk factors. Am J Alzheimers Dis Other Demen, 16(6), 353-359.
  • Sintonen, H. (2001). The 15D instrument of healthrelated quality of life: properties and applications. Ann Med, 33(5), 328-336. doi:10.3109/07853890109002086
  • Sorensen, S., Pinquart, M., & Duberstein, P. (2002). How effective are interventions with caregivers? An updated meta-analysis. Gerontologist, 42(3), 356-372.
  • Stjernsward, S., & Hansson, L. (2018). Effectiveness and usability of a web-based mindfulness intervention for caregivers of people with mental or somatic illness. A randomized controlled trial. Internet Interv, 12, 46-56. doi:10.1016/j.invent.2018.03.004
  • Torrance, G. W. (1997). Preferences for health outcomes and cost-utility analysis. Am J Manag Care, 3 Suppl, S8-20.
  • Vademecum. Vademecum. Retrieved from http://www.vademecum.es
  • Vandepitte, S., Van Den Noortgate, N., Putman, K., Verhaeghe, S., Faes, K., & Annemans, L. (2016). Effectiveness of Supporting Informal Caregivers of People with Dementia: A Systematic Review of Randomized and NonRandomized Controlled Trials. J Alzheimers Dis, 52(3), 929-965. doi:10.3233/JAD151011
  • Villagut, G., Ferrer, M., Rajmil, L., Rebollo, P., Permanyer-Miralda, G., Quinta, J., . . . Alonso, J. (2005). El Cuestionario de Salud SF-36 español: una década de experiencia y nuevos desarrollos. Gac Sanit, 19(2), 135- 150.
  • Waelde, L. C., Thompson, L., & GallagherThompson, D. (2004). A pilot study of a yoga and meditation intervention for dementia caregiver stress. J Clin Psychol, 60(6), 677-687. doi:10.1002/jclp.10259
  • Wells, K., ., & Dillon, E. (1952). The sit and reach a test of back and leg flexibility. Res Quart, 23, 115-118.
  • Willan, A. R. (2001). On the probability of costeffectiveness using data from randomized clinical trials. BMC Med Res Methodol, 1, 8.
  • World Health Organization. (2019). Dementia. Key facts. Retrieved from https://www.who.int/news-room/factsheets/detail/dementia
  • Yesavage, J., Brink, T., Rose TL., & Lum, O. (1983). Development and validation of a geriatric depression scale: a preliminary report. Journal of Psychiatry Research, 17(1), 37- 49.
  • Zarit, S., Reever, K., & Bach-Peterson, J. (1980). Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist, 20(6), 649-655. doi:10.1093/geront/20.6.649
  • Zhao, Y., Feng, H., Hu, M., Hu, H., Li, H., Ning, H., . . . Peng, L. (2019). Web-Based Interventions to Improve Mental Health in Home Caregivers of People With Dementia: Meta-Analysis. J Med Internet Res, 21(5), e13415. doi:10.2196/13415
  • Zijlstra, T. R., Braakman-Jansen, L. M., Taal, E., Rasker, J. J., & van de Laar, M. A. (2007). Cost-effectiveness of Spa treatment for fibromyalgia: general health improvement is not for free. Rheumatology (Oxford), 46(9), 1454-1459. doi:10.1093/rheumatology/kem157