Mentalising imagery therapy for family dementia caregivers: protocol for a scoping review

Introduction

Dementia is a chronic or progressive impairment of cognitive function caused by a variety of brain diseases that can affect memory, thinking, orientation, calculation, language and judgement.1 2 This disease is becoming a more widespread public health concern.3 There is an increasing number of people suffering from dementia as the population ageing.4 There are approximately 10 million new cases of dementia each year in the world, and that number is expected to rise to 132 million by 2050.5 6 Despite being thought of as an old-age disease, a little part of dementia diagnoses are given before the age of 65 and are called as ‘young onset dementia’, which accounts for about 5% of all dementias.7–9 As of now, there are no effective treatment options that can cure or alter the course of dementia, and patients will become completely dependent on others to care for them as the disease progresses in order to maintain basic daily living.

Families usually have the primary responsibility for providing informal caregiving to individuals with dementia. Informal caregiving for patients with dementia largely falls on family members such as parents, spouses, children and other relatives.4 In managing the daily care and needs of their loved ones with dementia, family caregivers play a crucial role. They often provide a range of activities, from assistance with daily living tasks, to managing medications and providing emotional support.10 In the USA, 83% of the assistance provided to older adults with dementia is provided by informal caregivers.11

Providing care for people with dementia is a long journey. Numerous family members continue to provide informal care even though they are often carrying significant physical, socioeconomic and psychological burdens.12 Informal caregivers of patients with dementia are more likely to suffer from a wide range of adverse health complications than other family caregivers.11 13 There is a lack of professional knowledge and care-related training among family caregivers.14 The stress of long-term care, combined with the increasing demand for care, gradually increases caregiver burden, anxiety or depression and lowers caregiver quality of life.15–17 According to statistics, the incidence of depression and anxiety was 34% and 44%, respectively, among family caregivers of patients with dementia, with depression being four times higher than that of family caregivers of other cognitively intact patients.18 However, the increasing burden of caregiving, as well as the psychological symptoms, can have an impact on patient health outcomes, so there is an urgent need to focus on caregivers’ physical and mental health and provide effective interventions.18 19

Over the past few decades, researchers have explored a variety of intervention options for caregivers of patients with dementia. These interventions mainly include education, cognitive–behavioural therapy, music therapy, peer support, mindfulness and multicomponent intervention.20 21 Despite the fact that existing intervention programmes are effective in reducing caregivers’ negative emotions and improving their own coping skills,22 informal caregivers of patients with dementia who are heavily involved in caregiving or have work commitments may not be able to fully participate in certain behaviour programmes that require in-person delivery, or higher economic cost.21 23 More research is needed to develop effective, simple and convenient psychological support programmes for dementia caregivers.

A new intervention programme called mentalising imagery therapy (MIT) has emerged as an effective solution for dementia caregivers. MIT combines guided imagery and mindfulness practices, which focuses on the participant’s connection to the external world in order to reduce emotional arousal, promote mindfulness skills and reduce symptoms of depression and anxiety.24 MIT is a new intervention developed by Jain and Fonagy24 and is currently used primarily among caregivers of patients with dementia. The therapy is relatively straightforward, with a 4-week intervention period that includes weekly positive thinking exercises such as low-intensity stretching and breath-focused meditation, as well as specific guided imagery exercises. MIT is currently being tested in different dementia caregiver populations in the form of application (APP)-based and group-based interventions.25–27 The study’s findings indicate that MIT has positive intervention effects on negative psychological emotions, caregiver burden and caregiver self-care ability.26 28 29

Currently, psychotherapeutic approaches that focus on mentalisation are a hot topic of research. MIT and mentalisation-based therapy are both based on mentalisation, but they differ in their application and focus. Mentalisation-based therapy is a broader approach to psychotherapy that focuses not only on an individual’s understanding of another’s state of mind but also on how they can apply that understanding to their own lives, which aims to help patients increase their ability to mentalise in order to better deal with their emotions, build healthy relationships and improve their mental health.30 Mentalisation-based therapy is commonly used to treat borderline personality disorder and self-harm, among other mental health issues.31 Mentalisation-based therapy typically involves discussion with a therapist to explore mentalising, whereas MIT emphasises guided imagery practices to enhance self-understanding and other-understanding, focusing on ecological connection, interconnectedness with the world, and mindfulness training.24

MIT has become a well-established psychological support intervention programme for caregivers with dementia over the last few years. However, research related to MIT is still limited, there has been no scoping review, and more information on the specific dose, type and evaluation of the intervention is required. To further improve and develop MIT, knowledge and experience from previous studies must be gathered. Concurrently, understanding the outcomes assessed in the existing literature will help healthcare providers understand the applicability of MIT. As a result, the purpose of this scoping review is to map and assess the nature, characteristics and outcomes of MIT-related studies.

Methodology

A protocol for the scoping review currently underway is outlined, along with the steps involved. As part of the scoping review process, we will follow the guidelines set by the Joanna Briggs Institute,32 Arksey and O’Malley’s methodological framework,33 as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension (PRISMA-ScR)34 to ensure that the work is rigorous and replicable. Open Science Framework has registered the protocol for the study, which will begin in January 2024 and end in April 2024.

Patient and public involvement

Neither patients nor the general public will be involved in the design of the protocol for this systematic review of literature.

Stage 1: identifying the research question

The review questions are as follows:

  1. What are the characteristics of the MIT for family caregivers of patients with dementia?

  2. What are the outcome measures used to evaluate the MIT?

  3. What are the implications of MIT for practice and future research?

Stage 2: identifying relevant studies

A literature search will be conducted in PubMed, Web of Science, Embase, Scopus, CINAHL and PsycINFO. Google Scholar will be used to search for grey literature. Each relevant database and information source was targeted with keywords and index terms according to our search methodology. To uncover additional research relevant to our analysis, we will also manually search the references cited in the included studies.

The research team will determine appropriate search terms. A search strategy will be developed with the help of experienced research librarians. The search terms will be comprehensively searched using the words mentalising imagery therapy, dementia and family caregiver as key terms. The PubMed search technique is used as an example (online supplemental appendix 1). Only English studies that were published after January 1, 2015 will be considered, as MIT is an emerging field of research, it has only gradually started to be applied in the clinic since 2015.

Supplemental material

Stage 3: study selection

In the selection process, literature will be maintained using Covidence, and duplicates will be removed prior to screening. Two researchers will independently conduct the literature selection according to the inclusion criteria, and any disagreement will be discussed with a third researcher.

A PICO (participants, intervention, comparison, outcomes) framework will be used to establish eligibility criteria for the studies. The following inclusion criteria will apply: primary studies on interventions for family caregivers aged 18 or older caring for patients with dementia, regardless of geographical location or intervention context (including online studies), and any study design or relevant systematic reviews. Exclusion criteria include studies that are not in English, conference abstracts, and articles for which we cannot obtain the full text.

To strengthen the review’s robustness, two reviewers will independently review the titles and abstracts of all identified studies, with potentially relevant ones being further evaluated by obtaining full texts. Only those studies that meet the eligibility criteria determined by both reviewers will be included in the final report. Any studies that do not meet the inclusion criteria will be removed from the review, and the reason for their removal will be clearly stated in the final full text. The final list of included studies will be confirmed by two reviewers. A PRISMA-ScR flow diagram (figure 1) will be provided during the study selection process.

Figure 1
Figure 1

Flow diagram of the study selection process based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines.

Stage 4: charting the data

In this scoping review, relevant data will be extracted from all studies by two independent reviewers. Reviewers will use preformatted forms to collect data, and the information will be recorded in Microsoft Excel. The information collected will include details such as the author, publication year, title, study type, country, research objectives, participant numbers, publish year, contents of MIT, intervention duration, delivery method and outcome measurements. The preliminary data extraction tool will undergo pilot testing and necessary modifications as data are being extracted from each study. Discrepancies between reviewers will be resolved through discussion or with the involvement of a third reviewer. In cases where data are missing or incomplete, we will contact the study authors.

Stage 5: collating, summarising and reporting the results

The extracted data will be presented in a structured tabular format, especially contents of MIT, intervention duration, delivery method and outcome measurements. A narrative synthesis will be used to summarise the research findings regarding the identified gaps and MIT interventions. These results will be evaluated in the context of the aim of the scoping review. As MIT is not currently applied to other populations, only studies of dementia caregiver-related MIT will be included in the final findings. Due to the fact that scoping reviews are aimed at mapping the basic principles that underlie a research area, the analysis will offer an overview rather than a formal assessment of individual study quality.

Step 6: stakeholder consultation

A stakeholder consultation will be conducted to validate the preliminary findings of this scoping review and identify potential knowledge gaps for future research. A total of 10–15 stakeholders will be involved, including clinicians, nurses, social workers, informal caregivers and methodological experts. The consultation process will be guided by the Delphi expert consultation method, which contains importance, feasibility and clinical gaps of the research findings. Using their perspectives and recommendations, we will ensure that the final manuscript contains comprehensive and insightful information.

Discussion

This study aims to investigate the adoption of MIT strategies among family caregivers of dementia patients and assess their current status and effectiveness. We hope to provide healthcare practitioners with valuable insights and recommendations for the effective integration of MIT interventions into clinical practice. This scoping review will help elucidate the status and outcomes of MIT interventions in dementia caregiving, adding a vital understanding of clinical practices and research gaps in the field. The consultation will enable us to clarify the meaning of MIT and the significance of its application more clearly and to better express and present its connotations. By using their views and suggestions, we will ensure that the final manuscript contains comprehensive and insightful information. However, no review of MIT studies has been found, and our study cannot be compared with other findings.

This study has some expected limitations. First, there may be some bias in the search results, with only English-language literature being included. We will choose the main commonly used databases for the search to avoid missing possible literature. Second, this study will not evaluate the quality of the included literature. The scoping review only summarises the current status of literature and describes the existing gaps, and quality evaluation may not be required.

To conclude, this scoping review will summarise an overview of current developments at MIT, especially contents of MIT, intervention duration, delivery method and outcome measurements. The findings of this study will provide valuable insights into the status and outcomes of MIT, identify gaps in existing research and provide recommendations for a more effective clinical practice.

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