Personal Blog # 33 … Concerns About AD? Be Sure to See the Right Doctor! ... 10/10/23

 

Personal Blog # 33 … Concerns About AD?  Be Sure to See the Right Doctor!

A friend of mine recently told me about the problems she went through trying to obtain an accurate diagnosis for the causes of increasingly worsening gastrointestinal issues her daughter was facing.  Despite being seen and treated by her primary care doctor, an internist, a gastroenterologist, and numerous MDs in hospital ERs, her issues continued to worsen.  Why?  It turned out that for many years she was repeatedly misdiagnosed and given medications that were not helpful.  Conditions such as anemia, appendicitis, nervous stomach, stress, hemorrhoids, and ulcerative colitis are just some of the misdiagnoses given to people who actually have Crohn’s.

At a certain point, my friend’s daughter was seen by a gastroenterologist with experience diagnosing and treating patients with Crohn’s disease.  Once properly diagnosed and treated for Crohn’s disease, there was immediate improvement in her condition and ability to function more normally.

According to the Mayo Clinic website, “Crohn's disease is a type of inflammatory bowel disease (IBD). It causes swelling of the tissues (inflammation) in your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition.  Inflammation caused by Crohn's disease can involve different areas of the digestive tract in different people, most commonly the small intestine. This inflammation often spreads into the deeper layers of the bowel.  Crohn's disease can be both painful and debilitating, and sometimes may lead to life-threatening complications. There's no known cure for Crohn's disease, but therapies can greatly reduce its signs and symptoms and even bring about long-term remission and healing of inflammation. With treatment, many people with Crohn's disease are able to function well.  (https://www.mayoclinic.org/diseases-conditions/crohns-disease/symptoms-causes/syc-20353304)

Doctors misdiagnosing various diseases is nothing new, and my friend’s daughter was fortunate to finally be with a doctor who correctly diagnosed and treated her condition.  However, there are steps one can take to help minimize chances of misdiagnoses.  By reading about some of the mistakes I made with my wife, some readers may be able to avoid similar mistakes with their loved ones when there are concerns about AD.

Readers of my articles and blog columns already know that my wife, who died in 2016 due to AD, had been misdiagnosed for several years.  When I first began to notice behavioral changes in my wife and grew increasingly concerned that those changes might be signs of AD, we discussed these changes with our primary care doctor.  That doctor administered an MMSE … Mini-Mental State Evaluation … a very common test used by doctors to screen for possible AD.  My wife aced the test with a perfect score.  Unfortunately, I didn’t know that the MMSE was never intended to be used to screen for possible AD because, among other reasons, it does not test higher order thinking skills.  Our doctor gave my wife a prescription to reduce stress and anxiety.

My mistake was thinking that all was well based upon that MMSE score.  Even though our family physician said he was not an expert in AD, he could not detect any problems that, in his opinion, would warrant any additional testing. 

Months later, and observing new and worsening behaviors that I now thought could possibly be signs of AD, we met with the most highly respected neurologist in my geographic area, chair of the neurology department at a large and well-respected hospital.  I was also quickly educating myself about AD by visiting various internet sites such as those of the NIH, Mayo Clinic, Johns Hopkins, and the Alzheimer’s Association.

I was maintaining weekly logs noting new or worsening behaviors that I felt were clear signs of Mild Cognitive Impairment (MCI), if not early signs of Alzheimer’s disease (AD).  During the next 12-18 months, at every visit with every doctor I shared my latest logs, but doctors dismissed my logs without comment … often not even bothering to take time to skim or read what I had written.  The neurologist treating my wife for stress, for anxiety, and depression then also had her meet weekly with a clinical psychologist. 

My mistake was thinking that any neurologist or clinical psychologist would be easily able to diagnose AD.  My wife’s neurologist, a specialist in other brain disorders, was not an expert in AD.  My wife’s psychologist was a specialist in treating anxiety disorders, not AD.  Signs of AD that were obvious to me were misinterpreted by them and her diagnosis remained stress, then anxiety, and then depression … not AD.  I shared what the neurologist and clinical psychologist were saying about my wife with our primary care doctor, telling him that what I was observing seemed to clearly indicate early stages of AD.  Our doctor said that, based upon the behaviors I was observing, it was possible that my wife was in early stages of AD … but he deferred to the opinion of the neurologist who had much more experience with brain issues.

My mistake was not being strong enough to challenge my wife who continued to resist going for a second opinion.  We “fought” over it, but invariably she’d adamantly argue that she didn’t need to see another doctor and I couldn’t force her to do so.  I backed down each time, but I should never have backed down.  My wife said that since our family doctor, the neurologist, and the clinical psychologist all agreed that her problems were due to stress, anxiety, and/or depression … not MCI  and certainly not AD … there was no need to get another opinion. 

I was only able to bring my wife for a second opinion after I decided to confront the psychologist in my wife’s presence after a particular session.  I asked if his wife was being treated for stress, anxiety, and/or depression … and if his wife not only was not improving but was actually getting worse … would he take his wife for a second opinion?  When he said, red-faced, that yes, he would do so, I turned to my wife and asked, “Now will you let me take you for a second opinion?”

I was not going to repeat my mistakes of the past.  I had already gathered information on three doctors whose entire practices were focused on diagnosing and treating people with AD.  Two were geriatric psychiatrists affiliated with an Alzheimer’s Disease Research Center (ADRC) and one was a neurologist at another major hospital.  I showed the information on all three doctors to my wife and she chose one of the two geriatric psychiatrists.  We made an appointment and when the doctor learned that I had been keeping weekly logs of her behaviors, he asked me to email copies of those logs prior to our visit.  We then had several email exchanges about those behaviors, and even before our first visit I felt that we were now finally seeing the right doctor! 

My wife’s initial 3+ hour evaluation included the MMSE but also many, many more tests. After just thirty minutes spent evaluating my wife, the geriatric psychiatrist said that my wife was definitely not suffering from stress, anxiety or depression.  He wanted her taken off all of those medications, saying that ”something is going on in her brain’s frontal lobe.”  One month after all of her testing was completed … extensive cognitive testing, blood work, brain scans, physical exams, etc. … I received a call from the ADRC that, after a team meeting discussing all of her test results, my wife was diagnosed with probable early onset AD.

What is my advice to people with concerns about possible signs of AD in their loved ones?  Don’t visit just any doctor.  See  only a doctor experienced in diagnosing and treating people with AD.  Not all brain doctors … not even specialists such as neurologists and geriatric psychiatrists … have enough experience with AD to diagnose it properly.  Make sure you see a doctor who can do this.

And one more thing, something that is very sad to note.  Not all ADRCs will even take the time to make an initial diagnosis for people with concerns about possible AD symptoms!  I only recently learned about a friend who felt that he may be experiencing early signs of AD.  He made an appointment to see a specialist at his local ADRC, but they refused to see him once they learned that he did not yet have “sufficient” testing by other doctors first … brain scans, blood work, etc.

I emailed the following question to the person in charge of ADRCs at the National Institutes of Health: “Can my friend simply go to an ADRC for a complete evaluation, or must he first undergo imaging and blood work and other tests by his internist or neurologist.  So far he is acing the MMSE given to him by his internist but yet he recognizes he is still having cognitive problems.  Can he just get a consult at his local ADRC?  Following is the response I received:

“Thank you for contacting the federal government’s National Institute on Aging (NIA), part of the National Institutes of Health (NIH) at the U.S. Department of Health and Human Services. NIA was established to improve the health and well-being of older adults through research. The institute conducts and supports basic, clinical, and social and behavioral research on aging and the special problems and needs of older adults and is the lead federal agency for Alzheimer’s disease and related dementias research.   We appreciate your interest in the services provided by the Alzheimer’s Disease Research Centers.  While NIA provides funding to these Centers, we are not involved in their daily operations. Therefore, you will need to contact each Center you are interested in to inquire about their protocols for diagnosis and testing.”

That response is very unfortunate.  An ADRC has precisely those experts who should be available to meet with people who have the earliest AD concerns.  Months of delay before seeing such experts will undoubtedly lead to increased mental anguish.  In addition, the need to undergo additional expensive testing is a critical issue if one does not have outstanding health insurance.  Conducting initial AD diagnoses are too important … they should be included in all ADRC mission statements and protocols for diagnosis and testing.

One more thing.  If you do go to a doctor who administers the MMSE and makes a decision solely based upon those test results, please go to another doctor … asap!  There are many evaluative instruments better than the MMSE to help in diagnosing MCI or AD.  No doctor should still be using the MMSE, a test created in 1975, as a sole test to diagnose probable AD.  A score of 24 or less on the MMSE is considered indicative of possible cognitive impairment.  As I noted, my wife continually got a score of 30 in her earliest years of undiagnosed AD.  But even two years after being diagnosed with AD at the ADRC, my wife was still scoring 25 or higher on the MMSE!  Enough said.

Personal Blog #32 … New AD Medication, Leqembi (Lecanemab), Receives FDA Approval and Coverage Under Medicare … 7/6/23

 

The U.S. Food and Drug administration (FDA) gave full approval today for Japanese drugmaker Eisai, and its American partner, Biogen, to market its latest medication, lecanemab (to be known as Leqembi) for those with mild Alzheimer’s disease (AD).  According to Teresa Buracchio, acting director of the Office of Neuroscience in the FDA's Center for Drug Evaluation and Research, “Today's action is the first verification that a drug targeting the underlying disease process of Alzheimer's disease has shown clinical benefit in this devastating disease." 

Six months ago the FDA gave conditional approval for this new medication, but there was much debate in the medical community about the effectiveness demonstrated by its data.  Medicare said it would not pay for routine use of Leqembi until the FDA gave its full approval.  Today the FDA has given its full approval.  The FDA acknowledged that after an 18-month clinical trial with 1800 participants, results showed that those taking the new medication showed a significant difference on an 18-point scale measuring cognitive functioning and memory.  According to FDA, this study showed that Leqembi “slowed memory and cognitive decline by about 5 months for those receiving the medication as opposed to those receiving the placebo.”

A doctor quoted this afternoon in a USA Today article said, “This drug is not a cure. It doesn't stop people from getting worse, but it does measurably slow the progression of the disease. That might mean someone could have an extra six months to a year of being able to drive."  A doctor quoted this afternoon in The New York Times stated, “The risks are very vivid.  Within the first few months, you may have small bleeds or swelling in your brain, which may or may not be symptomatic and if not detected in time can cause disability.”

The FDA indicated that Leqembi will carry a” black-box warning” about possible side effects such as brain swelling and bleeding. The warning does not mention patients who are taking blood thinners, but Leqembi’s label says that “additional caution should be exercised” when considering whether to give blood thinners to Leqembi patients.  As also noted in The New York Times article, “Concerns about safety have been stoked by reports of deaths of three clinical trial participants who experienced brain swelling and brain bleeding, two of whom were being treated with blood thinners. Eisai has said it is unclear if Leqembi contributed to their deaths because the patients had complex medical issues.“

 

In my Personal Blog #28, I noted that ”17% of the patients taking this medication suffered cerebral micro and macro hemorrhages and superficial siderosis compared to 8.7% in the placebo group.”  I also shared my feelings in PB #28 about medications yielding “statistical differences,” noting that although statistically significant those differences might not result in “real world” differences.

This new IV medication is priced at about $26,500 for a year’s supply of injections that are to be given every 2 weeks and Medicare will now cover about 80% of its costs.  This still leaves patients with 20% of the cost, plus other related expenses for doctor visits, required scans, etc.  Personally, I’d prefer that Medicare spend its money more wisely than subsidizing patients taking this new medication.  And I think patients can better spend their money on support groups, saving for the future when home health aides or assisted living or nursing home facilities may be needed, or for other present expenses or future costs.

So what is my take on this FDA approval of Leqembi?  Whereas I am truly pleased that we now have a medication that has shown it may be able to slow cognitive decline and memory loss by up to 5 months in an 18-month period of real time, I don’t think my late wife would have considered taking such a medication.  Why?  Three reasons:

First, getting IV injections every 2 weeks for a year would have been a very stressful experience.  Just getting ready to go and driving to and from the doctor’s office to receive IV injections twice a month would have been stressful.  In addition, my wife always felt pain with injections, bled easily, and her skin turned all pretty colors whenever receiving a needle for any reason … possibly due to all the heavy-duty heart medications she took each day, including 325 mg of daily aspirin.  Even had my wife  started this medication, I don’t think she would have continued for too long. Those IV needles would have been painful as well as stressful.

A second reason is the side effects.  AD is serious enough as it is, a death sentence with no cure and the 100% certitude of worsening conditions.  Gaining a few additional months of time to continue leading a more “normal” life before cognitive and memory issues worsen even more would be wonderful … but what a heavy price if those side effects occurred.  Dealing with AD and heart disease was enough of a double whammy for my wife.  Possibly compounding that with brain swelling, bleeding, headaches, etc. due to this medication could have made her situation even worse than it already was

The final reason is the real world “effectiveness” of this new medication.  Study participants taking the medication showed a gain of less than one half of one point on testing … a statistically significant outcome, perhaps, but I question how much of a clinical difference that difference would have really made in my wife’s life or in mine.  As that doctor quoted in The New York Times noted with respect to the slowing of decline with Leqembi, “The benefits of slowing are subtle. You’re not going to experience the perception of changes in your cognition or function in the same amount of time.”  As I noted in PB #28, not all studies demonstrating results showing “statistical differences” in testing translate into meaningful and/or observable differences in the real world.

By the time my wife was in early stages of AD, our lives had already changed dramatically.  A few more months of slower decline would have been welcome, but would probably not have changed much about our daily lives.  Especially when one considers that the trade-off to perhaps gaining a few months of slower decline might have led to losing the quality of life we still had.  Slowing decline doesn’t mean ending it and we may not have even noticed that slowing.  The added stress of two more doctor visits each month, the pain and after-effects of IV needles, and possible additional pain or hospitalization due to severe side effects of this new medication could have easily lessened whatever quality of life we still had.

So what is my bottom line reaction to this FDA approval of Leqembi?  It is this:  Would I have loved my wife to have declined at a slower rate for a few more months in those early stages?  Of course.  Would I have loved to have taken more trips with her? Absolutely.  But worrying about the possibility of her having a serious brain hemorrhage or other serious side-effect while traveling away from home would have worried me too much to have taken that chance. In fact, I would have been worried every single day, whether at home or not, had she been taking this new medication.

I haven’t even mentioned another real word effect of this new medication … the demands place upon the care partner of having to bring the AD patient to and from doctor appointments.  Even in early stages, AD patients may need assistance in dressing, mobility, may object to going out in bad weather or going out at a certain time of day, etc.   In addition, many care partners of AD patients are still working when their loved ones are in early stages, and time demands of taking loved ones to two visits each month for IV injections could be an additional burden for them as well.

So whereas I am truly pleased to welcome a new medication to try to help those with AD, I would not have found Leqembi worth the risk. 

Personal Blog #31 … Donanemab, a Proposed New AD Medication … 5/8/23

 

I debated whether or not to even write this blog offering my opinion about donanemab.  Last week there was yet another big pharma announcement of clinical trial data for a new medication as an effective treatment for those in early stages of Alzheimer’s disease (AD) … donanemab.  No one wants more than I do to learn about new effective treatments for those in any stage of AD.  However, I have been disappointed too many times by big pharma companies releasing announcements of positive clinical trial results without simultaneous disclosure of all supporting data and peer review commentary.  Early announcements of rosy results have too often overplayed the positive effects of new medications and too often downplayed serious negative side effects.  I fear that donanemab is just the latest AD medication that a big pharma company has touted as having promising results that are “statistically” significant but not really “clinically” significant, and with extremely dangerous side effects.  (Please see PB # 28, posted on 10/4/22, about my serious doubts about the “significant” published results and dangerous negative side effects of lecanemab (now sold under the brand name, Leqembi), last year’s new AD medication from Eisai and Biogen.  In that blog I also discuss how statistically significant differences in AD testing for new meds may be totally insignificant and meaningless with respect to functioning in the real world.)

According to an article published in Nature on May 4, “For the second time, an experimental drug has been shown to reduce the cognitive decline associated with Alzheimer’s disease. On May 3, pharmaceutical company Eli Lilly announced in a press release that its monoclonal antibody donanemab slowed mental decline by 35% for some participants in a 1,736-person trial — a rate comparable to that for competitor drug lecanemab.”  Lilly said it intends to seek FDA approval within the next month or two, will issue further results at a major AD conference in July, and seek publication of its data in a forthcoming peer reviewed journal.

Early reactions to this announcement have been mixed.  According to that same Nature article, “Researchers warn that until the full results are published, questions remain as to the drug’s clinical usefulness, as well as whether the modest benefit outweighs the risk of harmful side effects.  Some researchers who have reviewed the limited data released to date are doubtful of its effectiveness.”  Quoting Dr. Marsel Mesulam, a neurologist at Northwestern University, “The results that are described are extremely significant and impressive, but clinically their significance is doubtful.”

As reported in the May 3 NY Times article about donanemab, “24 percent of patients had the side effect of brain swelling and bleeding, and 6 percent had symptoms like dizziness, headache or fainting. Three patients in the Lilly trial died.  The company reported that two to three out of 10 patients taking donanemab progressed (to worsening stages of AD) over the next 18 months, compared to the expected three to four patients taking a placebo.” Lilly said that people with mild Alzheimer’s who received donanemab “showed 35% less clinical decline over 18 months than did those who received a placebo, and 40% less decline in their ability to perform daily tasks.”

According to the NY Times piece, Dr. Ronald Petersen, Mayo Clinic’s director of the Alzheimer’s Disease Research Center, said that “the donanemab results were modest but meaningful adding that  “patients and their families must be counseled about a dire side effect of donanemab - a risk of brain swelling that can result in death.”  Dr. Samuel Gandy, professor of Alzheimer’s disease research at Mount Sinai, noted that whereas the results for both lecanemab and donanemab were reported to be statistically meaningful, they have “only modest clinical benefit.” 

In an article about donanemab published in Science on May 3, the author wrote: “We cannot be sure that this drug will actually make a difference in the real-world care of patients with Alzheimer’s - not yet, anyway. This point is completely avoided in the Lilly press release, but it is nonetheless real and we will be hearing more about it from clinicians - well, if you listen closely above all the noise, that is.” Also noted is how the negative side effects in the donanemab trial were worse than those in the lecanemab trial.  For lecanemab, “the reported rates of ARIA-E and ARIA-H (measures of brain bleeds) were 13% and 17% of the trial participants, and the rates in this new donanemab trial were noticeably higher: 24% and 31%.”  That same article quoted a tweet from Dr. Robert Howard, a psychiatrist at University College London who has tested treatments for dementia.  Howard tweeted, “Looks as dangerous as lecanemab.”

I remain very skeptical while awaiting full data and peer review of results from Lilly’s new proposed medication, donanemab … and for the same reasons as noted in my PB #28 about lecanemab.  Here’s why: When my wife was diagnosed with early onset AD, we knew that most people, on average, progress through the stages of AD in about 8 years … some more quickly, some more slowly.  We thought that we could be reasonably confident of having at least 3 and maybe even 4 more really good years together before she would progress to moderate stages of AD.  And we did.  During those first few years after diagnosis, we traveled extensively both in this country and internationally.  We played our favorite word games like Scrabble and Boggle, continued to go bowling in our leagues, enjoyed going out by ourselves and with friends to see plays and movies, and enjoyed just sitting on a bench at the water’s edge on nice days. We had a very rewarding life together for those first three to four years after diagnosis.

Had a medication such as lecanemab or donanemab been available, would we have risked what turned out to be nearly four really good years together to take medication hoping my wife would be in the 35% of those who might gain an extra few good months, but all the while risking that she could be in the group of 24% who would suffer brain swelling or brain bleeds, stroke or death?  I think not. There is just too much downside risk, in my opinion … the high risk of negative side effects of this new medication simply outweigh any hope that there may be a slight reduction in the rate of decline for a few more months.  I await the published results and peer review of this new proposed medication later this summer or fall, but I am not very optimistic.

Personal Blog #30 … Medicare Quality Measures, Part II … 2/11/23

 

In my column posted on 11/4/22 … PB #29, “Medicare Quality Measures, Part l” … I wrote about a “quest” I was on to see if Medicare would consider making a doctor’s referral of an AD patient or caregiver to a support group qualify as a “quality measure.”  To briefly review, in response to my June article about support groups, a doctor had suggested that more doctors might refer AD patients and caregivers to support groups if referrals were considered Medicare “quality measures” … actions that would result in financial or other incentives for doctors to make such referrals.  I then described my unsuccessful efforts to reach someone at CMS … Centers for Medicare and Medicaid Services … who could give me information about this matter.  No email address was available for the head of CMS, Chiquita Brooks-LaSure, and no one contacted at CMS would give me her email address.

In late December, tired of waiting for a response from Medicare administrators I was able to email, I decided to try a hunch and sent an email to the head of CMS by using the same ID characteristics of email addresses for the lower level CMS administrators … first and last names or initials with periods and such, followed by the CMS email string of cms.hhs.gov.  Much to my surprise, within one day I received a detailed response from a high ranking CMS official who said my email to Brooks-LaSure was referred to him.  Aside from being very helpful, the official also provided me with websites to find additional information and wrote, in part:

“I directed your most recent email to our group of experts on quality measures, called the Quality Measurement and Value-Based Incentives Group (QMVIG) within the Center for Clinical Standards and Quality (CCSQ). You have definitely gotten to the right place to make sure your input is being submitted and that you’re getting the information from the best source.  I checked before I left for the holiday last week, and they were about to get back to you.  So you should hear from them soon.  I’ll follow up there again, and I’m sure they will respond back more fully with more robust information but … there are potentially payment incentives for our quality programs.”

I was very excited with this response and followed up by reading information on websites provided by the senior advisor.  However, a month went by with no response from QMVIG, so I wrote again to the CMS official in Ms. Brooks-LaSure’s office.  Within 48 hours I received a detailed response from an administrator of QMVIG.  Here are excerpts of that response to my email, specifically to three questions I raised:

“1. Would there be a specific billing or reimbursement advantage for doctors who would report using such a Medicare quality measure?  Potentially. Quality measures are commonly used in quality reporting programs or value based purchasing programs which seek to revise our payment systems by focusing on high value care (high quality/low cost). Depending upon the care setting, a program may apply penalties or bonuses based on provider performance on quality metrics. Some areas where Medicare does have payment is on caregiver health risk assessment through CPT code 96161. Additionally, through Medicare’s cognitive assessment and care plan services CPT code 99483, clinicians can refer people with suspected or diagnosed dementia to social services (such as support groups) and determine caregiver willingness to furnish care: https://www.cms.gov/files/document/cognitive-assessment-care-plan-services-cpt-code-99483.pdf

2. Would there be any other specific advantage to doctors who would report using such a Medicare quality measure? Other advantages include the ability to share performance information on measures with the public, which can be used as consumer tools when selecting a provider and leveraging results of quality measurement to identify areas where there is room for quality care improvement.

3. If the answer to questions 1 and/or 2 is yes, what would be my next step in trying to have Medicare consider AD support group referrals as "quality measures." It is a long process to have something be considered for a quality measure, and usually involves having a measure developer who has experience developing a measure – as quality measures used in federal programs require strict definitions, specifications, and testing for validity and reliability. However any measure by any developer may be submitted to CMS for consideration. Please see the Measure Blueprint for more information on this process (https://mmshub.cms.gov/blueprint-measure-lifecycle-overview). The measure would then be submitted to a consensus-based entity for endorsement, such as the National Quality Forum (https://www.qualityforum.org/what_we_do.aspx). The measure ultimately needs to be submitted to the Measures Under Consideration list. Information on the pre-rulemaking process can be found here https://mmshub.cms.gov/Pre-Rulemaking-Resources.”

My initial response to this administrator’s email, which also included a lot more relevant information, was that the CMS bureaucratic process for something to become a Medicare “quality measure” was a navigational process beyond my capabilities.  After checking out the websites and familiarizing myself more with the bureaucratic hoops I’d have to go through to make my quest successful, my initial response was confirmed.  I emailed the QMVIG administrator telling her that I now planned to contact an advocacy organization with the resources and expertise to deal with the CMS bureaucracy …perhaps AARP, The Alzheimer’s Association, or UsAgainstAlzheimer’s … since, as the administrator noted, “it is a long process to have something be considered for a quality measure, and usually involves having a measure developer who has experience developing a measure.”  My experience with educational and non-profit organizations is that they almost always hire or already have on staff one or more specialized individuals with the precise experience necessary in order to apply for state or federal grants in their field, and this quality measure quest seems to be much like a state or federal  grant application process.  I would expect a large AD advocacy organization to have people with such experience.

I plan to forward what I have learned to one or more AD advocacy organizations and hope one of them will pursue this quest to have CMS recognize doctor referrals to AD support groups as quality measures.  Then, perhaps, more people with AD and their caregivers will learn more about support groups and benefit from attending such groups.