Determinants of Informal Care, Burden, and Risk of Burnout in Caregivers of Stroke Survivors

Feasibility of an integrated multidisciplinary geriatric rehabilitation programme for older stroke patients: a process evaluation

Background

Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate aftercare aimed at reducing the impact of persisting problems after discharge from a geriatric rehabilitation unit. Therefore, we developed an integrated multidisciplinary rehabilitation programme consisting of inpatient neurorehabilitation treatment using goal attainment scaling, home based self-management training, and group based stroke education for patients and informal caregivers. We performed a process evaluation to assess to what extent this programme was performed according to protocol. Furthermore, we assessed the participation of the patients in the programme, and the opinion of patients, informal caregivers and care professionals on the programme.

Methods

In this multimethod study, process data were collected by means of interviews, questionnaires, and registration forms among 97 older stroke patients, 89 informal caregivers, and 103 care professionals involved in the programme.

Results

A part of patients and informal caregivers did not receive all key elements of the programme. Almost all patients formulated rehabilitation goals, but among two thirds of the patients the goal attainment scaling method was used. Furthermore, the self-management training was considered rather complex and difficult to apply for frail elderly persons with stroke, and the percentage of therapy sessions performed in the patients’ home environment was lower than planned. In addition, about a quarter of the patients and informal caregivers attended the education sessions. However, a majority of patients, informal caregivers and care professionals indicated the beneficial aspects of the programme.

Conclusion

This study revealed that although the programme in general is perceived to be beneficial by patients, and informal and formal caregivers, the feasibility of the programme needs further attention. Because of persisting cognitive deficits and specific care needs in our frail and multimorbid target population, some widely used methods such as goal attainment scaling, and self-management training seemed not feasible in their current form. To optimize feasibility of the programme, it is recommended to tailor these elements more optimally to the population of frail older patients.

Development and validation of a prediction model for home discharge in patients with moderate stroke: The Korean stroke cohort for functioning and rehabilitation study

BACKGROUND

Previous studies have investigated the predictors for home discharge without considering stroke severity.

OBJECTIVES

To develop a practical assessment tool that predicts home discharge for moderate stroke patients after subacute rehabilitation therapy in the tertiary hospitals.

METHODS

Stroke patients with National Institutes of Health Stroke Scale scores of 6 to 13 were included in this prospective cohort study. Various demographic, clinical, and functional factors were analyzed as potential predictive factors. A weighted scoring model was developed through the following three-step process: 1) selection of the factors by logistic regression analyses, 2) development of a weighted scoring model, and 3) validation of the generalizability of the model.

RESULTS

The home discharge rate was 51% (n = 372), and the overall mean length of stay of hospitalization was 32.5 days. 1) The Cognitive Functional Independence Measure, 2) the Functional Ambulation Categories, 3) the modified Charlson Comorbidity Index, and 4) marital status were independent predictors of home discharge. The coefficient value for marital status was adjusted to 1 in the scoring system, and the values of the other parameters were proportionally converted to the nearest integer. Possible total scores ranged from 0 to 13 in the model, with a higher score indicating a higher probability of home discharge. With a cutoff point of 7, this model showed 87.0% sensitivity and 86.2% specificity (area under the curve = 0.90).

CONCLUSIONS

This novel assessment tool can be useful in predicting home discharge after subacute rehabilitation of moderate stroke patients.

Creating a Caregiver Benefit Finding Scale of Family Caregivers of Stroke Survivors: Development and Psychometric Evaluation

In recent years, increased attention has been paid to the benefit finding of family caregivers due to the important role they play. Although some instruments measure benefit finding of caregivers, they do not comprehensively address it in terms specific to the family caregivers of stroke survivors, who require long-term, consistent care. This study is the first effort to develop a comprehensive Caregiver Benefit Finding Scale for the family caregivers of stroke survivors in a Chinese cultural setting. First, 50 items were extracted from a systematic literature review, and a semi-structured interview was conducted with 20 stroke family caregivers to develop the preliminary version of the scale (Version 1). Second, Delphi procedures with 20 experts were used to revise the first version and create Version 2 (37 items). Another six experts were recruited for content validation. Item content validity index (I-CVI) values ranged from 0.83 to 1.00, and the value of the scale CVI was 0.97. Third, 309 family caregivers completed the Version 2 questionnaire and the Chinese version of the Positive Aspects of Caregiving. Two weeks later, 35 family caregivers once again completed the questionnaires. An exploratory factor analysis produced four components (personal growth, health promotion, family growth, and self-sublimation) and 26 items for Version 3 (the cumulative proportion variance was 74.14%). Subsequently, 311 family caregivers completed Version 3. A confirmatory factor analysis confirmed the structure. The goodness of fit index (GFI) = 0.921, adjusted GFI = 0.901, normal fit index = 0.951, incremental fit index = 0.990, comparative FI = 0.990, and the root mean square error of approximation = 0.02 were within the acceptable range. Criterion-related validity was equal to 0.803. The model-based internal consistency index was 0.845 and the values of the Cronbach'α coefficient of the four dimensions were 0.885-0.953. The split-half reliability was 0.92, and the test-retest reliability was 0.994. These findings provide preliminary evidence of the validity and reliability of the Caregiver Benefit Finding Scale. The scale can help researchers and clinicians to achieve a more comprehensive understanding of stroke family caregivers' positive experience. This understanding is necessary for future efforts to address issues in benefit finding by targeting the underlying mechanism and intervention.

Experiences of Dysphagia after Stroke: An Interview Study of Stroke Survivors and Their Informal Caregivers

(1) Background: Swallowing difficulties (dysphagia) after stroke are not uncommon and is a consistent risk factor for stroke-associated pneumonia. This interview study explores the perspectives of stroke survivors, who had their swallowing assessed in the first few days of admission to hospital, and their informal caregivers. (2) Methods: A participatory approach was used involving people affected by stroke in the interpretation and analysis of the interview data. Data was thematically analysed and six themes were identified. (3) Results: These themes included how past-future experiences may influence a person’s emotional response to events; understanding what is happening and adjustment; the impact of dysphagia; attitudes to care; communication to patients and procedural issues. (4) Conclusion: The findings highlight the importance of effective public health messages to improve people’s responsiveness to the signs of stroke, standardisation of assessment and management procedures, effective communication to patients about the consequences of dysphagia, and the impact of dysphagia on the person who had the stroke and their informal caregiver.

Determinants of Burden and Satisfaction in Informal Caregivers: Two Sides of the Same Coin? The CUIDAR-SE Study

The aim of this study conducted in Spain was to analyze and compare burden, severe burden, and satisfaction among informal caregivers in relation to health-related quality of life (HRQoL), type and duration of caregiving, perceived social support, and use of social and health care services. We performed multivariate analyses to identify variables associated with caregiver burden, severe burden, and satisfaction with caregiving, stratified by gender. The results showed that secondary or third-level education, performance of ungratifying tasks, negative coping with caregiving, and more years providing care were associated with greater burden. Variables with protective effect were better perceived health of the person being cared for, better caregiver HRQoL, and high perceived social support. Women were 75% more likely to experience severe burden compared with male caregivers. Burden was reduced by high perceived social support in the case of women and by high caregiver HRQoL in the case of men. The main determinant of caregiving satisfaction for both men and women was perceived social support (OR = 3.11 and OR = 6.64). This study shows the need for interventions that promote gender equality and social support as a means of relieving burden and severe burden and improving satisfaction in both male and female caregivers.

Risk of Dependency: A Challenge for Health and Social Care Planning-Observational Stroke Cohort

BACKGROUND

After a stroke, families require the coordinated assistance of health and social care. Currently there is a lack of comprehensive evaluation and assessment tools to identify discharge needs, and there is separate management of health and social resources, and access to these services is variable between regions.

OBJECTIVE

The main objective of this study was to assess the factors associated with risk of dependency after stroke and propose a suitable instrument for identifying patients at higher risk.

METHODS

This was a 2-year prospective and community study of a stroke cohort. The primary outcome was recognized dependency. The potential predictors were considered in a multivariate regression and area under curve (AUC) to evaluate its discriminative capacity.

RESULTS

Overall, 233 stroke survivors were recruited, 49.8% of whom were women, and the average age was 78.1 ± 11.6 years. The total rate of dependency was 31.5 (95% confidence interval [CI] 26.1-37.7) cases/100 person-years. The independent factors associated with dependency outcome were age >80 years (hazard ratio [HR] 2.03, 95% CI 1.32-3.12, P = .001), Pfeiffer score ≥4 (HR 1.82, 95% CI 1.25-1.2.66, P = .002), Barthel score <60 (HR 1.79, 95% CI 1.21-2.66, P = .003), and Charlson score ≥3 (HR 1.49, 95% CI 1.02-2.16, P = .039). The AUC was 0.84 (95% CI 0.79-0.89; P < .001).

CONCLUSIONS

Stroke has serious effects on the dependency outcomes. The patient's age, cognitive or physical impairment, and comorbidities as measured on the Pfeiffer score, Barthel Index, and Charlson score identified people at high risk and may ease the integrated role of social and health services.

Association of formal and informal care with health-related quality of life and depressive symptoms: findings from the Caring for Adults Recovering from the Effects of Stroke study

AIM

To investigate the association between informal and formal care and stroke participants' self-reported health-related quality of life and depressive symptoms one year after the stroke event.

METHODS

We examined a national population-based sample of 123 stroke participants. Care received was defined as formal (outpatient therapy, care from home health aides, nurses, or therapists), informal (family caregiver), or shared (formal and informal). Hours of care were extracted from Medicare claims and caregiver self-report. A general linear model was used to compare health-related quality of life and depressive symptoms one year after the stroke for those who received shared care, only informal care or only formal care to those with no post-stroke care.

RESULTS

Among stroke participants, 12.2% received only formal care, 35.0% only informal care, 38.2% shared care, and 14.6% no care. Those with only informal care had greater self-reported depressive symptoms than those who received no care at all.

CONCLUSIONS

Shared care was the most common care configuration for stroke participants, but no significant associations were found between shared care and self-reported outcomes after adjusting for stroke participant characteristics. Further research is needed on the dose of informal and formal care and their coordination to better understand relationships with recovery.IMPLICATIONS FOR REHABILITATIONStroke is one of the leading causes of disability for adults in the USA and ongoing care is needed for survivors.Informal caregivers such as family members play an important role in recovery in addition to formal care provided by home health aides, nurses and therapists.This study showed that survivors with informal care had more severe depressive symptoms, while shared care provided by formal and informal caregivers may prevent further decline in patients with worse baseline health.

Measures used to assess impact of providing care among informal caregivers of persons with stroke, spinal cord injury, or amputation: a systematic review

PURPOSE

(1) To identify measures used to evaluate the impact of caregiving among caregivers of persons with stroke, spinal cord injury, and amputation; and (2) to systematically evaluate their clinimetric properties reported in validation studies.

MATERIALS AND METHODS

Two separate systematic reviews (Embase, PsycINFO, CINAHL, Pubmed/Medline) were conducted. COSMIN guidelines were used to assess clinimetric properties and methodological quality of studies.

RESULTS

(1) 154 studies published between 2008 and May 2019 were included, in which 48 measures were used, mostly describing negative impact. Thirty measures were used only once and not further described. (2) In general, structural validity, internal consistency, and hypothesis testing were often investigated. Reliability, cross-cultural and criterion validity to a lesser extent, and scale development and content validity were rarely described. Tests of measurement error and responsiveness were exceptional. Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire.

CONCLUSIONS

There is a wide variety of impact of caregiving measures. The present study provided a detailed overview of what is known about clinimetric characteristics of 18 different measures repeatedly used in research. The overview provides clinicians a guidance of appropriate measure selection.

PROSPERO REGISTRATION

CRD42018094796IMPLICATIONS FOR REHABILITATIONClinicians should be aware that information about measure development and clinimetric properties for most measures used to assess impact of informal caregiving is incomplete.Most supporting evidence was found for the Zarit Burden Interview Short Form, Caregiver Burden Scale and Positive Aspects of Caregiving Questionnaire.This overview of clinimetric properties provides clinicians guidance for selection of an appropriate measure.

An Intervention to Promote Medication Understanding and Use Self-Efficacy: Design of Video Narratives for Aging Patients at Risk of Recurrent Stroke

Background

The debilitating effects of recurrent stroke among aging patients have urged researchers to explore medication adherence among these patients. Video narratives built upon Health Belief Model (HBM) constructs have displayed potential impact on medication adherence, adding an advantage to patient education efforts. However, its effect on medication understanding and use self-efficacy have not been tested.

Objective

The researchers believed that culturally sensitive video narratives, which catered to a specific niche, would reveal a personalized impact on medication adherence. Therefore, this study aimed to develop and validate video narratives for this purpose.

Methods

This study adapted the Delphi method to develop a consensus on the video scripts’ contents based on learning outcomes and HBM constructs. The panel of experts comprised 8 members representing professional stroke disease experts and experienced poststroke patients in Malaysia. The Delphi method involved 3 rounds of discussions. Once the consensus among members was achieved, the researchers drafted the initial scripts in English, which were then back translated to the Malay language. A total of 10 bilingual patients, within the study’s inclusion criteria, screened the scripts for comprehension. Subsequently, a neurologist and poststroke patient narrated the scripts in both languages as they were filmed, to add to the realism of the narratives. Then, the video narratives underwent a few cycles of editing after some feedback on video engagement by the bilingual patients. Few statistical analyses were applied to confirm the validity and reliability of the video narratives.

Results

Initially, the researchers proposed 8 learning outcomes and 9 questions based on HBM constructs for the video scripts’ content. However, following Delphi rounds 1 to 3, a few statements were omitted and rephrased. The Kendall coefficient of concordance, W, was about 0.7 (P<.001) for both learning outcomes and questions which indicated good agreement between members. Each statement’s Cronbach alpha was above .8 with SD values within a range below 1.5 that confirmed satisfactory content and construct validity. Approximately 75% (6/8) of members agreed that all chosen statements were relevant and suitable for video script content development. Similarly, more than 80% (8/10) of patients scored video engagement above average, intraclass correlation coefficient was above 0.7, whereas its Kendall W was about 0.7 with significance (P<.001), which indicated average agreement that the video narratives perceived realism.

Conclusions

The Delphi method was proven to be helpful in conducting discussions systematically and providing precise content for the development of video narratives, whereas the Video Engagement Scale was an appropriate measurement of video realism and emotions, which the researchers believed could positively impact medication understanding and use self-efficacy among patients with stroke. A feasibility and acceptability study in an actual stroke care center is needed.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000174280; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=373554&isReview=true