Predicting longitudinal changes in caregiver physical and mental health: a stress process model

Oncology patients' experiences in experimental medicine cancer trials: a qualitative study

OBJECTIVES

The study aimed to explore patients' experiences of experimental cancer medicine (ECM) clinical trials.

DESIGN

The study's design was qualitative. Two focus groups with patients were undertaken followed by semistructured interviews, to explore patients' experiences of ECM clinical trials. Interviews and focus groups were audiorecorded and transcribed verbatim. Data were analysed using thematic analysis.

SETTING

A regional cancer centre (tertiary care) in North-West England.

PARTICIPANTS

Twelve patients (aged 52-79) participated in one of the two focus groups and 22 patients (aged 42-83) participated in interviews.

PRIMARY OUTCOME MEASURE

Patients' experiences of an ECM trial.

RESULTS

Four main themes were identified from the analysis: decision making, information needs, the experience of trial participation and impact of trial participation. Subthemes are presented in the manuscript.

CONCLUSION

To make fully informed decisions about trial participation, patients required the simplification of trial information and wanted more information about side effects, their response to trial treatment and the overall trial progress throughout the trial. Patients highlighted the need for improvement for the support provided to their family and friends.

Alzheimer's Disease Caregiver Characteristics and Their Relationship with Anticipatory Grief

In Alzheimer's disease, two fundamental aspects become important for caregivers: ambiguity and ambivalence. Thus, anticipatory grief is considered an active psychological process that is very different from the mere anticipation of death. The present study aims to determine which characteristics of family caregivers of people with dementia, such as age, gender, educational level, relationship with the person with dementia, years with dementia or years as a caregiver, are related to the presence of anticipatory grief. A cross-sectional design was employed. The sample consisted of a total of 129 subjects who cared for a family member with dementia. A sociodemographic data sheet and a battery of tests measure the presence of anticipatory grief, caregiver burden and/or psychopathology. The results obtained allowed us to confirm some of the hypotheses regarding the anticipatory grief construct, the importance of the care time factor, in years and per day, as well as the relevance of the previous demographic and psychopathological profile (being female, spouse function and possible depressive symptomatology). Likewise, from the prediction analyzes performed, it seems that these variables can predict anticipatory grief. These results propose interesting opportunities to formulate care proposals to professionals and family caregivers in relation to care tasks and caregiver skills.

Do Informal Caregivers Expect to Die Earlier? A Longitudinal Study with a Population-Based Sample on Subjective Life Expectancy of Informal Caregivers

INTRODUCTION

Subjective life expectancy is a good predictor of health and could therefore be a relevant factor in the informal caregiving context. However, no research has been conducted on the perception of life expectancy by informal caregivers. This is the first study that examines the association between transitioning into, and out of, informal caregiving, and subjective life expectancy, and the relevance of employment status and gender for these associations.

METHODS

A longitudinal study was conducted with data from the German Ageing Survey (waves 2008, 2011, 2014, and 2017). Up to 20,774 observations pooled over all waves were included in the main models. In total, 1,219 transitions into and 1,198 transitions out of informal caregiving were observed. Fixed effects (FE) regression analysis was used. Moderator and stratified analyses were conducted with gender and employment status used as moderator variables and to stratify the sample. Sociodemographic information, health, and lifestyle factors were controlled for.

RESULTS

Results of adjusted FE regression analyses indicated a significant reduction of subjective life expectancy when transitioning into informal caregiving. No significant change was found when transitioning out of informal caregiving. Subjective life expectancy was significantly decreased when employed individuals transitioned into informal caregiving and significantly increased when they transitioned out of caregiving. Findings for women transitioning into informal caregiving indicated a significant decrease in subjective life expectancy, while no significant change was found among men.

CONCLUSION

The study's findings indicate that informal caregivers, female and employed caregivers in particular, perceive informal care provision as dangerous for their longevity and expect to die earlier when transitioning into informal caregiving. Thus, supportive interventions for informal caregivers, particularly employed and female informal caregivers, are recommended.

Quality improvement study on early recognition and intervention of caregiver burden in a tertiary hospital

Background

Caregivers play a crucial role in taking over the important task of looking after patients post-hospitalisation. Caregivers who are unfamiliar with patients’ post-discharge care often experience caregiver stress, while patients may see deterioration in their condition. As caregivers are our core partners in healthcare, it is therefore necessary for patient navigators to recognise, assess and address caregivers’ needs or burden as early as on admission to hospital. Patient navigators are trained registered nurses whose main role is to provide patients and caregivers with personalised guidance through the complex healthcare system.

Objectives

This quality improvement study examined the efficacy of using the Zarit Burden Interview as a tool in helping patient navigators recognise caregiver burden early and the effectiveness of targeted interventions on caregiver burden.

Methods

Various quality improvement tools were used. Eighty-six patient-caregiver dyads who met the inclusion criteria were enrolled. Informal caregivers were assessed for caregiver burden using the Zarit Burden Interview during hospital admission (T0) and again at 30 days postdischarge (T1), post-intervention.

Results

There was significant improvement in the Zarit Burden mean scores from T0 to T1 reported for the 80 dyads who completed the study, even after adjusting for covariates (T0 mean=11.08, SD=7.64; T1 mean=2.48, SD=3.36, positive ranks, p<0.001). Highest burden identified by most caregivers were the personal strain; trying to meet other responsibilities and uncertain about what to do in caring for their loved one. By recognising the different aspects of caregiver burden early, patient navigators were able to focus their interventions.

Conclusion

Early recognition of caregiver burden and targeted interventions were found to be effective at reducing caregiver burden in a tertiary hospital.

What do caregivers value and is there agreement in perception of met needs between nurses and caregivers?

INTRODUCTION

There is an increasing reliance on informal caregivers to continue the care of patients after discharge. This is a huge responsibility for caregivers and some may feel unprepared for the role. Without adequate support and understanding regarding their needs, patient care may be impeded. This study aimed to identify the needs valued by caregivers and if there was agreement between acute care nurses and caregivers in the perception of whether caregiver needs were being met.

METHODS

We conducted face-to-face interviews with 100 pairs of acute care nurses and caregivers. Participants were recruited from inpatient wards through convenience sampling. Questionnaires included demographic data of nurses and caregivers, patients' activities of daily living, and perception of caregiver needs being met in six domains of care. Independent t-test was used to compare mean values in each domain, and intraclass correlation coefficient was used to compare agreement in perception.

RESULTS

Caregivers valued reassurance the most. Three domains of care needs showed significant differences in perception of caregiver needs being met:reassurance (p = 0.002), honesty and timeliness (p = 0.008), and kindness and genuine care (p = 0.026). There was poor agreement in all six domains of caregiver needs being met between nurses and caregivers.

CONCLUSION

Although caregivers valued reassurance the most, there was poor agreement between acute care nurses and caregivers in the perception of caregiver needs being met. Hence, more attention should be paid to the caregiver's needs. Further studies can examine reasons for unmet caregiver needs and interventions to improve support for them.

Development and validation of a screener based on interRAI assessments to measure informal caregiver wellbeing in the community

Background

Informal caregivers are invaluable partners of the health care system. However, their caring responsibilities often affect their psychological wellbeing and ability to continue in their role. It is of paramount importance to easily identify caregivers that would benefit from immediate assistance.

Methods

In this nonexperimental cohort study, a cross-sectional analysis was conducted among 362 informal caregivers (mean age 64.1 years, SD ± 13.1) caring for persons with high care needs (mean age 78.6 years, SD ± 15.0). Caregivers were interviewed using an interRAI-based self-reported survey with 82 items covering characteristics of caregivers including key aspects of wellbeing. A factor analysis identified items in the caregiver survey dealing with subjective wellbeing that were compared against other wellbeing measures. A screener, called Caregiver Wellbeing Index (CWBI), consisting of four items with response scores ranging from 0 to 2 was created. The CWBI was validated in a follow-up study in which 1020 screeners were completed by informal caregivers of home care clients. Clinical assessments of the care recipients (n = 262) and information on long-term care home (LTCH) admission (n = 176) were linked to the screener dataset. The association between the CWBI scores and caregiver and care recipient characteristics were assessed using logistic regression models and chi-square tests. The reliability of CWBI was also measured.

Results

The CWBI scores ranging from zero to eight were split in four ‘wellbeing’ levels (excellent, good, fair, poor). In the validation study, fair/poor psychological wellbeing was strongly associated with caregiver reports of inability to continue in their role; conflict with family; or feelings of distress, anger, or depression (P < 0.0001). Caregivers caring for a care recipient that presented changes in behavior, cognition, and mood were more likely to present fair/poor wellbeing (P < 0.0001). Additionally, caregivers with high CWBI scores (poor wellbeing) were also more likely to provide care for someone who was admitted to a LTCH (OR 3.52, CI 1.32–9.34) after controlling for care recipient and caregiver characteristics. The Cronbach alpha value 0.89 indicated high reliability.

Conclusion

The CWBI is a valid screener that can easily identify caregivers that might benefit from further assessment and interventions.

Positive Effects of Cognitive Behavioral Therapy on Depression, Anxiety and Stress of Family Caregivers of Patients with Prostate Cancer: A Randomized Clinical Trial

Background:

The family caregivers of patients with cancer mightexperience various physical, mental, and spiritual difficulties, the neglect of which can causeseriousproblems for theentirefamily. If caregivers are left without appropriate treatment and intervention, their level of physical and mental health will substantially decrease-they will, in other words, become “hidden patients.”

Materials and Methods:

The current study is a clinical trial of 80 family caregivers of patients with prostate cancer, who were allocated to control and experimental groups. The experimental group received 10 sessions of group cognitive behavioral therapy. The 21-item Depression Anxiety Stress Scales were completed before the intervention as well4 and 8 weeks after. Data were analyzed using descriptive statistics (means and standard deviations) andvariousstatistical tests.

Results:

The results showed thatthecognitivebehavioral intervention reduceddepression, anxiety, and stress among familycaregivers.

Conclusion:

Because of the positive impact of this intervention, its implementation in clinical care by nurses is recommended.

Association of the Commitments and Responsibilities of the Caregiver Within the Family to the Disease Activity in Patients With Rheumatoid Arthritis: A Report From Turkey

Objectives

This study aims to investigate the commitments and responsibilities of the family caregiver of rheumatoid arthritis patients and determine the association of these to the disease activity.

Patients and methods

The study included a total of 240 subjects, consisting of 60 rheumatoid arthritis patients (8 males, 52 females; mean age 50.4±11.1 years; range 25 to 76 years) with their respective 60 primary caregivers (42 males, 18 females; mean age 43.1±15.3 years; range 12 to 77 years) and 60 OA patients (7 males, 53 females; mean age 62.8±9.0 years; range 45 to 85 years) with their respective 60 primary caregivers (38 males, 22 females; mean age 47.6±13.2 years; range 27 to 87 years). Disease severity and pain of patients were assessed through visual analog scale. Sedimentation and C-reactive protein values were recorded during routine visits. Patients were stratified by disease activity that was determined by disease activity score-28. Caregivers of patients evaluated disease severity and pain by visual analog scale, and completed Caregiver Reaction Assessment (CRA) and Caregiver Strain Index questionnaires. For a more objective assessment, tasks related to care, household, and assistance and allocated time periods for each group of tasks were queried.

Results

When CRA and Caregiver Strain Index were compared in terms of disease activity, patients significantly differed in impact on schedule subscale of CRA (p<0.05). Similarly, disease activity was significantly associated with impact on finance subscale of CRA (p<0.05). Impact on health subscale of CRA was also correlated with disease activity; i.e., the higher the disease activity score-28, the more negative impact on health of the caregiver.

Conclusion

Patient care is an important part of rheumatoid arthritis management. Chronic diseases form commitment on patient's caregiver. That the care of the patient may be associated with many factors related to both the patient and the caregiver should not be underestimated. We suggest that caregiver's strain may be correlated with disease activity.

Internal resources among informal caregivers: trajectories and associations with well-being

PURPOSE

The experiences, skills, and internal resources that informal caregivers bring into their role may play a critical part in their mental health and well-being. This study examined how caregiver internal resources changed over a 10 year period, and how this was related to caregivers' well-being.

METHODS

Data are from the Midlife in the United States (MIDUS) study, a national sample of adults, at two time points: 1995-1996 (T1) and 2004-2006 (T2). We identified subjects who reported being a caregiver at T2 and starting care after T1 (mean age = 56; 65% female). We examined internal resources: sense of control (personal mastery); primary and secondary control strategies (persistence in goal striving, positive reappraisal, and lowering expectations); and social support seeking, and psychological and subjective well-being. We evaluated how internal resources changed over time, and how these trajectories were associated with well-being at T2 using multivariable linear regressions.

RESULTS

Most caregivers had stable levels of internal resources (between 4 and 13% showed an increase or decrease). Caregivers with increasing or high-stable levels of personal mastery had significantly better well-being scores on 6 out of 8 subscales compared with low-stable levels [effect sizes (ES) between 0.39 and 0.79]. Increasing persistence was associated with better personal growth and environmental mastery (ES = 0.96 and 0.91), and increasing and high-stable positive reappraisals were associated with better affect (ES = 0.63 and 0.48) compared with low-stable levels. Lowering aspirations and support seeking were not associated with well-being outcomes.

CONCLUSIONS

Practices or interventions that support or improve internal resources could potentially improve caregiver well-being.

"It Just Consumes Your Life": Quality of Life for Informal Caregivers of Diverse Older Adults With Late-Life Disability

Little is known about the quality of life (QoL) for informal caregivers of disabled older adults aged 65+ with diverse backgrounds. Forty-two caregivers were interviewed in English and Cantonese about their caregiving experiences, their recollections of QoL over time, and the factors influencing their appraisals. Overall, 52% of caregivers experienced a decline in QoL. Factors associated with decreased QoL were less time for self, competing financial demands, and the physical and emotional impact of the patient's illness. Factors associated with no change in QoL were minimal caregiving responsibilities, a sense of filial duty, and QoL being consistently poor over time. Factors associated with improved QoL were perceived rewards in caregiving, receiving institutional help, and increased experience. Chinese caregivers were more likely to cite filial duty as their motivator for continued caregiving than were Caucasian caregivers. In conclusion, informal caregivers take on a huge burden in enabling older adults to age in the community. These caregivers need more support in maintaining their QoL.

Support and negativity in interpersonal relationships impact caregivers' quality of life in pediatric food allergy

PURPOSE

This study examined interpersonal relationship processes as they relate to health-related quality of life (HRQL) in caregivers of food-allergic children. Research questions explored the relative contributions of social support and social negativity to caregivers' adaptation as well as mechanisms of moderation, mediation, and moderated mediation through which these influences affect the association of time since children's food allergy diagnosis to caregivers' HRQL.

METHODS

Caregivers (N = 299) of food-allergic children were recruited from parent groups associated with a food allergy nonprofit organization. Participants completed web-based questionnaires assessing demographics and child allergy characteristics, the extent of support and negativity experienced in their social relationships related caregiving, and their HRQL. Multiple regression analyses were used to examine relations among time since diagnosis, interpersonal relationship processes, and caregiver HRQL.

RESULTS

Social negativity was directly related to diminished caregiver HRQL and was a stronger predictor of caregiver HRQL than social support. The effect of time since diagnosis on caregiver HRQL was indirect through social support, and this mediating effect did not depend on caregivers' experience of social negativity.

CONCLUSIONS

Interpersonal relationship processes appear influential in the adaptation of caregivers in the context of pediatric food allergy. Psychosocial interventions targeting support and negativity in caregivers' social relationships may help improve their HRQL.

Health trajectories of family caregivers: associations with care transitions and adult day service use

OBJECTIVE

The study examines family caregivers' health changes over 1 year on four health dimensions and explores the association of differential health trajectories with adult day service (ADS) use and caregiving transitions.

METHOD

The participants were 153 primary caregivers of individuals with dementia (IWDs) who provided information on care situations and their own health at baseline, 6-month, and 12-month interviews.

RESULTS

Caregivers showed increasing functional limitations and decreasing bodily pain over time, whereas role limitation and general health perception remained stable. Furthermore, caregivers' trajectories of functional limitation were associated with their extent of ADS use at baseline and their relatives' placement.

DISCUSSION

Health is multidimensional; all dimensions of caregiver health do not change in a uniform manner. The findings underscore the importance of the association of caregiving transitions and caregiver health and the potential health benefits of ADS use for family caregivers.

Caregiving frequency and physical function: the Women's Health Initiative

BACKGROUND

Informal caregiving is common for older women and can negatively affect health, but its impact on physical function remains unclear. Using inverse probability weighting methods, we quantified the association of caregiving with physical function over 6 years.

METHODS

Study participants were 5,649 women aged 65 years and older at baseline of the Woman's Health Initiative Clinical Trial (multicenter recruitment, 1993-1998) with complete caregiving data and function at baseline and at least one follow-up. Caregiving was self-reported (low-frequency if ≤2 times per week and high-frequency if ≥3 times per week). Performance-based measures of physical function including timed walk (meters/second), grip strength (kilograms), and chair stands (number) were measured at baseline and years 1, 3, and 6. Associations and 95% confidence intervals of baseline caregiving with physical function were estimated by generalized estimating equations with inverse probability weighting by propensity and attrition scores, calculated by logistic regression of baseline health and demographic characteristics.

RESULTS

Over follow-up, low-frequency caregivers had higher grip strength when compared with noncaregivers (mean difference = 0.63kg, confidence interval: 0.24, 1.01). There were no observed differences between high-frequency caregivers and noncaregivers on grip strength or for either caregiver group when compared with noncaregivers on walk speed or chair stands. Rates of change in physical function measures did not differ by caregiving status.

CONCLUSIONS

Caregiving was not associated with poorer physical function in this sample of older women. Low-frequency caregiving was associated with better grip strength at baseline which persisted through follow-up. This study supports the concept that informal caregiving may not have universally negative health consequences.

The heterogeneous course of depressive symptoms for the dementia caregiver

Caregiving may be burdensome to caregivers, negatively affecting health and impacting decisions to institutionalize patients. It is unclear how caregiver depression changes over longer periods or whether heterogeneous trajectories for caregivers are apparent. The goals of this article are to characterize the course of depressive symptoms among caregivers over time and to examine the impact of baseline patient and caregiver characteristics on these trajectories. Patients with dementia and their caregivers were followed every 6 months for up to 6 years or until death (n = 133). Growth mixture modeling identified trajectories of caregiver depression over time. Most caregivers had stable trajectories of symptoms, with a smaller subset showing evidence of wear-and-tear. Patient clinical characteristics had no impact on symptom course for caregivers. Future work should utilize a longitudinal perspective and consider that there may be heterogeneous trajectories for caregivers. Those caregivers who follow a wear-and-tear trajectory may require targeted interventions to improve outcomes.

Correlates of health-related quality of life in African American and Caucasian stroke caregivers

OBJECTIVE

Stroke is a leading cause of long-term disability in the United States. Family caregivers are susceptible to negative outcomes as a result of their caregiving role. A stress process model was utilized to identify characteristics of stroke caregivers who are at risk for poor physical and mental health-related quality of life (QOL).

RESEARCH METHOD

Individuals who experienced an incident stroke event within the previous year were identified from a larger epidemiologic study of stroke incidence. These stroke survivors were enrolled in the Caring for Adults Recovering from the Effects of Stroke (CARES) study along with their primary family caregivers (N = 146 dyads). Caregivers completed a baseline telephone interview that assessed physical and mental health-related QOL, problems their family members were experiencing, appraisals of those problems, and caregiver resources.

RESULTS

Objective stressors, appraisals, and caregiver resources were related to caregiver physical and mental health-related QOL, ps <.05. Objective stressors were found to have a stronger association with caregiver mental health than physical health. Hierarchical regression models showed the relative importance of each category of predictors. In the final models, older age and receiving more support were associated with worse physical health-related QOL whereas African American race and fewer stroke survivor problems were associated with better mental health.

CONCLUSIONS

The correlates of health-related QOL identified in this national sample of caregivers can help identify stroke caregivers who are at risk for poor adjustment to the caregiving role and aid in identifying areas that can potentially be intervened upon for these caregivers.

Modeling trajectories and transitions: results from the New York University caregiver intervention

BACKGROUND

Current research fails to capture the temporal dynamics of chronic disease in favor of cross-sectional snapshots of symptoms and outcomes.

OBJECTIVE

The aim of this study was to estimate the effects of comprehensive psychosocial support on trajectories of spouse caregivers' well-being related to the nursing home placement transition.

METHOD

Data from the New York University Caregiver Intervention, a randomized controlled trial of a comprehensive support program for spouse caregivers of persons with Alzheimer's disease, were utilized. A convenience sample of 406 spouse caregivers of community-dwelling persons with Alzheimer's disease was enrolled over a 9.5-year period in an Alzheimer's disease research center in New York City. Outcome measures, including the Zarit Burden Inventory and Geriatric Depression Scale, were used to assess the differential effects of nursing home placement and of the intervention on spouse caregivers. In-person interviews of spouse caregivers took place every 4 months during the first year of participation and every 6 months thereafter for up to 16 years; 385 caregivers provided sufficient follow-up data for all analyses.

RESULTS

Longitudinal models found that wives were more likely than husbands to indicate reductions in burden in the months after placement in an institution. Wives also reported greater decreases in depressive symptoms after placement in an institution when compared with husbands.

DISCUSSION

The inclusion of transitions and health trajectories in a randomized controlled trial offers an intriguing picture of how comprehensive psychosocial interventions can help families navigate the challenges of chronic disease care. The results also indicate how advances in nursing science can facilitate future research in the modeling of trajectories and transitions in the dementia care context.

Behavioral symptoms of dementia: a dyadic effect of caregivers' stress process?

This study used multilevel modeling to evaluate a newly revised model in which dementia caregivers' stress process variables-perceived stress and emotional-behavioral responses-were posited as predictors of behavioral symptoms of dementia (BSD) within community-based dyads. Secondary analyses were conducted on data from a primary two-group (experimental and control) trial, in which experimental participants received a home monitoring system for managing nighttime activity in individuals with dementia. Models indicated that caregivers' trajectories did not differ significantly between groups over time; however, the time-by-group interaction of BSD approached significance. Because BSD were not targeted, this indicated that the system may have indirectly lowered BSD. In addition, caregivers' perceived stress and emotional-behavioral responses predicted BSD, on average (across all occasions) and from occasion to occasion, with higher levels associated with worse BSD. These limited results provide support for further research to investigate the nature of these relationships.

Caring for family members with chronic physical illness: a critical review of caregiver literature

This article reviews 19 studies (1987-2004) on quality of life for family caregivers helping those with chronic physical illness. Here we explore the concepts of and instruments used to measure caregivers' quality of life. We were particularly interested in understanding stress-related variables and documenting factors influencing quality of life based on family stress theory. Findings show that various positive and negative terms equated with quality of life were used to measure them. Results indicate that stress-related variables as possible predictors influencing caregivers' quality of life include: patient and caregiver characteristics, stressors, stress appraisal, stress coping methods, and social support. Our recommendations touch upon applying theory for intervention, developing measurement, making operable the concepts for measuring, and the need for longitudinal and comprehensive study.