Caring for a service member or Veteran following traumatic brain injury influences caregiver mental health

Health outcomes before and during the COVID-19 pandemic in caregivers of service members and veterans with traumatic brain injury

PURPOSE

To examine change in health-related quality of life (HRQOL) during the COVID-19 pandemic in caregivers of service members/veterans (SMVs) with traumatic brain injury (TBI), by comparing HRQOL during the first year of the pandemic to HRQOL 12 months pre-pandemic.

METHODS

Caregivers (N = 246) were classified into three COVID-19 Pandemic Impact groups based on impact ratings of the pandemic on HRQOL: No Impact (n = 50), Mild Impact (n = 117), and Moderate-Severe Impact (n = 79). Caregivers completed 19 measures across physical, social, caregiving, and economic HRQOL domains, and a measure of SMV Adjustment. T-scores were used to determine individual symptom trajectories for each measure as follows: Asymptomatic (pre + during < 60 T); Developed (pre < 60 + during ≥ 60 T); Improved (pre ≥ 60 T + during < 60 T); and Persistent (pre + during ≥ 60 T).

RESULTS

Using ANOVA, during the pandemic, the Moderate-Severe Impact group reported worse scores on 19 measures (d = 0.41-0.89) compared to the No Impact group and 18 measures (d = 0.31-0.62) compared to the Mild Impact group (d  = 0.31-0.38). The Mild Impact group reported worse scores on two measures compared to the No Impact group (d = 0.42-0.43). Using the entire sample, the majority of HRQOL measures were classified as Asymptomatic (47.2-94.7%), followed by Persistent (2.4-27.2%). Few were classified as Developed (0.4-12.6%) or Improved (2.4-13.8%). Using repeated measures ANOVA, no meaningful effects sizes were found for mean scores on all measures completed pre-pandemic compared to during the pandemic (d ≤ 0.17).

CONCLUSION

The vast majority of caregivers reported stability in HRQOL pre-pandemic compared to during the pandemic. The COVID-19 pandemic was not associated with a high prevalence of decline in caregiver HRQOL.

Value-consistent rehabilitation is associated with long-term psychological flexibility and quality of life after traumatic brain injury

Meaningful steps have been taken toward using holistic approaches in outpatient rehabilitation for traumatic brain injury (TBI) (i.e., treating the whole individual); however, research and practice continue to disproportionately focus on adapting to physical and cognitive changes. Research suggests treatment focusing on individual values may be important for psychological adjustment after TBI. The current study sought to explore individual values across multiple life domains in those with TBI as well as what values outpatient rehabilitation was helpful for, and to examine discrepancies between these factors (i.e., value-consistent rehabilitation) in relation to important long-term treatment outcomes. 215 adults with a history of TBI who had participated in outpatient rehabilitation completed online surveys assessing how consistent outpatient rehabilitation was with individual values, psychological flexibility, and quality of life. The life domains with the greatest discrepancies between individual importance and rehabilitation helpfulness were spirituality, intimate relations, and family relations. Greater value-consistent rehabilitation was associated with higher levels of psychological flexibility and quality of life beyond demographics and injury characteristics. Our findings provide further support in favour of holistic, client-centred approaches that are facilitated by neurological rehabilitation programs.

Measurement Properties of the Mayo-Portland Adaptability Inventory (MPAI-4) and Related Measures: A Systematic Review

OBJECTIVE

To assess the Mayo-Portland Adaptability Inventory-version 4 (MPAI-4) and related measures' measurement properties and the quality of evidence supporting these results; and identify the interpretability and feasibility of the MPAI-4 and related measures.

DATA SOURCES

We conducted a systematic review according to COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. We searched 9 electronic databases and registries, and hand searched reference lists of included articles.

STUDY SELECTION

Two independent reviewers screened and selected all articles. From 605 retrieved articles, 48 were included.

DATA EXTRACTION

Two independent reviewers appraised the evidence quality and rated the extracted classical test theory and Rasch results from each study.

DATA SYNTHESIS

We used meta-analysis and COSMIN's approach to synthesize measurement properties evidence (insufficient, sufficient), and the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to synthesize evidence quality (very low, low, moderate, high) by diagnosis (traumatic brain injury [TBI], stroke), and setting (inpatient, outpatient). The MPAI-4 and its subscales are sufficiently comprehensible (GRADE: very low), but there is currently no other content validity evidence (relevance, comprehensiveness). The MPAI-4 and its participation index (M2PI) have sufficient interrater reliability for stroke and TBI outpatients (GRADE: moderate), whereas interrater reliability between TBI inpatients and clinicians is currently insufficient (GRADE: moderate). There is no evidence for measurement error. For stroke and TBI outpatients, the MPAI-4 and M2PI have sufficient construct validity (GRADE: high) and responsiveness (GRADE: moderate-high). For TBI inpatients, the MPAI-4 and M2PI have mixed indeterminant/sufficient construct validity and responsiveness evidence (GRADE: moderate-high). There is 1 study with mixed insufficient/sufficient evidence for each MPAI-4 adaptation (21- and 22-item MPAI, 9-item M2PI) (GRADE: low-high).

CONCLUSION

Users can be most confident in using the MPAI-4 and M2PI in TBI and stroke outpatient settings. Future research is needed on reliability, measurement error, predictive validity, and content validity of the MPAI-4 and its related measures across populations and settings.

Caring again: Support for parent caregivers of wounded, ill, and/or injured adult children veterans

BACKGROUND

Parents often provide care to adult children veterans with polytrauma, traumatic brain injury, and/or post-traumatic stress disorder.

OBJECTIVE

This two-arm randomized clinical trial compared interventions to help parent caregivers improve their depression, anxiety, and burden and manage care by decreasing troubling and concerning behaviors.

METHODS

Interventions were six one-hour structured one-on-one behavioral sessions (REACH) or six 30-minute prerecorded online educational webinars. Both focused on knowledge, strategies for care, and coping, but REACH sessions were targeted, interactive, and skills-based. Quantitative and qualitative data were collected by telephone. Quantitative analyses included chi-squared test or independent samples t-test and repeated measures mixed linear modeling, with theme development for qualitative data.

RESULTS

There were 163 parent caregivers, mostly mothers. During six months, participants in both arms improved significantly in depression, anxiety, burden, and reported veteran troubling and concerning behaviors. REACH caregivers showed a group by time improvement in concerning behaviors. Benefits included resources, self-reflection, not feeling alone, new skills, improved self-efficacy, and helping others. Specific concerns include exclusion from military and veteran care briefings and concern for the future.

CONCLUSION

The positive response to both interventions provides opportunities for organizations with varying resources to provide support for parent caregivers. Interventions need to be targeted to parents' particular concerns and needs.

Relationship satisfaction among spouse caregivers of service members and veterans with comorbid mild traumatic brain injury and post-traumatic stress disorder

This study examined relationship satisfaction and health-related quality of life (HRQOL) among spouse caregivers assisting service members and veterans (SMV) with comorbid uncomplicated mild traumatic brain injury (MTBI) and post-traumatic stress disorder (PTSD). Spouse caregivers (N = 205) completed the Couples Satisfaction Index (CSI), 12 HRQOL measures, and the Mayo-Portland Adaptability Inventory 4^th Edition (MPAI-4). T-scores were classified as "clinically elevated" using a cutoff of ≥60T. The sample was also classified into "Satisfied" (≥13.5, n = 113, 55.0%) or "Dissatisfied" (<13.5, n = 92, 44.0%) relationship categories. Using stepwise regression analysis, Anxiety, Family Disruption, Vigilance, Emotional Support, Feeling Trapped, and MPAI-4 Adjustment were identified as the strongest predictors of CSI total scores (p < 0.001), accounting for 41.6% of the variance. Squared semi-partial correlations revealed that 18.1% of the variance was shared across all six measures, with 7.8% to 1.5% of unique variance accounted for by each measure separately. When comparing the number of clinically elevated measures simultaneously, the Dissatisfied group consistently had a higher number of clinically elevated scores compared to the Satisfied group (e.g., 3-or-more clinically elevated scores: Dissatisfied = 40.2%, Satisfied = 8.8%, OR = 6.93, H = 0.76). Caring for a SMV with comorbid TBI and PTSD can have a profound impact on the spouse caregiver's HRQOL, relationship satisfaction, and family functioning. The findings from the current study continue to support the need for family involvement in the SMV's treatment plan, but more effort is needed to integrate behavioral health treatment that focuses on the family member's own issues into military TBI and PTSD systems of care.

Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life

STUDY OBJECTIVES

To examine the relationship between caregiver sleep impairment and/or service member/veteran (SMV) adjustment post-traumatic brain injury, with caregiver health-related quality of life (HRQOL).

METHODS

Caregivers (n = 283) completed 18 measures of HRQOL, sleep impairment, and SMV adjustment. Caregivers were classified into 4 sleep impairment/SMV adjustment groups: 1) Good Sleep/Good Adjustment (n = 43), 2) Good Sleep/Poor Adjustment (n = 39), 3) Poor Sleep/Good Adjustment (n = 55), and 4) Poor Sleep/Poor Adjustment (n = 146).

RESULTS

The Poor Sleep/Poor Adjustment group reported significantly worse scores on most HRQOL measures and a higher prevalence of clinically elevated T-scores (≥ 60T) on the majority of comparisons compared to the other 3 groups. The Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups reported worse scores on the majority of the HRQOL measures and a higher prevalence of clinically elevated scores on 7 comparisons compared to the Good Sleep/Good Adjustment group. Fewer differences were found between the Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups. The Poor Sleep/Poor Adjustment group reported a higher prevalence of severe ratings for SMV Irritability, Anger, and Aggression compared to the Good Sleep/Poor Adjustment group.

CONCLUSIONS

While the presence of either caregiver sleep impairment or poor SMV adjustment singularly was associated with worse caregiver HRQOL, the presence of both sleep impairment and poor SMV adjustment was associated with further impairment in HRQOL. Caregivers could benefit from sleep intervention. Treatment of SMVs neurobehavioral problems may improve the SMV's recovery and lessen sleep problems, distress, and burden among their caregivers.

CITATION

Brickell TA, Wright MM, Sullivan JK, et al. Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life. J Clin Sleep Med. 2022;18(11):2577-2588.

Is Traumatic Brain Injury Severity in Service Members and Veterans Related to Health-Related Quality of Life in Their Caregivers?

OBJECTIVE

To examine the relationship between service member/veteran (SM/V) traumatic brain injury (TBI) severity with caregiver health-related quality of life (HRQOL).

SETTING

Military treatment facility.

PARTICIPANTS

Caregivers (N = 316) of SM/Vs following a TBI divided into 2 groups based on SM/V TBI severity: (1) caregivers of SM/Vs following an uncomplicated mild TBI (UnMTBI Caregiver group, n = 246), and (2) caregivers of SM//Vs following a complicated mild, moderate, severe, or penetrating TBI (STBI Caregiver group, n = 70). The STBI Caregiver group was further divided into 2 subgroups: Parent (n = 21) versus Intimate Partner (n = 49). The UnMTBI Caregiver group consisted of intimate partners.

DESIGN

Prospective cohort.

MAIN MEASURES

Caregivers completed 15 HRQOL measures.

RESULTS

Using analysis of variance and chi-square analysis, the UnMTBI Caregiver group reported worse scores on 12 HRQOL measures and more clinically elevated scores for 6 of 15 comparisons than the STBI Caregiver group. The UnMTBI Caregiver group also reported worse scores on 10 HRQOL measures than intimate partners in the STBI Caregiver group and 5 measures than parents in the STBI Caregiver group. Parents reported worse scores on 3 measures than intimate partners in the STBI Caregiver group. The UnMTBI Caregiver group reported more clinically elevated scores for 7 of 15 comparisons than intimate partners in the STBI Caregiver group.

CONCLUSION

Intimate partner caregivers of an SM/V following a remote uncomplicated MTBI reported worse HRQOL than intimate partners and parent caregivers of an SM/V following a more severe TBI, mostly likely due to SM/V physical and mental health comorbidities. Interventions that focus on the SM/V's TBI and other comorbidities, the caregiver's behavioral health problems, and the relationship and family factors that interact with each other will likely have the most success in improving individual and family outcomes for military families.

Aggression in Military Members With Mild Traumatic Brain Injury and Post-Traumatic Stress Disorder Is Associated With Intimate Partner Health-Related Quality of Life

OBJECTIVE

We aimed to examine the relationship between service member/veteran (SMV) aggression and health-related quality of life (HRQOL) in their intimate partners.

METHODS

This prospective cohort study included 201 female intimate partner caregivers of post-9/11 male SMVs with a diagnosis of uncomplicated mild traumatic brain injury and post-traumatic stress disorder from a military treatment facility. Caregivers completed 17 HRQOL measures and rated the level the SMV experiences problems with verbal or physical expressions of irritability, anger, or aggression on the Mayo-Portland Adaptability Inventory, 4th edition. Caregivers were classified into three SMV Aggression groups: i) none or very mild (n = 53); ii) mild (n = 47); and iii) moderate or severe (n = 101). HRQOL scores were classified as clinically elevated using a cutoff of 60T or higher.

RESULTS

Using χ² analysis, the moderate or severe group had a significantly higher proportion of clinically elevated scores on 15 HRQOL measures compared with the none or very mild group, and six measures compared with the mild group. The mild group had higher scores on two measures compared with the none or very mild group. Using analysis of covariance (and controlling for caregiver strain), the moderate or severe group had significantly higher scores on 11 HRQOL measures compared with the none or very mild group, and two measures compared with the mild group. The mild group had higher scores on five measures compared with the none or very mild group.

CONCLUSIONS

Many caregivers who report moderate to severe SMV aggression after a traumatic brain injury, report poor HRQOL beyond the strain of care provision. Traumatic brain injury and post-traumatic stress disorder programs should screen for and treat SMV aggression, and attend to the health needs of their caregivers.

Pain interference and health-related quality of life in caregivers of service members and veterans with traumatic brain injury and mental health comorbidity

PURPOSE

To examine (1) the relationship between caregiver pain interference with caregiver health-related quality of life (HRQOL), caregiver age, and service member/veteran (SMV) functional ability, and (2) change in caregiver pain interference longitudinally over 5 years.

METHOD

Participants were 347 caregivers of SMVs diagnosed with traumatic brain injury (TBI). Caregivers completed the SF-12v2 Health Survey Bodily Pain scale at an initial baseline evaluation and up to four annual follow-up evaluations. Caregivers were divided into three pain interference groups: High Pain Interference (n = 104), Neutral Pain Interference (n = 117), and Low Pain Interference (n = 126). Caregivers also completed 15 HRQOL measures and a measure of SMV functional ability.

RESULTS

The High Pain Interference group reported more clinically elevated scores on 13 measures compared to the Low Pain Interference group, and seven measures compared to the Neutral Pain Interference group. The Neutral Pain Interference group had more clinically elevated scores on three measures compared to the Low Pain Interference group. The High and Neutral Pain Interference groups were older than the Low Pain Interference group. Parent caregivers were older than intimate partner/sibling caregivers, but did not report worse pain interference. Caregiver age, and measures of Fatigue, Strain, Perceived Rejection, and Economic QOL were the strongest predictors of pain interference (p < .001), accounting for 28.2% of the variance. There was minimal change in Bodily Pain scores over five years. The interaction of time and age was not significant (X² = 2.7, p = .61).

CONCLUSION

It is important to examine pain in the context of HRQOL in caregivers, regardless of age.

Military Injuries-Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study

Background

Veterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves.

Objective

In this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE.

Methods

We conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another.

Results

This study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022.

Conclusions

New national initiatives aim to incorporate the caregiver into the veteran’s treatment plan; however, we know little about the impact of caregiving—both positive and negative—on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home.

International Registered Report Identifier (IRRID)

PRR1-10.2196/30975