Stroke: The Increasing Complexity of Carer Needs

Caregiver burden, hopelessness, and anxiety: Association between sociodemographic and clinical profiles of patients with stroke

OBJECTIVES

This study aimed to evaluate the association between the sociodemographic characteristics of caregivers and patients with stroke, clinical data on stroke, and disability with caregiver burden, hopelessness, and anxiety.

MATERIALS AND METHODS

This cross-sectional study included patients with stroke of either sex, aged >18 years. Data were collected between January 2020 and July 2021. Patient demographic included age, sex, stroke type, severity, etiology, topography, treatment, and stroke recurrence. Stroke disability was assessed using the modified Rankin Scale and Barthel Index at 90 days post-discharge. Additionally, caregiver burden, hopelessness, and anxiety were evaluated during patient consultations using the Zarit Burden Interview (ZBI), Beck Hopelessness Scale (BHS), and Beck Anxiety Inventory (BAI).

RESULTS

We included 104 patients with stroke and their caregivers. Overall caregiver burden was moderate (ZBI: 24 [25]), with mild hopelessness (BHS: 4 [4]) and minimal to mild anxiety (BAI: 8 [13]). The linear regression model presented in Table 3 showed that female caregivers scored up to 11 points higher on the Zarit Burden Interview (p = 0.011). Additionally, increased patient age was associated with a higher caregiver burden (p = 0.002) on the Zarit Burden Interview. Posterior circulation stroke and total anterior circulation stroke were also associated with higher Zarit Burden Interview scores compared to lacunar stroke (p = 0.017). Age was not associated with caregiver burden in the entire sample. However, an association between age and caregiver burden was found only in the female group. Furthermore, women aged 65 years and older experienced a more severe burden than women aged 18 to 64 years (p<0.001). Stroke disability was not associated with caregiver burden.

CONCLUSIONS

Older female caregivers were significantly affected when caring for stroke patients. Total anterior circulation stroke and Posterior circulation stroke increased Zarit Burden Interview scores. However, no association was observed between stroke disability and the caregiver burden.

Prevalence of depression and associated factors among caregivers of stroke survivors in developing countries: A systematic review and meta-analysis

BACKGROUND

Stroke is a leading cause of death and disability worldwide. While caregivers play a vital role in recovery, their long-term support can affect their mental well-being. This study aims to estimate the pooled prevalence of depression and associated factors among caregivers of stroke survivors in developing countries.

METHOD

A comprehensive literature search using the preferred reporting items for systematic review and meta-analysis (PRISMA) statement was conducted on Scopus, PsycINFO, EMBASE, Google Scholar, Psychiatry Online, and PubMed/MEDLINE. Data were extracted via a Microsoft Excel spreadsheet and analyzed via STATA version 11.0. Egger regression tests and funnel plot analysis were used to check for publication bias, and the I2 statistic was used to evaluate statistical heterogeneity. Sensitivity and subgroup analyses were also conducted to identify potential causes of heterogeneity.

RESULTS

Seventeen articles from 12 different countries were analyzed. The pooled prevalence of depression among caregivers of stroke survivors was 48.75% (95% confidence interval (CI): 38.64- 58.86). However, the prevalence of depression ranged widely from 17.2%-76%, which may be due to the variation in the depression assessment tools used, types of caregivers, and continent. A long duration of caregiving was the only significant factor associated with depression among caregivers of stroke survivors.

CONCLUSION

The current systematic review and meta-analysis revealed a high prevalence of depression among caregivers of stroke survivors in developing countries. However, there was significant heterogeneity between studies, which could be explained by differences in the depression assessment tools used, types of caregivers, and continents. Factors such as long caregiving times were significantly associated with depression among caregivers of stroke survivors. The study suggests that the depression assessment tool utilized itself could have modified the prevalence of depression among caregivers of stroke survivors. Therefore, a single depression assessment tool needs to be authorized.

Social Isolation and Social Support Influence Health Service Utilisation and Survival after a Cardiovascular Disease Event: A Systematic Review

Both cardiovascular disease (CVD) and social health carry high health and economic burdens. We undertook a systematic review to investigate the association between social isolation, low social support, and loneliness with health service utilisation and survival after a CVD event among people living in Australia and New Zealand. Four electronic databases were systematically searched for the period before June 2020. Two reviewers undertook the title/abstract screen. One reviewer undertook a full-text screen and data extraction. A second author checked data extraction. Of 756 records, 25 papers met our inclusion criteria. Included studies recruited 10-12,821 participants, aged 18-98 years, and the majority were males. Greater social support was consistently associated with better outcomes on four of the five themes (discharge destination, outpatient rehabilitation attendance, rehospitalisation and survival outcomes; no papers assessed the length of inpatient stay). Positive social health was consistently associated with better discharge designation to higher independent living. As partner status and living status did not align with social isolation and social support findings in this review, we recommend they not be used as social health proxies. Our systematic review demonstrates that social health is considered in cardiac care decisions and plays a role in how healthcare is being delivered (i.e., outpatient, rehabilitation, or nursing home). This likely contributes to our finding that lower social support is associated with high-intensity healthcare services, lower outpatient rehabilitation attendance, greater rehospitalisation and poorer survival. Given our evidence, the first step to improve cardiac outcomes is acknowledging that social health is part of the decision-making process. Incorporating a formal assessment of social support into healthcare management plans will likely improve cardiac outcomes and survival. Further research is required to assess if support person/s need to engage in the risk reduction behaviours themselves for outpatient rehabilitation to be effective. Further synthesis of the impact of social isolation and loneliness on health service utilisation and survival after a CVD event is required.

Co-design and evaluation of a patient-centred transition programme for stroke patients, combining case management and access to an internet information platform: study protocol for a randomized controlled trial - NAVISTROKE

BACKGROUND

Stroke affects many aspects of life in stroke survivors and their family, and returning home after hospital discharge is a key step for the patient and his or her relatives. Patients and caregivers report a significant need for advice and information during this transition period. Our hypothesis is that, through a comprehensive, individualised and flexible support for patients and their caregivers, a patient-centred post-stroke hospital/home transition programme, combining an Internet information platform and telephone follow-up by a case manager, could improve patients' level of participation and quality of life.

METHODS

An open parallel-group randomized trial will be conducted in two centres in France. We will recruit 170 adult patients who have had a first confirmed stroke, and were directly discharged home from the stroke unit with a modified Rankin score ≤3. Intervention content will be defined using a user-centred approach involving patients, caregivers, health-care professionals and social workers. Patients randomized to the intervention group will receive telephonic support by a trained case manager and access to an interactive Internet information platform during the 12 months following their return home. Patients randomized to the control group will receive usual care. The primary outcome is patient participation, measured by the "participation" dimension score of the Stroke Impact Scale 6 months after discharge. Secondary outcomes will include, for patients, quality of life, activation, care consumption, as well as physical, mental and social outcomes; and for caregivers, quality of life and burden. Patients will be contacted within one week after discharge, at 6 and 12 months for the outcomes collection. A process evaluation alongside the study is planned.

DISCUSSION

Our patient-centred programme will empower patients and their carers, through individualised and progressive follow-up, to find their way around the range of available healthcare and social services, to better understand them and to use them more effectively. The action of a centralised case manager by telephone and the online platform will make it possible to disseminate this intervention to a large number of patients, over a wide area and even in cases of geographical isolation.

TRIAL REGISTRATION

ClinicalTrials NCT03956160 , Posted: May-2019 and Update: September-2021.

A psychosocial intervention for stroke survivors and carers: 12-month outcomes of a randomized controlled trial

Background and Purpose: Stroke can have a devastating impact on the mental and physical health of stroke survivors and their carers. We aimed to evaluate the effectiveness of a novel psychosocial intervention designed to improve health outcomes in both groups.Methods: We conducted a randomized controlled trial of a personalized psychosocial intervention (eight 1-hour weekly sessions plus one booster) compared to usual care for adult stroke survivors and carers. Participants recruited from hospital services and community referrals completed questionnaires at baseline, 3, 6, and 12 months. Primary outcomes were quality of life and self-efficacy; secondary outcomes were depressive and anxiety symptoms, coping, illness perception, work and social adjustment, carer strain, and carer satisfaction. Mixed-effect model repeated measures analysis between groups and across time was conducted.Results: Of the 173 participants recruited (89 stroke survivors; 84 carers), a total of 137 participants - 73 stroke survivors (intervention n = 42; usual care n = 31) and 64 carers (intervention n = 35; usual care n = 29) - underwent analysis up to 12 months. No statistically significant differences were found in the primary outcomes between groups over time, though a significant improvement in carer satisfaction was found at 6 months in the intervention group compared to the usual care group.Conclusion: A personalized psychosocial intervention resulted in a significant improvement in carer satisfaction at 6 months but in no other outcomes. A lack of available services and barriers to social engagement may have impeded the effectiveness of this intervention.

An Evaluation of the Family Informal Caregiver Stroke Self-Management Program

BACKGROUND

Caregivers are often unprepared and overwhelmed with the responsibilities of providing care to stroke survivors, which can lead to negative physical and psychological effects.

PURPOSE

To evaluate the impact of the Family Informal Caregiver Stroke Self-Management (FICSS) program on burden and life changes resulting from providing care among family caregivers of stroke survivors.

METHODS

A prospective pre-test and post-test design using quantitative and qualitative data was used to evaluate the program with a convenience sample of 42 caregivers. The four-module facilitated program consisted of small group-guided discussion. Quantitative evaluations were completed at baseline, 2 weeks and 6 months (post-intervention), and qualitative data were collected at 2 weeks and 6 months. Life changes and burden were measured using the Bakas Caregiving Outcome Scale (BCOS) and the Oberst Caregiving Burden Scale (OCBS), respectively.

RESULTS

The BCOS scores increased consistently over time, showing significant differences at 6 months compared with 2 weeks (mean difference: 5.29, 95% confidence interval [CI]: 0.30-10.28, p=0.04) and baseline (mean difference: 7.58, 95% CI: 2.92-12.23, p=0.001). The OCBS time scores decreased consistently over time, showing a significant difference at 6 months compared with baseline (mean difference: -5.20, 95% CI: -0.96 to -9.44, p=0.02). The OCBS difficulty scores fluctuated over time, resulting in no overall difference from baseline to 6 months. Qualitative themes were consistent with the positive quantitative findings.

CONCLUSION

Study results suggest that the FICSS program may result in reduced caregiver burden and improved life changes resulting from providing care.

Effects of early motivational interviewing on post-stroke depressive symptoms: A pilot randomized study of the Good Mood Intervention program

AIMS

The aim of this pilot randomized study was to investigate the feasibility of early motivational interviewing, for reducing mood after acute stroke.

BACKGROUND

Depression is a frequent consequence of stroke that can adversely affect recovery.

METHODS

DESIGN: Pilot randomized study. Intervention group patients received 3, individual motivational interviewing sessions by nurses or social workers prior to hospital discharge.

PARTICIPANTS

Adult patients with acute stroke during 2013 to 2014.

BLINDING

Research assistant who collected data was blind to group assignment.

OUTCOMES

Data were collected at 3 time points: baseline, 1-month, and 3-month follow-up. Outcome measures (anxiety, depression, quality of life) were analysed by descriptive statistics.

RESULTS

Forty-eight patients were enrolled, and 79% retention was achieved at 3 months. Eight participants withdrew (16.7%), and 2 were unable to participate (death: 2.1% and new onset aphasia: 2.1%), leaving 38 participants in the final cohort (Intervention: N = 18, Control: N = 20). Anxiety, depression, and quality of life measures did not alter significantly in the study period.

CONCLUSIONS

Carefully designed studies are required to investigate the effectiveness of early motivational interviewing for improving mood after stroke. The therapy can be administered by nurses, but significant resources are required in terms of training and fidelity.

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography

Objective

To describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services.

Design

Systematic review and meta-ethnography.

Data sources

Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015).

Eligibility criteria

Primary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services.

Data synthesis

A set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria.

Results

51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke.

Limitations

Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems.

Conclusions

Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services.

Systematic review registration number

PROSPERO 2015:CRD42015026602

The Stroke and Carer Optimal Health Program (SCOHP) to enhance psychosocial health: study protocol for a randomized controlled trial

BACKGROUND

Stroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers.

METHODS

This study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted.

DISCUSSION

We believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management.

TRIAL REGISTRATION

ACTRN12615001046594 . Registered on 7 October 2015.

Trialling of an optimal health programme (OHP) across chronic disease

Population ageing is a worldwide phenomenon, most advanced in developed countries and expected to continue over the next few decades. As people are surviving longer with age-associated disease and disability, there is an imperative to identify innovative solutions for an already overburdened health care system. Such innovations need to be focused on disease management, taking into consideration the strong associations that have been established between psychosocial factors and pathophysiological mechanisms associated with chronic disease. Aside from personal and community costs, chronic diseases produce a significant economic burden due to the culmination of health care costs and lost productivity. This commentary reports on a programme of research, Translating Research, Integrated Public Health Outcomes and Delivery, which will evaluate an optimal health programme that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of those with chronic disease. The effectiveness of the optimal health programme will be evaluated across three of the most significant contributors to disease burden: diabetes mellitus, chronic kidney disease and stroke. Cost-effectiveness will also be evaluated. The findings derived from this series of randomised controlled trials will also provide evidence attesting to the potential applicability of the optimal health programme in other chronic conditions.

Tracking patterns of needs during a telephone follow-up programme for family caregivers of persons with stroke

PURPOSE

Programmes that address stroke family caregiver needs and skill-building are recommended based on the literature and patient care guidelines for stroke rehabilitation. The purpose of this study was to explore patterns of perceived needs and skill-building during a stroke caregiver intervention programme.

METHOD

Descriptive statistics were used to analyse data from 123 stroke caregivers enrolled in the intervention group of a randomised controlled clinical trial. Caregivers received eight weekly telephone sessions, with a booster session a month later. At each session, the Caregiver Needs and Concerns Checklist (CNCC) was used to identify and prioritise current needs that were then addressed through skill-building strategies.

RESULTS

Perceived needs changed over time. Information about stroke was the highest priority need during Session 1. Managing survivor emotions and behaviours was the highest priority for Sessions 2 through 4. Caregivers generally waited until Sessions 5 through 9 to address their own emotional and physical health needs. Physical and instrumental care needs were relatively low but stable across all nine sessions. Skill-building was consistently high, though it peaked during Sessions 2 and 3.

CONCLUSIONS

Tracking patterns of needs and skill-building suggest appropriate timing for targeting different types of family caregiver support during stroke rehabilitation. Implications for Rehabilitation Family caregivers of stroke survivors play an essential role in the rehabilitation process of the stroke survivor. Identifying and addressing the priority needs and concerns of stroke caregivers during the early discharge period enables caregivers to provide sustained support for the stroke survivor. Rehabilitation professionals are in a key position to address evolving caregiver needs and concerns as they transition to home settings with follow-up care.

Telephone Assessment and Skill-Building Kit for Stroke Caregivers: A Randomized Controlled Clinical Trial

BACKGROUND AND PURPOSE

There are few evidence-based programs for stroke family caregivers postdischarge. The purpose of this study was to evaluate efficacy of the Telephone Assessment and Skill-Building Kit (TASK II), a nurse-led intervention enabling caregivers to build skills based on assessment of their own needs.

METHODS

A total of 254 stroke caregivers (primarily female TASK II/information, support, and referral 78.0%/78.6%; white 70.7%/72.1%; about half spouses 48.4%/46.6%) were randomized to the TASK II intervention (n=123) or to an information, support, and referral group (n=131). Both groups received 8 weekly telephone sessions, with a booster at 12 weeks. General linear models with repeated measures tested efficacy, controlling for patient hospital days and call minutes. Prespecified 8-week primary outcomes were depressive symptoms (with Patient Health Questionnaire Depressive Symptom Scale PHQ-9 ≥5), life changes, and unhealthy days.

RESULTS

Among caregivers with baseline PHQ-9 ≥5, those randomized to the TASK II intervention had a greater reduction in depressive symptoms from baseline to 8, 24, and 52 weeks and greater improvement in life changes from baseline to 12 weeks compared with the information, support, and referral group (P<0.05); but not found for the total sample. Although not sustained at 12, 24, or 52 weeks, caregivers randomized to the TASK II intervention had a relatively greater reduction in unhealthy days from baseline to 8 weeks (P<0.05).

CONCLUSIONS

The TASK II intervention reduced depressive symptoms and improved life changes for caregivers with mild to severe depressive symptoms. The TASK II intervention reduced unhealthy days for the total sample, although not sustained over the long term.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01275495.

Caring for caregivers after a stroke

Stroke usually occurs in the latter years of life, is sudden and all too often unexpected and unforgiving. When non-fatal, stroke, the second leading cause of disability after dementia, is nearly always disabling (World Health Organization (WHO), 2011). Due to common ensuing physical and cognitive impairments, many stroke survivors are unable to care for themselves in the following weeks, months, and possibly years (Lutz et al., 2011). Thus, the caregiver role is instant and often long-term with no or very little time to adapt to the many, varied and immediate challenges.

The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of psychosocial interventions for family caregivers on their psychosocial and physical wellbeing, quality of life, and the use of healthcare resources by stroke survivors.

METHODS

Electronic English and Chinese bibliographic databases were searched (inception to January 2012) for clinical trials. Two reviewers independently selected and appraised study quality. When possible, data from randomized controlled trials (RCTs) were statistically pooled. Otherwise, a narrative summary was used.

RESULTS

Eighteen studies (psychoeducation and social support group) were included. Pooled analysis of two individual psychoeducation programs showed a small effect on improving family functioning (SMD: -0.12; 95% CI: -0.23 to -0.01; p=0.03). Caregivers receiving psychoeducation that aimed at equipping caregivers with the skills of problem-solving, caregiving, and stress-coping appeared to have a more positive influence on the caregivers' psychosocial wellbeing and a reduced use of healthcare resources by stroke survivors.

CONCLUSION

Evidence on the effects of psychosocial interventions was limited. More RCTs of multifaceted psychoeducation programs are needed to further examine the optimal dose and format.

PRACTICAL IMPLICATIONS

To support caregivers across the stroke trajectory, the core skills of problem-solving and stress-coping should be included in the psychosocial interventions.

The Experience of Engaging in Occupation following Stroke: A Qualitative Meta-Synthesis

Introduction:

A meta-synthesis is a means of extracting data from multiple qualitative studies about the same topic, re-analysing the findings and bringing them together as a collective whole. Data from six qualitative studies that investigated the experience of engaging in occupation following a stroke were extracted and reanalysed with the purpose of gaining a greater understanding of the subjective experience to inform occupational therapy practice.

Methods:

Six databases were systematically searched for literature published in English during 1990–2011. Seven studies were appraised using the Critical Appraisal Skills Programme tool; six of these were included in the meta-synthesis.

Findings:

Five conceptual themes regarding occupational engagement emerged from the review: an emotional response, impact on identity, role of significant others, community access and the process of occupational adaptation.

Conclusion:

Engagement in occupation following a stroke is linked to self-identity and an emotional response; both of these, in turn, have an impact on capacity for occupational adaptation. Individuals are situated within a context of significant others and community. These findings give occupational therapists greater insight into the experience of older people following stroke in community settings.

Anxiety and depression associated with caregiver burden in caregivers of stroke survivors with spasticity

OBJECTIVE

To investigate the relationship between anxiety/depression and caregiver burden in informal caregivers of stroke survivors with spasticity.

DESIGN

Data were collected via online surveys from informal caregivers 18 years or older who cared for stroke survivors.

SETTING

Internet-based survey.

PARTICIPANTS

2007 through 2009 U.S. National Health and Wellness Survey database or Lightspeed Research general panel respondents (N=153).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Anxiety and depression were self-reported by the caregiver as a physician diagnosis. Depression severity was measured by the Patient Health Questionnaire-9 (PHQ-9). Caregiver burden was measured by the Oberst Caregiving Burden Scale (OCBS) and the Bakas Caregiving Outcomes Scale (BCOS). Logistic regression analyses were conducted with anxiety, depression, and the PHQ-9 depression severity categories as a result of each caregiver burden scale.

RESULTS

Data were analyzed for 153 informal caregivers; they were mostly women (70.6%) and white (78.4%), with a mean age of 51.6 years. For every 1-point increase in the OCBS Difficulty Scale, the odds of anxiety or depression were 2.57 times as great (P<.001) and 1.88 times as great (P=.007), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 2.48 times as great (P<.001). For every 1-point decrease in the BCOS, the odds of anxiety or depression were 2.43 times as great (P<.001) and 2.27 times as great (P=.002), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 4.55 times as great (P<.001).

CONCLUSIONS

As caregiver burden increases, caregivers are more likely to have anxiety and depression. Depression severity also increases. Providing treatment to stroke survivors with spasticity that lessens the time and more importantly, the difficulty of caregiving may lead to a reduction in caregiver anxiety and depression.

The effectiveness of caregiver psychosocial interventions on the psychosocial wellbeing, physical health and quality of life of stroke family caregivers and their stroke survivors: A systematic review

BACKGROUND

Family caregivers play a significant role in the rehabilitation of stroke survivors. Various types of psychosocial interventions have been developed to improve the well-being of both stroke survivors and their caregivers. However, studies showed the results to be mixed and provided insufficient evidence about the optimal dose, approach and format of interventions.

OBJECTIVES

To identify the best available evidence related to the effectiveness of psychosocial interventions for family caregivers on the psychosocial and physical wellbeing of family caregivers and stroke survivors.

INCLUSION CRITERIA

Adult patients were community-dwelling stroke survivors with a clinical diagnosis of stroke. Family caregivers were adult family members of stroke survivors who were the primary caregivers.Trials of psychosocial interventions for family caregivers that aimed at improving the wellbeing of caregivers and stroke survivors.Randomised controlled trials, quasi-randomised, historical cohort and pre- and post-test studies.Primary outcomes were psychosocial wellbeing, physical health, and quality of life of both family caregivers and their stroke survivors. Secondary outcomes were family functioning, intervention satisfaction and use of social resources.

SEARCH STRATEGY

Thirty-nine electronic bibliographic databases in English and Chinese were searched from their inception to March 2011 and yielded 5,327 citations.Methodological quality The JBI Critical Appraisal Checklists were used to critically appraise study quality.Data Collection Two reviewers extracted and summarised the details of included studies using the JBI-MAStARI data extraction form independently.Data synthesis Standardised mean difference and 95% confidence interval were calculated for the summary effect of continuous data measured by different scales, and mean difference and 95% confidence interval were calculated for each included study using the same scale. Narrative summary was used when statistical pooling was not possible.

RESULTS

A total 18 studies involving 1,723 family caregivers and 1,836 stroke survivors, were included. Three types of psychosocial interventions, including counselling, psychoeducation and social support group were identified. On the basis of two studies examining the outcomes of counselling intervention, there was a significant improvement in family functioning (SMD: -0.12; 95% CI: -0.23 to -0.01; p = 0.03) immediately post-intervention. Caregivers receiving psychosocial interventions also reported a higher level of satisfaction when compared to those receiving usual care. No statistically significant effects on physical health, psychosocial wellbeing and quality of life of caregivers, or on their stroke survivors were found.

CONCLUSIONS

The review demonstrated evidence of positive effect of psychosocial interventions on family functioning of caregivers. More well designed randomised controlled trials are needed to further examine the optimal dose and format of psychosocial interventions owing to the diversity of interventions.

Mapping a Research Agenda for Home Care Safety: Perspectives from Researchers, Providers, and Decision Makers

Le but de cette conception qualitative et interprétative était d’examiner les perspectives des chercheurs, des pourvoyeurs de soins de santé et et des décideurs aux sujets des risques principaux, des préoccupations et des problèmes émergents rattachées à la sécurité de soins à domicile qui informerait une ligne d’enquête de recherche. La sécurité, tel qu’elle s’applique spécifiquement à ce context des soins à domicile, n’a pas encore été définie. Par conséquent, afin de profiter de diverses parties prenantes sur les questions de securité relatives aux soins à domicile est nécessaire afin d’informer les orientations stratégiques pour la recherche future. Afin de commencer à tracer un programme de recherche, une analyse en trois parties de l’environnement a été realisée: (a) une étude pilote avec les bénéficiaires et les fournisseurs de soins à domicile; (b) des entretiens avec des informateurs clés, les chercheurs, les fournisseurs de soins de santé, et les décideurs; et (c) une revue de la littérature dans trois domaines thématiques. Seulement les résultats des entrevues des informateurs clés sont présentés ici.

An investigation of family carers' needs following stroke survivors' discharge from acute hospital care in Australia

PURPOSE

 To expand understanding of informal stroke care-giving, validated tools previously used in Hong Kong and in the U.K. were used with Australian stroke carers to assess their stroke-related knowledge, perceived needs, satisfaction with services received and sense of burden after stroke patients' discharge home from acute hospital care.

METHODS

 Record audit and telephone interviews with two cohorts of 32 carers recruited in Sydney and Brisbane 1 and 3 months post-hospital discharge, using validated scales and open questions in May-July 2006.

RESULTS

 Female carers, those with prior care-giving responsibility, and those interviewed at three compared to one month post-discharge reported greatest needs and burden from the care-giving role; needs alone significantly predicted burden. Getting information and being prepared for life after discharge were central concerns. Some felt this was accomplished, but inadequate information giving and communication mismatches were apparent.

CONCLUSIONS

 Service providers need to develop partnership working with stroke families and provide a network of services and inputs that cut across conventional boundaries between health and social care, public, private and voluntary organisations, with care plans that deliver what they delineate. Stroke care-givers have common issues across countries and healthcare systems; collaborative research-based service development is advocated.

Needs, barriers and facilitators experienced by spouses of people with aphasia

PURPOSE

Little is known about how spouses cope with their needs as a result of their partner's aphasia. This study described spouses' needs and identified the barriers and facilitators to satisfying them.

METHODS

Four associations of people with aphasia were approached. Eleven spouses were interviewed in small groups. They described the results of their inquiries and efforts to satisfy their needs because their partner had aphasia (mean time since onset 6 years 8 months) as a result of stroke or surgery. Discussions were transcribed and coded. Excerpts were grouped into categories.

RESULTS

Spouses mainly needed support and respite, and perceived their partner to need help for communication and well-being. Personal factors like the availability of close others to provide help were facilitating. However, participants encountered barriers, mainly organisational, i.e. the help needed did not exist. Some needs persisted over time.

CONCLUSIONS

Results confirm the long-term needs of spouses in adjusting to the aphasia of their partner, as well as the limited services available to them. Many of the needs reflected spouses' concerns about their partner, while others were a consequence of their caregiving role as well as the unavailability of support. Spouses of people with aphasia should have access to support during and after rehabilitation.

Profile, burden, and quality of life of Israeli stroke survivor caregivers: a longitudinal study

The aims of this study were to (1) delineate the sociodemographic profile of Israeli primary caregivers of stroke survivors; (2) examine the changes in caregivers' burden, physical and emotional health, social support network, and quality of life (QOL) during the first 6 months after the stroke occurrence; and (3) identify the predictors of caregivers' QOL for that time period. Primary caregivers (N = 140) were assessed at three intervals during this period: within 2 weeks after the stroke occurrence, in the geriatric rehabilitation ward, and at 3 and 6 months poststroke in the community. Results of the study revealed that during the 6-month period, caregivers' physical health remained stable. After 3 months, depression levels decreased, as did the need for instrumental support in and outside the home. Nevertheless, satisfaction with informal support and family relationships decreased, as did QOL. Burden decreased consistently at 3- and 6-month intervals. After 6 months, perception of health and QOL improved, whereas the other variables remained stable. These results indicate that overall, this population of caregivers adapted to their role over the 6-month period. At each of the three intervals, QOL was explained by the same four variables, although with differential weights: number of diseases, confidence in the support system, burden, and sharing a household with the survivor. The results of this study contribute to nurses' ability to identify caregivers at risk and develop appropriately timed interventions for empowering caregivers in their role fulfillment.

Stroke caregiver outcomes from the Telephone Assessment and Skill-Building Kit (TASK)

PURPOSE

Stroke caregivers often express the need for information about stroke and assistance with stroke-related care in the early discharge period. The Telephone Assessment and Skill-Building Kit (TASK) is an 8-week program that addresses caregiver needs. This study explored the efficacy of the TASK program in improving stroke caregiver outcomes.

METHOD

Guided by a conceptual model, 6 outcomes (optimism, task difficulty, threat appraisal, depressive symptoms, life changes, general health perceptions) were measured in 40 caregivers randomized to the TASK (n=21) or an attention control group (n=19). Data were analyzed using analysis of covariance (ANCOVA), controlling for baseline scores and minutes spent with the nurse.

RESULTS

Significant increases in optimism at 4 weeks, 8 weeks, and 12 weeks were found, with medium effect sizes for the TASK group relative to the control group (p<.05). Significant improvements in task difficulty at 4 weeks, and threat appraisal at both 8 weeks and 12 weeks were also found (p<.05).

CONCLUSION

Caregivers receiving the TASK intervention improved in optimism, task difficulty, and threat appraisal. Further testing of an enhanced version of the TASK program is warranted, with attention directed toward more distal stroke caregiver outcomes.

Formal support of stroke survivors and their informal carers in the community: a cohort study

This cohort study, aims to explore formal care provision to stroke survivors and their informal carers in the community in the UK. An initial cohort of 105 cohabitant carers of first-time stroke patients was recruited while the stroke patient was in hospital. Structured face-to-face interviews were carried out with carers prior to discharge of the stroke patient home, at 6 weeks after discharge, and 15 months after stroke. Questionnaires included measures of psychological health (CIS-R), physical health (self-rated health), social well-being (relationship quality and Sarason's social support questionnaire), handicap of the stroke survivor (Oxford Handicap Scale) and formal community support (amount of formal support and carer satisfaction). Multiple services were involved with most survivor-carer pairs (mean 5.4; range 2-9; SD = 1.7), and 74% of carers were satisfied with formal support provided. Number of services decreased with time (5.5 versus 4.1, t = 4.201, d.f. = 52, P < 0.001, 95% confidence interval: 0.71-2.01) but not time allocated. Using stepwise linear regression, service provision early after discharge was predicted by: level of handicap, recruitment centre, carer self-rated health, number of informal supporters and other care commitments. Satisfaction was predicted by quality of informal support and activity restriction. Fifteen months after stroke, predictors of formal care were: level of handicap, quality of informal support and previous caring experience. Predictors of satisfaction were: quality of the relationship between the stroke survivor and carer, age and mood. Quality of services was good, but carers lacked information, had insufficient help and were not consulted enough. Carer distress is common, yet not currently a factor influencing support provision. Formal care provided adapts with time reflecting the importance of quality of support from friends and family rather than quantity of informal supporters. These factors should be taken into consideration when planning and providing formal support for stroke survivors and their carers.

The cost of cerebral ischaemia

Cerebral ischaemia is a major cause of disability and death globally and has a profoundly negative impact on the individuals it affects, those that care for them and society as a whole. The most common and familiar manifestation is stroke, 85% of which are ischaemic and which is the second leading cause of death and most common cause of complex chronic disability worldwide. Stroke survivors often suffer from long-term neurological disabilities significantly reducing their ability to integrate effectively in society with all the financial and social consequences that this implies. These difficulties cascade to their next of kin who often become caregivers and are thus indirectly burdened. A more insidious consequence of cerebral ischaemia is progressive cognitive impairment causing dementia which although less abrupt is also associated with a significant long-term disability. Globally cerebrovascular diseases are responsible for 5.4 million deaths every year (1 in 10 of total). Approximately 3% of total healthcare expenditure is attributable to cerebral ischaemia with cerebrovascular diseases costing EU healthcare systems 21 billion euro in 2003. The cost to the wider economy (including informal care and lost productivity) is even greater with stroke costing the UK 7-8 billion pound in 2005 and the US $62.7 billion in 2007. Cerebrovascular disease cost the EU 34 billion euro in 2003. From 2005 to 2050 the anticipated cost of stroke to the US economy is estimated at $2.2 trillion. Given the global scale of the problem and the enormous associated costs it is clear that there is an urgent need for advances in the prevention of cerebral ischaemia and its consequences. Such developments would result in profound benefits for both individuals and their wider societies and address one of the world's most pre-eminent public health issues.

Between freedom and reclusion: social support as a quality-of-life component in the family caregiver-dependent person binomial

This is a qualitative study which uses Grounded Theory as its methodological framework and Symbolic Interactionism as a theoretical base to understand the experience of family caregivers for Cerebrovascular Accident (CVA) patients with regard to social support during their rehabilitation process at home. The components (themes and categories) of the phenomenon assuming home care and specifically the themes assuming care with support and assuming care without support were inter-related for the purpose of comparison and analysis, in order to apprehend how the interaction between them occurred. It was observed that, in addition to the recovery of the patient's autonomy, social support is one of the intervenient components in the quality of life for the family caregiver-disabled person binomial, particularly with respect to the caregiver's freedom to resume his/her life plan.

Evidence-based educational guidelines for stroke survivors after discharge home

Stroke survivors today are discharged home from the hospital more quickly than in the past because of shifting economic realities. Survivors continue to experience significant impairments after discharge and families may be poorly prepared for the full extent of caregiving responsibilities. This article describes 39 comprehensive educational guidelines that have been tested with 72 stroke survivors and families during 1,150 home visits throughout the first 6 months after discharge from inpatient rehabilitation. Two case studies illustrate use of the guidelines with stroke survivors and their families.