A Systematic Review of Caregiver Burden following Stroke

Caregiver burden and familial impact in Down Syndrome Regression Disorder

BACKGROUND

Down Syndrome Regression Disorder (DSRD) is an acute or subacute neurocognitive regression in individuals with Down syndrome (DS), characterized by a loss of previously acquired cognitive, adaptive, and social skills. DSRD profoundly affects individuals' ability to engage in activities of daily living, making them highly dependent on their caregivers who must provide significantly more support than before the DSRD diagnosis. This study aimed to examine caregiver burden, quality of life, and depression among caregivers of individuals with DSRD versus caregivers of those with DS and other neurological disorders (DSN).

DESIGN/METHODS

In this cross-sectional study, caregivers of individuals with DSRD (n = 228) and DSN (n = 137) were recruited through Children's Hospital Los Angeles neurology clinic and a Facebook DSRD support group. Participants completed standardized questionnaires assessing quality of life (PedsQL Family Impact Module), caregiver burden (Zarit Caregiver Burden Assessment, ZCB), and depression (Glasgow Depression Scale, GDS), along with additional items addressing other factors of caregiver well-being. Data were analyzed using bivariate comparisons and univariate regression models to assess differences between groups.

RESULTS

Caregivers of individuals with DSRD were more likely than caregivers of those with DSN to report increased financial burden (p = 0.003), housing changes (p = 0.02), disrupted sleep (p < 0.001), negative impacts on social networks (p < 0.001), and worsened mental health (p < 0.001). Furthermore, DSRD caregivers reported significantly higher levels of burden (mean difference [95% CI]: 8.3 [6.3, 9.7]) and depression symptoms (2 [0.7, 3.4]), reflecting greater perceived stress and burden. They also had lower quality of life scores (-27.9 [-30.2, -25.5]), indicating a more substantial impact on overall well-being and daily functioning compared to DSN caregivers. Additionally, caregivers in the DSRD group had higher odds (odds ratio [95% CI]: 4.7 [2.9, 7.7)] of meeting clinical depression criteria (GDS score ≥ 13) than caregivers in the DSN group.

CONCLUSIONS

Caregivers of individuals with DSRD experience significantly greater distress and burden compared to those caring for individuals with DSN. The elevated risk of depression, combined with reduced quality of life and increased burden, underscores the multimodal nature of the challenges faced by this population.

Stroke survivors' health literacy is not associated with caregiver burden: a cross-sectional study

Caregivers to stroke survivors often experience a multifaceted strain defined as caregiver burden. Low health literacy among caregivers may contribute to increased caregiver burden but there is limited research specifically examining the association between stroke survivors' health literacy and caregiver burden. Therefore, the aim here is to explore if there is an association between stroke survivors' health literacy and caregiver burden one year after stroke. Participants were 50 caregivers and 50 stroke survivors who were followed up in a longitudinal study on care transitions after stroke. Data were collected one year after the stroke survivors' discharge from hospital and analysed using ordinal logistic regression. Most of the caregivers, median age 71 years, reported being satisfied with their lives (85%) and a low caregiver burden (74%). Stroke survivors' health literacy was not associated with caregiver burden. However, lower needs of assistance in daily activities, lower levels of depression, higher levels of participation and increased age in stroke survivors were associated with lower caregiver burden. In conclusion, stroke survivors' health literacy was not associated with caregiver burden one year after stroke. Future studies with larger samples, focusing on populations with lower functioning after stroke and higher caregiver burden, are recommended.

Effect of Social Support on Caregiver's Functional Disability Due to Spouse's Functional Disability

OBJECTIVES

To examine the effect of social support on the risk of caregiver's functional disability due to spouse's functional disability.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

In this cohort study using the Ohsaki Cohort 2006 Study data, the baseline survey was conducted from December 1, 2006, to December 15, 2006, and included 7598 older adults, including 3799 couples, ≥65 years of age.

METHODS

The incidence of spouse's functional disability was defined as certification for the Long-term Care Insurance, which uses a nationally uniform standard of functional disability. The primary outcome was the incidence of the caregiver's functional disability, and the follow-up period was between December 16, 2006, and November 30, 2019. Five social support questionnaires were used to assess the degree of emotional and instrumental social support available to each participant. The Cox proportional hazards model was used to evaluate the incidence of functional disability among caregivers after the occurrence of spouses' functional disability. Subgroup analyses were also conducted according to the status of emotional and instrumental social support.

RESULTS

The caregiver's functional disability increased significantly among those whose spouses had functional disability compared with those whose spouses had no disability [multivariate hazard ratio (HR), 1.86]. Emotional and instrumental social support showed significant positive interactions on this association (emotional and instrumental support: P for interaction < .01 and < .01, respectively), and the risk of caregiver's disability was higher among those without social support than among those with social support (with emotional support: HR, 1.84; without emotional support: HR, 2.51; with instrumental support: HR, 1.85; without instrumental support: HR, 2.31).

CONCLUSIONS AND IMPLICATIONS

Social support may help to alleviate the increased risk for caregiver's functional disability due to the spouse's functional disability.

Carer strain in post-stroke emotionalism: a cross-sectional analysis

OBJECTIVES

Post-stroke emotionalism (PSE) is a common, under-researched neurologic symptom of stroke, characterised by frequent crying episodes not under usual social control. Currently, there are no data on carer strain in the context of emotionalism after stroke. We aimed to explore the degree of carer strain in carers of individuals with diagnosed PSE compared with carers of individuals with stroke but no PSE to examine whether carer strain varies with particular characteristics of the cared for individual (patient age, sex, social deprivation, stroke type, functional status, mood status) and to quantify the impact of PSE on carer strain, after accounting for other factors.

DESIGN

Cross-sectional observation study.

SETTING

Nine secondary care stroke units in Scotland, UK.

PARTICIPANTS

102 informants of people with stroke.

PRIMARY AND SECONDARY OUTCOME MEASURES

The Modified Carer Strain Index was completed at 6 months post-stroke as part of the Testing Emotionalism After Recent Stroke (TEARS) longitudinal cohort study between 1 October 2015 and 30 September 2018. Stroke survivor diagnostic status was determined using TEARS-Diagnostic Interview based on published, widely accepted diagnostic criteria of emotionalism.

RESULTS

There was little evidence of association between carer strain and sex, age, deprivation level or stroke type of the cared for individual. There was strong evidence that carer strain was associated with both increased functional dependence post-stroke (-0.30 to -0.02, p=0.026) and presence of PSE (0.16 to 1.73, p=0.019).

CONCLUSIONS

Even after accounting for increased functional dependence, our study data indicates that caring in a PSE context may significantly increase carer strain, comparable to a six-point reduction on the Barthel Index.

TRIAL REGISTRATION NUMBER

NRS Stroke Research Network ID 18980.

Navigating Challenges and Coping Strategies Among Family Caregivers of Memory-Impaired Stroke Survivors in Metro Cebu, Philippines

This study explored the lived experiences of family caregivers for stroke survivors with memory impairments in Metro Cebu, Philippines, using a qualitative design. In-depth semi-structured interviews with six caregivers were analyzed using Yin's five-phase thematic analysis. Three key themes emerged: (1) Nurturing Patient Well-Being, highlighting the emotional and physical demands of caregiving; (2) Navigating the Trials of Caregiving, detailing the emotional, psychological, and financial challenges caregivers face; and (3) Altered Life Course, illustrating the lifestyle changes and coping mechanisms employed. The findings emphasize the need for structured support systems and tailored caregiving guidelines for occupational therapists to assist caregivers.

Post-stroke Cognition is Associated with Stroke Survivor Quality of Life and Caregiver Outcomes: A Systematic Review and Meta-analysis

Disability arising from post-stroke cognitive impairment is a likely contributor to the poor quality of life (QoL) stroke survivors and their carers frequently experience, but this has not been summarily quantified. A systematic literature review and meta-analysis was completed examining the association between general and domain-specific post-stroke cognitive functioning and adult stroke survivor QoL, caregiver QoL, and caregiver burden. Five databases were systematically searched, and eligibility for inclusion, data extraction, and study quality were evaluated by two reviewers using a standardised protocol. Effects sizes (r) were estimated using a random effects model. Thirty-eight studies were identified, generating a sample of 7365 stroke survivors (median age 63.02 years, range 25-93) followed for 3 to 132 months post-stroke. Overall cognition (all domains combined) demonstrated a significant small to medium association with QoL, r = 0.23 (95% CI 0.18-0.28), p < 0.001. The cognitive domains of speed, attention, visuospatial, memory, and executive skills, but not language, also demonstrated a significant relationship with QoL. Regarding caregiver outcomes, 15 studies were identified resulting in a sample of 2421 caregivers (median age 58.12 years, range 18-82) followed for 3 to 84 months post-stroke. Stroke survivor overall cognitive ability again demonstrated a significant small to medium association with caregiver outcomes (QoL and burden combined), r = 0.17 (95% CI 0.10-0.24), p < 0.001. In conclusion, lower post-stroke cognitive performance is associated with significant reductions in stroke survivor QoL and poorer caregiver outcomes. Cognitive assessment is recommended early to identify those at risk and implement timely interventions to support both stroke survivors and their caregivers.

Sigma-1 receptor signaling: A potential therapeutic approach for ischemic stroke

Strokes constitute over 50% of all neurological diseases, standing as the foremost cause of physical and mental disability. Currently, there are no widely accepted gold standard treatments for ischemic strokes beyond intravenous thrombolysis and mechanical thrombectomy applied during the acute therapeutic window. Therefore, the need for novel treatments targeting crucial signaling mediators involved in ischemic stroke is of utmost importance. The sigma-1 receptor (S1R), a molecular chaperone located at mitochondria-associated endoplasmic reticulum membranes (MAM), has exhibited neuroprotective effects when modulated by synthetic and endogenous agents across various cerebrovascular diseases. In this review, we describe the emerging therapeutic role of S1R agonists and antagonists in regulating blood-brain barrier (BBB) dysfunction, neuroinflammation, and neurocognitive impairment following ischemic stroke.

Family's Caregiving Status and Post-Stroke Functional Recovery During Subacute Period from Discharge to Home: A Retrospective Study

Background/Objectives: Family members, often informal caregivers, play a crucial role in providing home care for stroke survivors. The period following discharge to home after receiving acute stroke management in a hospital includes the subacute phase of stroke and remains critical to the recovery of stroke patients. This study evaluated the association between family caregiving and post-stroke functional recovery after discharge to home. Methods: Data from 402 patients with stroke were obtained from the Korea University Ansan Hospital Stroke Center from January 2019 to May 2022. The family's caregiving status was evaluated for family burden and supportable environment in the home. This study's outcome of interest was the modified Rankin Scale (mRS) at discharge to home and three months after stroke onset. The repeated mRS scores were analyzed using the Linear Mixed Model. Results: Median days from discharge to 3 months after stroke onset was 81.0 days. The median score of mRS at discharge was 2.0, and the score at three months after stroke onset was 2.0. The distribution of mRS score 0-2 was 60.9% at discharge and 72.1% at three months after stroke onset. In Linear Mixed Models after adjustments with covariables, the family's caregiving status was positively associated with repeated mRS scores (β = 0.17; 95% confidence interval = 0.11, 0.23; p < 0.001). Conclusions: These findings suggest that family caregiving to patients with stroke might be associated with post-stroke functional recovery within the period from discharge to home until three months after stroke onset.

The impact of sex and gender on burden for caregivers of stroke patients: A narrative review

BACKGROUND

When a patient is disabled after stroke, they require both emotional support and medical management and may require the assistance of a caregiver. Given the often-sudden onset of disability and the complex challenges related to caring for someone after stroke, caregivers can experience a heavy burden. Caregiver burden negatively affects quality of care, quality of life, and physical and psychological health. The impact of gender on caregiver burden has been in many other conditions; however, the association has not yet been thoroughly assessed in stroke.

OBJECTIVE

The aim of this paper is to define caregiver burden, discuss how it is assessed, discuss unique aspects of burden for stroke caregivers, and determine the impact of sex and gender on stroke caregiver role and burden.

METHODS

A narrative review was performed to synthesize the available literature and explore how the role of sex and gender impact caregiving for patients who have suffered stroke and whether sex and gender of the caregiver contribute to caregiver burden r.

RESULTS

Review of the available literature suggests that sex and gender significantly impact caregiving burden following stroke dipropionately affecting women.

CONCLUSIONS

Caregiving for patients who have suffered stroke is often provided by women both inside the home and when patients are within institutions. Women who serve as caregivers to stroke patients may be at higher risk of experiencing burden and its negative effects, including emotional strain, anxiety, and/or depression. More research is needed to determine the best ways to provide support for women who act as caregivers for stroke patients to mitigate caregiver burden.

A systematic review and meta-analysis of randomized controlled trials to reduce burden, stress, and strain in informal stroke caregivers

OBJECTIVES

To understand the nature and effectiveness of interventions aimed at improving informal stroke caregiver burden, stress, and strain.

DATA SOURCES

In line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of CENTRAL, CINAHL, MEDLINE, Embase, APA PsycInfo, and Web of Science was conducted in May 2022.

REVIEW METHODS

Studies were eligible if they included an intervention designed for informal stroke caregivers, reported on caregiver burden, strain, or stress, were published in English, and used a randomized controlled trial design. An updated search was conducted in June 2024. The methodological quality of studies was appraised using the Cochrane risk-of-bias tool for randomized trials. The data were pooled, and a meta-analysis was completed for caregiver burden and strain outcomes.

RESULTS

Nineteen studies met inclusion criteria and were meta-analyzed. Interventions ranged from 4 days to 12 months. Most studies incorporated educational and/or support components. Meta-analyses revealed nonsignificant effects on caregiver burden or strain. Significant between-group differences for caregiver strain and burden were, however, found in seven studies.

CONCLUSION

Limited studies, small sample sizes, and conflicting results made definitive conclusions on the most effective intervention characteristics for improving caregiver outcomes difficult. Of the 19 studies, seven found significant between-group differences for caregiver outcomes postintervention, and these tended to incorporate educational components and comprised between seven and nine sessions. Further high-quality research is required to identify optimal format, duration, and frequency for improving caregiver outcomes.

Developing SSC program for disabled elderly to promote ADL independence in nursing home using MRC framework for complex interventions

OBJECTIVE

To develop SSC program for promoting the independence of disabled elderly in Activities of Daily Living (ADL) care in nursing homes.

METHODS

This intervention aligns with the Medical Research Council (MRC) Framework for complex interventions. The following three steps were undertaken: (1) identifying the evidence base; (2) identifying/developing theory; (3) modeling processes and outcomes.

RESULTS

We successfully developed the complex intervention program of self-supporting care (SSC). The program comprises two integral parts: (1) self-supporting care interventions (SSC-i); (2) self-supporting care implementation interventions (SSC-ii).

CONCLUSIONS

Through adherence to the MRC framework, an evidence-based SSC program for managing ADL among disabled elderly individuals in nursing homes was developed. These findings offer a detailed specification of the SSC intervention protocol, which can serve as a valuable resource for healthcare professionals and researchers in subsequent phases, particularly in pilot testing the efficacy of the intervention and promote independence among disabled elderly individuals.

Sustaining Joy in Serious Neurologic Illnesses

The goals of medicine tend to be framed around addressing suffering, pathology, and functional deficits. While this is a natural orientation when dealing with serious illness, it is also incomplete and neglects significant opportunities to improve the quality of life of patients, families, and clinicians. The "total enjoyment of life" is a multidimensional framework that can serve as a positive counterbalance to the "total pain of illness." It allows clinicians, researchers, policymakers, and other stakeholders to take a systematic and comprehensive approach to the active promotion of well-being. The five opportunities for enhancing well-being in this framework are meaning, social connections, happiness/contentment, spiritual transcendence, and pleasure. Applying these concepts in clinical settings, patients, families, and clinicians can together find opportunities to increase the total enjoyment of life in the face of incurable and intractable illnesses. For family care partners, these concepts can be applied to improve self-care, enhance relationships, and develop more creative approaches to supporting a loved one living with illness. Clinicians working with these concepts may find their clinical work more satisfying and impactful and can also apply these concepts to their own lives to increase wellness. In clinical research, this framework can be applied to improve intervention effectiveness and relevance of outcome measures. Lastly, these concepts have the potential to impact public health approaches that focus on well-being and flourishing as the goal and metric of a healthy society.

Depression Mediates the Association Between Burden and Quality of Life in Informal Caregivers of Stroke Survivors: Meta-analytic Structural Equation Modeling

OBJECTIVE

This study aims to use Meta-analytical structural equation modeling (MASEM) to clarify the relationship between burden, depression, and quality of life in informal caregivers of stroke survivors.

DATA SOURCES

The databases of PubMed, Cochrane Library, Embase, China Knowledge Resource Integrated Database, Wan Fang Database, and Chinese Biomedical Database were comprehensively searched before January 16, 2023.

STUDY SELECTION

Two researchers performed an independent initial search by using a unified search strategy. Observational studies investigating the relation between burden, depression, and quality of life in informal caregivers of stroke survivors were included. The studies that met the inclusion criteria were appraised by "Quality Assessment and Validity Tool for Correlational Studies".

DATA EXTRACTION

PRISMA guidelines were used for this study. Data extraction was performed independently by 2 researchers. The following data were extracted: study author, year of publication, country, language, sample size, age, sex (%women), the caregivers' relation with stroke survivor, measures, type of outcome reported in the study, study design, and main conclusion.

DATA SYNTHESIS

The analysis included 18 articles that reported 23 effect sizes (N=3284). The MASEM findings showed that caregiver burden was positively associated with caregiver depression (β=0.474, 95% CI [0.398, 0.550]), caregiver depression was negatively associated with caregiver quality of life (β=-0.316, 95% CI [-0.545, -0.087]). Furthermore, the association between caregiver burden and quality of life was completely mediated by caregiver depression (β=-0.150, 95% CI [-0.271, -0.041]).

CONCLUSIONS

Using the MASEM approach, we observed that caregiver depression completely mediated the relation between burden and quality of life in informal caregivers of stroke survivors. Although the results did not allow for causal inference, this result suggested that for burdened stroke survivors' informal caregivers efforts should be made to their mental health to eliminate the internal barriers, then eventually improve their quality of life.

Adaptation and content validation of a patient-reported measure of treatment burden for use in stroke survivors: the patient experience with treatment and self-management in stroke (PETS-stroke) measure

PURPOSE

Stroke survivors often live with significant treatment burden yet our ability to examine this is limited by a lack of validated measurement instruments. We aimed to adapt the 60-item, 12-domain Patient Experience with Treatment and Self-Management (PETS) (version 2.0, English) patient-reported measure to create a stroke-specific measure (PETS-stroke) and to conduct content validity testing with stroke survivors.

MATERIALS AND METHODS

Step 1 - Adaptation of PETS to create PETS-stroke: a conceptual model of treatment burden in stroke was utilised to amend, remove or add items. Step 2 - Content validation: Fifteen stroke survivors in Scotland were recruited through stroke groups and primary care. Three rounds of five cognitive interviews were audio recorded and transcribed. Framework analysis was used to explore importance/relevance/clarity of PETS-stroke content. COSMIN reporting guidelines were followed.

RESULTS

The adapted PETS-stroke had 34 items, spanning 13 domains; 10 items unchanged from PETS, 6 new and 18 amended. Interviews (n = 15) resulted in further changes to 19 items, including: instructions; wording; item location; answer options; and recall period.

CONCLUSIONS

PETS-stroke has content that is relevant, meaningful and comprehensible to stroke survivors. Content validity and reliability testing are now required. The validated tool will aid testing of tailored interventions to lessen treatment burden.

Caregiver burden and impact on COVID-19 patient participation and quality of life one year after ICU discharge - A prospective cohort study

OBJECTIVES

to investigate changes in caregiver strain, mental health complaints and QoL in caregivers of COVID-19 ICU survivors in the first year after discharge, and their associations with patients' participation and quality of life.

METHODS

Post-ICU COVID-19 survivors, needing inpatient rehabilitation and their informal caregivers were included. Caregiver self-administered questionnaires included quality of life, self-rated health, caregiver strain, anxiety and depression symptoms, post-traumatic stress and coping style. Patients' participation in society was assessed and quality of life.

RESULTS

67 patients (78% male) and 57 caregivers (23.6% male) were included. Three months post-ICU, caregivers experienced caregiver strain (32%), anxiety (41%), depressive symptoms (16%) and PTSD (24%). One year post-ICU, rates decreased, still being 11%, 26%, 10% and 5%, respectively. Caregiver anxiety symptoms and self-rated health at three months were associated with worse patient levels of participation and quality of life one year after ICU discharge (p < 0.05).

CONCLUSIONS

COVID-19 caregivers experience high levels of mental health complaints one year after a patient's ICU discharge. Furthermore, our results indicate that patient participation levels and quality of life one year after ICU discharge may be negatively associated by caregiver complaints.

PRACTICAL IMPLICATIONS

Counselling and routine assessment of emotional complaints and unmet needs of the informal caregiver should be incorporated and addressed in the rehabilitation treatment of (COVID-19) post-ICU patients.

Exploring the Inclusion of Person-Centered Care Domains in Stroke Transitions of Care Interventions: A Scientific Statement From the American Heart Association

BACKGROUND

Health care teams along the stroke recovery continuum have a responsibility to support care transitions and return to the community. Ideally, individualized care will consider patient and family preferences, best available evidence, and health care professional input. Person-centered care can improve patient-practitioner interactions through shared decision-making in which health professionals and institutions are sensitive to those for whom they provide care. However, it is unclear how the concepts of person-centered care have been described in reports of stroke transitional care interventions.

METHODS

A secondary analysis of a systematic review and meta-analysis was undertaken. We retrieved all included articles (n=17) and evaluated the extent to which each intervention explicitly addressed 7 domains of person-centered care: alignment of care with patients' values, preferences, and needs; coordination of care; information and education; physical comfort; emotional support; family and friend involvement; and smooth transition and continuity of care.

RESULTS

Most of the articles included some aspects of person-centeredness; we found that certain domains were not addressed in the descriptions of transitional care interventions, and no articles mentioned all 7 domains of person-centered care. We identified 3 implications for practice and research: (1) delineating person-centered care components when reporting interventions, (2) elucidating social and cultural factors relevant to the study sample and intervention, and (3) clearly describing the role of family and nonmedical support in the intervention.

CONCLUSIONS

There is still room for greater consistency in the reporting of person-centeredness in stroke transitions of care interventions, despite a long-standing definition and conceptualization of person-centered care in academic and clinically focused literature.

Impact of healthcare-associated infections within 7-days of acute stroke on health outcomes and risk of care-dependency: a multi-centre registry-based cohort study

Healthcare-associated infections (HCAIs) in patients admitted with acute conditions remain a major challenge to healthcare services. Here, we assessed the impact of HCAIs acquired within 7-days of acute stroke on indicators of care-quality outcomes and dependency. Data were prospectively collected (2014-2016) from the Sentinel Stroke National Audit Programme for 3309 patients (mean age = 76.2 yr, SD = 13.5) admitted to four UK hyperacute stroke units (HASU). Associations between variables were assessed by multivariable logistic regression (odds ratios, 95% confidence intervals), adjusted for age, sex, co-morbidities, pre-stroke disability, swallow screening, stroke type and severity. Within 7-days of admission, urinary tract infection (UTI) and pneumonia occurred in 7.6% and 11.3% of patients. Female (UTI only), older age, underlying hypertension, atrial fibrillation, previous stroke, pre-stroke disability, intracranial haemorrhage, severe stroke, and delay in swallow screening (pneumonia only) were independent risk factors of UTI and pneumonia. Compared to patients without UTI or pneumonia, those with either or both of these HCAIs were more likely to have prolonged stay (> 14-days) on HASU: 5.1 (3.8-6.8); high risk of malnutrition: 3.6 (2.9-4.5); palliative care: 4.5 (3.4-6.1); in-hospital mortality: 4.8 (3.8-6.2); disability at discharge: 7.5 (5.9-9.7); activity of daily living support: 1.6 (1.2-2.2); and discharge to care-home: 2.3 (1.6-3.3). In conclusion, HCAIs acquired within 7-days of an acute stroke led to prolonged hospitalisation, adverse health consequences and risk of care-dependency. These findings provide valuable information for timely intervention to reduce HCAIs, and minimising subsequent adverse outcomes.

Assessing the mediating role of family resilience between caregiver burden and caregiver capacity: a cross-sectional study among Chinese stroke survivors and family caregivers in a real-world setting

OBJECTIVES

To investigate the relationships among caregiver burden, family resilience, and caregiver capacity in the care of stroke survivors. We hypothesised that family resilience would mediate the relationship between caregiver burden and caregiver capacity.

DESIGN

A cross-sectional study design was used.

SETTING

The study was conducted in a tertiary care setting in Ningbo City, Zhejiang Province, China.

PARTICIPANTS

The study involved 413 stroke survivors and their primary caregivers.

OUTCOME MEASURES

The primary caregivers completed the Shortened Chinese Version of the Family Resilience Assessment Scale, Zarit Caregiver Burden Interview and Family Caregiver Task Inventor and provided their sociodemographic information. Stroke survivors were assessed for activities of daily living, and their sociodemographic information was provided. Data were analysed, controlling for sociodemographic variables and focusing on the mediating effect of family resilience.

RESULTS

Caregiver burden was influenced by the activities of daily living of stroke survivors, caregiver age and caregiver health status (p<0.05). Higher caregiver burden was associated with lower family resilience (p<0.01). Lower caregiver capacity corresponded to heavier caregiver burden (p<0.01). Family resilience mediated the relationship between caregiver burden and caregiver capacity (b=0.1568; 95% CI: 0.1063 to 0.2385).

CONCLUSIONS

Enhancing family resilience can reduce caregiver burden and improve caregiver capacity in stroke care. These findings underscore the importance of developing interventions focused on nursing skills and family resilience.

Mental Health Conditions in Partners and Adult Children of Stroke Survivors

Importance

Family caregiving after critical illness has been associated with several adverse health outcomes, including various aspects of mental health, but research focusing specifically on family members of stroke survivors is limited.

Objectives

To examine the associations of stroke in a partner or parent with the risk of depression, substance use disorders, anxiety disorders, and self-harm or suicide.

Design, Setting, and Participants

This nationwide, population-based cohort study used data from Danish nationwide administrative and clinical registries (2004-2021). Participants included partners and adult children of survivors of stroke. Data analysis was performed from March to December 2023.

Exposure

Having a partner or parent who survived stroke.

Main Outcomes and Measures

The Aalen-Johansen estimator was used to compute propensity score-weighted 3-year absolute risks, risk differences, and risk ratios for depression, substance use disorders, anxiety disorders, and self-harm or suicide among partners or children of survivors of stroke compared with partners or children of survivors of myocardial infarction (MI) and matched individuals from the general population.

Results

The study included a total of 1 923 732 individuals: 70 917 partners of stroke survivors (median [IQR] age, 68 [59-76] years; 46 369 women [65%]), 70 664 partners of MI survivors (median [IQR] age, 65 [55-73] years; 51 849 women [73%]), 354 570 partners of individuals from the general population (median [IQR] age, 68 [59-76] years; 231 833 women [65%]), 207 386 adult children of stroke survivors (median [IQR] age, 45 [36-52] years; 99 382 women [48%]), 183 309 adult children of MI survivors (median [IQR] age, 42 [33-49] years; 88 078 women [48%]), and 1 036 886 adult children of individuals from the general population (median [IQR] age, 45 [36-52] years; 496 875 women [48%]). Baseline characteristics were well balanced across cohorts after propensity score weighting. Among partners of stroke survivors, the 3-year absolute risk was 1.0% for depression, 0.7% for substance use disorders, 0.3% for anxiety disorders, and 0.04% for self-harm or suicide. Risk ratio point estimates for the assessed outcomes ranged from 1.14 to 1.42 compared with the general population and from 1.04 to 1.09 compared with partners of MI survivors. The elevated risk of depression in partners of stroke survivors was more pronounced after severe or moderate stroke than after mild stroke. Among adult children of stroke survivors, the 3-year absolute risk was 0.6% for depression, 0.6% for substance use disorders, 0.2% for anxiety disorders, and 0.05% for self-harm or suicide. Both absolute risks and risk ratios for adult children of stroke survivors were smaller than those reported in the partner analyses.

Conclusions and Relevance

In this cohort study of partners and adult children of stroke survivors, risks of several mental health conditions and self-harm or suicide were moderately higher compared with the general population and, to a lesser extent, partners and adult children of MI survivors. These findings highlight the potential consequences of stroke among family members, particularly partners, and its findings may possibly serve as a quantitative foundation for the development of future stroke rehabilitation services.

Healthcare professionals' experiences of delivering a stroke Early Supported Discharge service - An example from Ireland

OBJECTIVE

To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic.

DESIGN

Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis.

SETTING

Nine Early Supported Discharge service sites in Ireland.

PARTICIPANTS

Purposive sampling identified 16 healthcare professionals.

RESULTS

Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families.

CONCLUSIONS

Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

COVID-19-related anxiety and obsession levels in stroke patients and family caregivers and their effects on caregiver burden

PURPOSE

The aim of this study is to describe coronavirus disease 2019 (COVID-19)-related dysfunctional anxiety and thinking in patients with stroke and caregivers who are family members and their effects on caregiver burden.

METHODS

This cross-sectional study included 79 stroke patients and their primary caregivers who were hospitalised in a tertiary rehabilitation hospital. Coronavirus Anxiety Scale (CAS) and Obsession with COVID-19 Scale (OCS) were used to assess the levels of COVID-19-related dysfunctional anxiety and obsession of the patients and their caregivers. Caregiver burden was assessed via the Zarit Burden Interview (ZBI).

RESULTS

In the patients with stroke, COVID-19-related anxiety and COVID-19-related obsession rates were 13.9% (n = 11) and 7.6% (n = 6), respectively, while 17.7% (n = 14) of caregiver family members had COVID-19-related anxiety and 11.4% (n = 9) had COVID-19-related obsession. The CAS score of caregivers showed a significant positive correlation with the CAS and OCS scores of patients (p = 0.000, r = 0.423; p = 0.007, r = 0.300, respectively). The OCS score of caregivers showed a significant positive correlation with the OCS scores of the patients (p = 0.000, r = 0.476). The mean ZBI score of caregiver family members was 31.9 ± 13.5. A significant positive correlation was observed between the caregiver's OCS and CAS scores and ZBI scores (p = 0.002, r = -0.349; p = 0.004, r = 0.323, respectively).

CONCLUSION

In this study, a significant relationship between caregiver burden and COVID-19-related anxiety and obsession in the caregivers of stroke patients was identified. Therefore, caregivers of stroke patients should not be forgotten during pandemics and should receive physical and psychological support.

Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study

PURPOSE

Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke.

MATERIAL AND METHODS

An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis.

RESULTS

Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors.

CONCLUSIONS

Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.

The caregiver burden of informal caregivers for stroke patients with and without dysphagia: A multi-center, cross-sectional study in Türkiye

Objectives

The aim of this study was to investigate the caregiver burden (CB) of informal caregivers for stroke survivors with and without dysphagia and to assess the relationship between the CB levels of informal caregivers for stroke survivors with dysphagia, patients' swallowing-related quality of life (QoL), and patients' stroke-specific QoL.

Patients and methods

This multi-center, prospective, cross-sectional study included a total of 120 stroke patients (76 males, 44 females; mean age: 61.1±12.3 years; range, 19 to 86 years) between October 2019 and 2020. Of the patients, 57 had dysphagia and 63 had no dysphagia. The Functional Oral Intake Scale (FOIS) was used to classify the degree of functional dietary limitation caused by each patient's swallowing impairment. Patients and caregivers completed the Eating Assessment Tool (EAT-10), Swallowing Quality of Life (SWQoL) questionnaire, Stroke Impact Scale (SIS), and the Zarit Caregiver Burden Interview (ZBI).

Results

The CB levels were higher in those caring for stroke patients with dysphagia than in those caring for stroke patients without dysphagia. Caregiver burden was found to be associated with patients' swallowing-related QoL and stroke-related QoL. Significant predictors of high CB scores (F=2.55, R2=0.59; p=0.007) were being an employed caregiver (B=17.48, p=0.003), being a caregiver with high school (B=-19.6, p=0.03), and secondary school (B=-16.28, p=0.02) educational status, being son, daughter (B=30.63, p=0.007) or other relative of the patient (B=20.06, p=0.01), lower FOIS stage (B=-3.14, p=0.011), lower SWQoL (B=0.52, p=0.009) and lower SIS (B=-0.37, p=0.04) scores.

Conclusion

Caregivers of stroke patients with dysphagia suffer from a higher CB than those without dysphagia. In stroke patients with dysphagia, swallowing-related QoL is associated with the QoL levels of stroke patients and the CB levels of their caregivers. Employment status, educational status of caregiver, caregiver's relativity to the patient, FOIS stage, swallowing and stroke related QoL of the patients are factors related to burden levels of caregivers of stroke patients with dysphagia. These results may help health professionals to understand dysphagia as an essential source of CB and consider it, while planning treatments.

Long-term psychological outcomes following stroke: the OX-CHRONIC study

BACKGROUND

Stroke survivors rate longer-term (> 2 years) psychological recovery as their top priority, but data on how frequently psychological consequences occur is lacking. Prevalence of cognitive impairment, depression/anxiety, fatigue, apathy and related psychological outcomes, and whether rates are stable in long-term stroke, is unknown.

METHODS

N = 105 long-term stroke survivors (M [SD] age = 72.92 [13.01]; M [SD] acute NIH Stroke Severity Score = 7.39 [6.25]; 59.0% Male; M [SD] years post-stroke = 4.57 [2.12]) were recruited (potential N = 208). Participants completed 3 remote assessments, including a comprehensive set of standardized cognitive neuropsychological tests comprising domains of memory, attention, language, and executive function, and questionnaires on emotional distress, fatigue, apathy and other psychological outcomes. Ninety participants were re-assessed one year later. Stability of outcomes was assessed by Cohen's d effect size estimates and percent Minimal Clinically Important Difference changes between time points.

RESULTS

On the Montreal Cognitive Assessment 65.3% scored < 26. On the Oxford Cognitive Screen 45.9% had at least one cognitive impairment. Attention (27.1%) and executive function (40%) were most frequently impaired. 23.5% and 22.5% had elevated depression/anxiety respectively. Fatigue (51.4%) and apathy (40.5%) rates remained high, comparable to estimates in the first-year post-stroke. Attention (d = -0.12; 85.8% stable) and depression (d = 0.09, 77.1% stable) were the most stable outcomes. Following alpha-adjustments, only perceptuomotor abilities (d = 0.69; 40.4% decline) and fatigue (d = -0.33; 45.3% decline) worsened over one year. Cognitive impairment, depression/anxiety, fatigue and apathy all correlated with worse quality of life.

CONCLUSION

Nearly half of participants > 2 years post-event exhibited psychological difficulties including domains of cognition, mood, and fatigue, which impact long-term quality of life. Stroke is a chronic condition with highly prevalent psychological needs, which require monitoring and intervention development.

Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review

Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices.

Healthcare professionals' perspectives of the provision of, and challenges for, eating, drinking and psychological support post stroke: findings from semistructured interviews across India

AIM

This qualitative study explores with health professionals the provision of, and challenges for, postdischarge stroke care, focussing on eating, drinking and psychological support across India.

DESIGN

Qualitative semistructured interviews.

SETTING

Seven geographically diverse hospitals taking part in a Global Health Research Programme on Improving Stroke Care in India.

PARTICIPANTS

A purposive sample of healthcare professionals with current experience of working with patients who had a stroke.

RESULTS

Interviews with 66 healthcare professionals (23 nurses (14 staff nurses; 7 senior nurse officers; 1 intensive care unit nurse; 1 palliative care nurse)); 16 doctors (10 neurologists; 6 physicians); 10 physiotherapists; 5 speech and language therapists; 4 occupational therapists; 4 dieticians; 2 psychiatrists; and 2 social workers resulted in three main themes: integrated inpatient discharge care planning processes; postdischarge patient and caregiver role and challenges; patient and caregiver engagement post discharge.

CONCLUSIONS

Discharge planning was integrated and customised, although resources were limited in some sites. Task shifting compensated for a lack of specialists but was limited by staff education and training. Caregivers faced challenges in accessing and providing postdischarge care. Postdischarge care was mainly hospital based, supported by teleservices, especially for rural populations. Further research is needed to understand postdischarge care provision and the needs of stroke survivors and their caregivers.

Depression status and functional outcome of patients with ischemic stroke and the impact on caregivers living in Chengdu: a cross-sectional study

Objectives

To investigate the associations between risk factors and depression symptoms in ischemic stroke (IS) survivors and the effect of IS survivors' depression status and functional outcomes on caregiver burden in Chengdu, China.

Methods

In this cross-sectional study, we recruited a convenience sample of patients with IS and paired caregivers living in Chengdu from February 2022 to May 2022. Depression symptoms were assessed using the 17-item Chinese Hamilton Depression Rating Scale, the social support of patients was assessed using the perceived social support scale (PSSS), caregiver burden was assessed using the Zarit burden interview (ZBI). Multivariable logistic regression analysis was used to analyze the data between risk factors and depression symptoms, and multiple linear regression models were constructed to examine the depression symptoms and functional outcomes of stroke survivors, and caregiver burden.

Results

In total, 966 IS survivors and paired caregivers were included in this study. Among IS survivors, 35.51% (343/966) experienced depression. Age [adjusted odds ratio (aOR), 1.02; 95% confidence interval (CI), 1.00-1.04; p = 0.036], the National Institutes of Health Stroke Scale (NIHSS) score (aOR, 1.57; 95% CI, 1.47-1.68; p < 0.001), and PSSS score (aOR, 0.86; 95% CI, 0.84-0.89; p < 0.001) were associated with an increased risk of depression. The NIHSS score (b = 2.57, p < 0.001), patients' depression status (b = 2.54, p < 0.001), duration of care (b = 0.359, p = 0.006), and social support of caregivers (b = -0.894, p = 0.038) were significantly associated with the ZBI score.

Conclusion

The PSSS score was a major risk factor for the development of depression in IS survivors, and patients' depression status and severe functional deficits had a negative impact on the ZBI score of the main caregivers. Social support can reduce the ZBI score.

Psychological status on informal carers for stroke survivors at various phases: a cohort study in China

Background

In China, the risk of stroke is higher than that in developed countries such as Europe and North America. Informal caregivers play a major role in providing support to stroke survivors. Currently, only limited studies on changes in psychological state of the caregivers at different stages of stroke have been published.

Purpose

To investigate the stress and psychological state of informal caregivers of stroke patients in different periods and to explore the factors that affect their states.

Methods

202 informal caregivers of stroke patients were selected in a 3a-grade hospital in Chengdu, Sichuan. Follow-up was conducted by face-to-face interviews, telephone calls, or home visits on days 3, 2 months, and 1 year after onset. We investigated the basic information about the caregivers, including their anxiety, depression and social support conditions. We analyzed the pressure and psychological conditions of informal caregivers at different stages of stroke and analyzed its influencing factors. The data were displayed by the number and percentage of the cases; the continuous variables were described by means and standard deviation. In addition, the data were compared by Pearson correlation analysis and logistic regression analysis.

Results

(1) Within 3 days after the onset of stroke, the informal caregivers had the highest stress, the most severe anxiety and depression, the heaviest burden, and the lowest score of medical-social support. Over time, the pressure and burden of the caregivers are gradually decreasing, anxiety and depression are increasing, and social support is also increasing. (2) The stress and psychological status of informal stroke caregivers are affected by multiple factors, including the caregiver's age, relationship with the patient, patient's age, and patient's physical conditions.

Conclusion

The stress and psychological status of informal caregivers varied in the different stages of stroke, and they were affected by several factors. Medical staff should pay attention to informal caregivers while providing care for patients. Relevant interventions may be developed based on the results to improve the health of informal caregivers and thus to promote the health of patients.

Stress in Caregivers of Stroke Patients During Rehabilitation: An Observational Study

INTRODUCTION

Stroke causes a high burden of death and disability all over the world. The majority of stroke survivors continue to have difficulties, and their families must shoulder a considerable portion of the expenditures of ongoing rehabilitation and long-term care. In India, stroke rehabilitation is still underachieved due to various reasons leading to delay or incomplete recovery of the patients thus adding up more burden on the caregivers. Thus, studying the caregiver burden of stroke rehabilitation will help policymakers tackle this issue faced by our lower economically challenged citizens.

OBJECTIVES

The objective is to measure the perceived burden on caregivers during stroke rehabilitation.

METHODS AND MATERIALS

The observational study was conducted by interviewing the stroke survivors' caregivers and visiting the physiotherapy OPD using the caregiver burden scale/questionnaire.

RESULTS

The study had 76 caregivers, 51.32% were women and 48.68% were men. The average age for caregivers was 42 years and 55 years for patients. The average duration of giving care was six months. The perceived caregiver burden score was low (mean-19.61) suggesting that not all assistance is associated with stress. The correlation of each burden measure with Modified Rankin Scale for disability is significantly correlated (r=0.7, P<0.0001). Further investigation revealed that caregivers had considerably higher levels of stress when the patient needed to exercise, walk or use the restroom. A low yearly income, a higher secondary education, and a small number of family members were shown to be connected with individuals who scored the highest on stress.

CONCLUSION

Based on this study, we conclude that people with low income residing in nuclear families require more support for caregiving during rehabilitation. We recommend that health and welfare policy measures be developed to lessen caregiver burden in order to improve caregivers' post-stroke experiences.

Qualitative study exploring heterogeneity in caregiving experiences post-stroke in Singapore

OBJECTIVE

Stroke, a common illness in older adults, accounts for up to 4% of direct medical costs in developed nations. Informal caregiving contributing a significant proportion of economic burden post-stroke warrants a deeper understanding of the caregiving context to sustain caregiving arrangement. While literature exists describing differences in motivation and preferences of caregivers, limited literature explores differences in caregiving experiences of different types of caregivers (ie, spouse, adult-child, sibling or others). Addressing this gap, our study aimed to explore the caregiving experience of stroke survivors and their family caregivers across different caregiver identities in an Asian setting.

DESIGN

Qualitative descriptive study.

SETTING

Community setting.

PARTICIPANTS

We conducted semi-structured interviews with 26 stroke survivors and 35 caregivers purposively sampled from an outpatient rehabilitation setting, an outpatient clinic and a support organisation. Data were analysed using thematic analysis.

OUTCOME MEASURES

Themes including caregiving experience of stroke survivors and their family caregivers across different caregiver identities.

RESULTS

Following five themes were reported: caregiver reserve, coping strategies, caregiver burden, competing commitments and role of foreign domestic worker (FDW) in family caregiving. Spouse caregivers were less willing to ask for help, commonly adopted faith-based, and spacing or recharging types of coping, reported emotional strain and shared limited accounts of FDWs. Adult-child caregivers were more willing to ask for help, engaged in alternative care arrangements involving FDWs, commonly adopted action-focussed coping and reported multidimensional caregiver burden.

CONCLUSION

Our findings illustrated the heterogeneity in factors affecting caregiving experience across spouse and adult-child caregivers. Practical implications include conducting a needs assessment for caregiver-stroke survivor dyads and providing tailored support, training and information to help caregivers cope better.

An intervention to support stroke survivors and their carers in the longer term: results of a cluster randomised controlled feasibility trial (LoTS2Care)

BACKGROUND

To address the limited provision of longer-term stroke care, we conducted a programme of research (LoTS2Care) to develop and test an intervention to form part of a replicable longer-term care strategy. New Start, a programme of facilitated self-management, was developed to be delivered at 6 months post-stroke by trained facilitators. Here, we report the findings from the final workstream of this programme, which aimed to evaluate the feasibility and acceptability of implementing a future definitive cluster randomised controlled trial of the developed intervention (New Start) to support stroke survivors and their carers in the longer term.

METHODS

A feasibility cluster randomised controlled trial was conducted in English and Welsh NHS stroke services. Stroke services (clusters) were randomised on a 1:1 basis to implement New Start or continue with usual care only. Community-dwelling stroke survivors between 4 and 6 months post-stroke were invited to participate in the trial by post. Outcome measures were collected via post at 3, 6 and 9 months after recruitment. Recruitment and follow-up rates, delivery and uptake of the intervention, data collection feasibility (including postal outcome measures of health and disability, mental well-being at 3, 6, and 9 months post-recruitment) and safety were assessed.

RESULTS

Ten stroke services were recruited. A total of 1127 stroke survivors were screened for participation, and 269 were registered (New Start, n = 145; usual care, n = 124). Retention was high with 239 (89%) stroke survivors being available for follow-up at 9 months, and high return rates of postal questionnaires were achieved (80.3% at 9 months). Intervention training was successfully delivered, and New Start was offered to 95.2% of trial participants in the intervention arm. Uptake was variable, however, ranging from 11.8 to 75.0%. There were no safety concerns.

CONCLUSIONS

Stroke service recruitment and longer-term stroke survivor postal recruitment and outcome data collection are feasible; however, refinement of intervention targeting and delivery is required prior to undertaking a definitive trial.

TRIAL REGISTRATION

ISRCTN38920246. Registered 22 June 2016 ( http://www.isrctn.com/ISRCTN38920246 ).

A Bibliometric Analysis of Stroke Caregiver Research from 1989 to 2022

Many stroke survivors suffer with varying degrees of disability and require assistance. Family members commonly act as informal caregivers, caring for these stroke survivors and ensuring care adherence. However, many caregivers reported a poor quality of life and physical and psychological distress. Due to these issues, multiple studies have been conducted to understand the experience of caregivers, the outcomes of caregiving, and interventional studies among caregivers. This study aims to explore the intellectual landscape of studies on stroke caregivers using bibliometric analysis. Studies with "stroke" and "caregiver" terms in the title were extracted from the Web of Sciences (WOS) database. The resulting publications were analysed using the 'bibliometrix' package in R. There were 678 publications analysed, dating from 1989 to 2022. The USA has the highest number of publications (28.6%), followed by China (12.1%) and Canada (6.1%). The most productive institution, journal and author were The University of Toronto (9.5%), 'Topics in Stroke Rehabilitation' journal (5.8%) and Tamilyn Bakas (3.1%), respectively. Co-occurrences keywords analysis revealed mainstream research on stroke survivors, burden, quality of life, depression, care, and rehabilitation, reflecting the timeless hotspot in the field. This bibliometric analysis helps us understand the current state of stroke caregiver research and its recent developments. This study can be used to evaluate research policies and promote international cooperation.

Honoring What We Say We Do: Developing Real-World Tools for Routine Family Caregiver Assessment and Support in Outpatient Palliative Care

Background: Family caregivers are essential to the care of patients with serious illness and supporting caregivers alongside patients is a core tenet of palliative care. While there is increasing recognition of the need to support family caregivers, there are limited resources to assess and support their needs in a systematic way in outpatient palliative care practice. Objectives: The aim of this study is to develop an approach to conducting assessments of routine needs and support of family caregivers in outpatient palliative care practice using a quality improvement framework. Setting: Seven, interdisciplinary, outpatient palliative care teams in California collaborated in this study. Measurements: Family caregivers were surveyed about levels of distress and support using a 10-point scale and asked about specific areas of need for support. Usefulness of a supportive caregiver resource was also measured on a 10-point scale, in addition to qualitative assessment of clinician satisfaction and feasibility of routine caregiver assessment and support. Results: Seven hundred thirty-six caregiver needs assessments were conducted and 44 supportive tool kits were distributed. A majority of family caregivers reported moderate or severe distress related to caregiving (score ≥4 on a 10-point scale). The most common sources of distress included emotional distress, worry caregiving was negatively impacting their own health, and planning for the future. Most caregivers reported feeling moderately or very well supported, most commonly by family, friends, and faith/spirituality. Caregivers rated the supportive tool kit an 8.4 on a 10-point usefulness scale and 92% would recommend it to others. Conclusions: We successfully developed and piloted practical clinical tools for routine family caregiver screening and support.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Regression-based prognostic models for functional independence after postacute brain injury rehabilitation are not transportable: a systematic review

BACKGROUND AND OBJECTIVES

To identify and summarize validated multivariable prognostic models for the Functional Independence Measure® (FIM®) at discharge from post-acute inpatient rehabilitation in adults with acquired brain injury (ABI).

METHODS

This review was conducted based on the recommendations of the Cochrane Prognosis Methods Group and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases were systematically searched in May 2021 and updated in April 2022. Main inclusion criteria were: a) adult patients with ABI, b) validated multivariable prognostic model, c) time of prognostication within 1-week of admission to post-acute rehabilitation, and d) outcome was the FIM® at discharge from post-acute rehabilitation.

RESULTS

The search yielded 3,169 unique articles. Three articles fulfilled the inclusion criteria, accounting for n = 6 internally and n = 2 externally validated prognostic models. Discrimination was estimated as an area under the curve between 0.76 and 0.89. Calibration was deemed to be assessed insufficiently. The included models were judged to be of high risk of bias.

CONCLUSION

Current prognostic models for the FIM® in post-acute rehabilitation for patients with ABI lack the methodological rigor to support clinical use outside the development setting. Future studies addressing functional independence should ensure appropriate model validation and conform to uniform reporting standards for prognosis research.

Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke

BACKGROUND

Rates of return-to-work after stroke are low, yet work is known to positively impact people's wellbeing and overall health outcomes.

OBJECTIVE

To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation.

PARTICIPANTS

The experiences of 31 participants (aged 25-76 years) who had or had not returned to work after stroke were explored.

METHODS

Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach.

RESULTS

Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics.

CONCLUSION

The range and severity of impairments experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.

Contributing Factors to the Burden on Primary Family Caregivers of Stroke Survivors in South Korea

The purpose of this study is to identify the factors associated with the burden on primary family caregivers of stroke patients at home without care services. For this study, the Korean Stroke Cohort for Functioning and Rehabilitation (KOSCO) data were used. Of the total 8010 caregivers, 1133 family caregiver burden was assessed with the shortened Caregiver Burden Inventory (CBI) 3 months after stroke. Patient and caregiver-related factors affecting the heavier burden of caregivers were identified by comparing the heavier caregiver burden group and the lighter caregiver burden group, which divided according to the CBI scores. The 719 (63.5%) family caregiver cared for patients at home without care services. Logistic regression analysis showed that four or more comorbidities (p = 0.002), neurological impairment at early onset (p < 0.001), dependence on daily life (p < 0.001), aphasia (p = 0.024), and depression(p < 0.001) were associated with a heavier burden of care. According to the shortened CBI, caregivers tended to be concerned more about psychological stress than physical strain. The findings suggest the importance of proactively guiding the emotional support services to caregivers who are at high risk of the heavier burden of patient care.

Predictors of caregiver burden in caregivers of individuals with traumatic or non-traumatic brain injury: A scoping review

BACKGROUND

Caregivers of individuals with traumatic (TBI) or non-traumatic (nTBI) brain injuries are at risk of significant caregiver burden. Consequently, it is crucial to examine predictors of caregiver burden to enable early identification and intervention.

OBJECTIVE

To examine predictors of caregiver burden in caregivers of individuals with TBI/nTBI.

METHODS

A scoping review was conducted in the bibliographic databases PubMed, EMBASE (Ovid) and APA PsycInfo (EBSCO). Search terms included: 'acquired brain injur*', 'traumatic brain injur*', 'brain injur*', 'non-traumatic brain injur*', or 'stroke*' combined with 'burden', 'caregiver burden', 'perceived burden', or 'caregiver strain'. The search was limited to articles written in English and published in academic journals between 2000 and March 2022. EndNote was used to manage the references and identify duplicates.

RESULTS

Twenty-four studies were included. Care recipient-related predictors of caregiver burden included more severe injuries, functional disabilities (including decreased physical and neuropsychological functioning), and worse mental health. Caregiver-related predictors included more time spent caregiving, worse mental health, and unmet needs. For several predictor variables, evidence was mixed or vague.

CONCLUSION

The results highlight which caregivers are at risk of caregiver burden and point to several areas of potential intervention to prevent caregiver burden. Future research should explore the relationship between characteristics of the caregiver and caregiver burden, including coping style, problem-solving techniques, and personality, as these have been sparsely investigated and are potentially modifiable through intervention. Further research is needed to elucidate if burden can be prevented by interventions targeting caregivers at risk. Addressing these gaps may clarify the link between caregiver burden and predictor variables and assist in development of interventions that may prevent burden.

Quality of life and caregiver burden in pediatric glaucoma: A systematic review

Pediatric conditions can lead to significant caregiver burden and poor quality of life (QoL). This systematic review describes research relating to caregiver burden and QoL of caregivers of pediatric glaucoma patients. A systematic database search of Embase, Medline, PsycINFO, CINAHL, Web of Science, and the three journals within the Association for Research in Vision and Ophthalmology (ARVO) was conducted in October 2021. Publications underwent abstract and full-text screening and were included if they reported pediatric caregivers' QoL using quantitative or qualitative methods. Review articles, publications not in English, and articles focusing on adult glaucoma patients were excluded. Studies then underwent risk of bias assessment and data extraction. Of the 105 publications identified, 8 publications with 667 participants were included in the review. Studies indicated significantly higher burden and poor QoL in caregivers. Female sex, lower education level, lower income, and working status of caregivers were associated with poorer QoL and greater burden. Additionally, more severe and longer duration of the child's disease negatively impacted these measures of caregiver wellbeing. Additionally, studies found significant improvement in caregiver QoL after patients underwent surgery with combined trabeculotomy-trabeculectomy. In conclusion, few studies have investigated the impact of pediatric glaucoma on caregivers. This review of the existing studies found poor QoL and high levels of caregiver burden within this population. Given the lifelong nature of pediatric glaucoma, there is a need for further longitudinal research focusing on the caregivers of these pediatric patients. Long-term follow-up would allow for a greater understanding of how caregiver QoL changes over the course of the disease.

Effects and mechanisms of mindfulness training and physical exercise on cognition, emotional wellbeing, and brain outcomes in chronic stroke patients: Study protocol of the MindFit project randomized controlled trial

Background

Post-stroke cognitive and emotional complications are frequent in the chronic stages of stroke and have important implications for the functionality and quality of life of those affected and their caregivers. Strategies such as mindfulness meditation, physical exercise (PE), or computerized cognitive training (CCT) may benefit stroke patients by impacting neuroplasticity and brain health.

Materials and methods

One hundred and forty-one chronic stroke patients are randomly allocated to receive mindfulness-based stress reduction + CCT (n = 47), multicomponent PE program + CCT (n = 47), or CCT alone (n = 47). Interventions consist of 12-week home-based programs five days per week. Before and after the interventions, we collect data from cognitive, psychological, and physical tests, blood and stool samples, and structural and functional brain scans.

Results

The effects of the interventions on cognitive and emotional outcomes will be described in intention-to-treat and per-protocol analyses. We will also explore potential mediators and moderators, such as genetic, molecular, brain, demographic, and clinical factors in our per-protocol sample.

Discussion

The MindFit Project is a randomized clinical trial that aims to assess the impact of mindfulness and PE combined with CCT on chronic stroke patients' cognitive and emotional wellbeing. Furthermore, our design takes a multimodal biopsychosocial approach that will generate new knowledge at multiple levels of evidence, from molecular bases to behavioral changes.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT04759950.

A systematic review comparing caregiver burden and psychological functioning in caregivers of individuals with schizophrenia spectrum disorders and bipolar disorders

BACKGROUND

Informal primary caregivers provide crucial supports to loved ones experiencing serious mental illnesses with profound outcomes for the caregivers themselves. A comprehensive understanding of how different serious mental illnesses change the caregiving experience may provide important insight into the ways in which caregivers can be better supported in their role. The aim of this review was to synthesize the comparative literature examining caregiver burden and psychological functioning (anxiety, depression, distress, and psychological wellbeing) between caregivers of people with schizophrenia spectrum disorders and bipolar disorder.

METHODS

Studies were included if they compared caregivers across both diagnostic groups and used measures assessing either caregiver burden or psychological functioning of caregivers. Databases searched up until 11th of January 2022 included: Medline COMPLETE, Embase, PsycINFO and CINAHL. Reference list scans and grey literature searches across government, organisational and dissertation databases were also conducted.

RESULTS

Twenty-eight studies comprising 6166 caregivers were included. Fourteen studies suggested that caregiving burden was comparable across both groups. The effects of caring on caregiver mental health and stress were comparable across both groups. However, methodological limitations were noted, including a reliance on cross-sectional studies, multiple and sometimes competing definitions of caregiving burden, variable sample sizes, and variation in measures used.

CONCLUSION AND IMPLICATIONS

The experience of providing care is multidimensional and complex. Symptoms and functional difficulties experienced by people being cared for may affect caregivers more so than diagnosis. Caregivers play a vital role in helping people with serious mental illness. Supporting caregivers by reducing their burden and improving their psychological functioning may help them to continue to provide support, and cope with, the challenges of providing care.

Formal Health and Social Services That Directly and Indirectly Benefit Stroke Caregivers: A Scoping Review of Access and Use

Stroke can be a life altering event that necessitates considerable amounts of formal and informal care. The impacts of stroke often persist over time requiring ongoing support for stroke survivors. Family members provide the majority of care and experience many life changes as a result of their caregiving role including social, financial, employment and health impacts. Formal supports such as counselling, respite, and health promotion initiatives that directly benefit caregivers or benefit them indirectly through supporting the stroke survivor, are well-placed to help caregivers manage their caregiving role. However, to date little is known about formal service use by stroke caregivers and the factors that influence their service use. This scoping review provides a critique and synthesis of what is known about stroke caregivers' access and use of formal services intended to support them. Findings suggest that while services are available, caregivers' ability to use them are impacted by both facilitators and barriers. Facilitators included: sex, age, and having a higher household income (depending on services used). Barriers included: high cost, poor service quality and deficient knowledge/communication regarding service availability. This review highlights a significant gap in our knowledge of caregivers' experience in accessing and using formal services.

Feasibility of an Online Langerian Mindfulness Program for Stroke Survivors and Caregivers

Mindfulness is promising for individuals with neurological disorders and their caregivers to improve psychological well-being. The potential application of a Langerian mindfulness intervention, focused on attention to variability, however, is still unknown. The objective of the study was to determine the feasibility (usability, satisfaction, and potential effectiveness on psychological well-being) of an online mindfulness intervention for stroke survivors and caregivers. Using mixed methods, 11 stroke survivors and three caregivers participated in a 3-week, online, Langerian mindfulness intervention. A semi-structured interview assessed the intervention's usability and gathered feedback. Self-reported measures about psychological well-being were documented remotely 3 times (preintervention, postintervention, and 1-month follow-up). Qualitatively, participants were highly satisfied with the intervention and reported subjective benefits, but the usability of the online platform was poor. None of the self-reported measures changed over time. This study provided evidence of feasibility of an online Langerian mindfulness intervention in a new population: stroke survivors and caregivers.

Individualized Home-based rehabilitation after stroke in France: a pragmatic study of a Community Stroke Rehabilitation Team

BACKGROUND

Community stroke rehabilitation teams (CSRT) provide an individualized home-based rehabilitation service to patients recovering from stroke.

OBJECTIVE

To examine whether there is an improvement in the social participation of patients who received a rehabilitation program provided by CSRT. The secondary objectives were to show if there is an improvement in the patients' quality of life and a reduction in the caregiver burden.

METHODS

Retrospective cohort study, pragmatic in real-care conditions. The rehabilitation program delivered by the CSRT was adapted to the needs of the patients and caregivers. The outcome questionnaires included: the Frenchay Activity Index (FAI), the Minizarit, the EuroQol EQ5D, and the Barthel Index. The primary outcome measure was the FAI.

RESULTS

We included 206 patients followed by the CSRT over the 2018-2020 study period, for whom the primary endpoint was present. The mean age was 66.3 ± 12.7 years, the post-stroke delay was 16.4 ± 32.7 months, and the Barthel index was 66.42 ± 12.6. The duration of the rehabilitation program was on average 162 ± 109 days. We observed a significant improvement in the FAI, from 12.9 ± 10.4 to 17.85 ± 12.4 (p < 0.00001); in the EuroQol, from 57.51 ± 19.96 to 66.36 ± 18.87 (p < 0.00001); in the mini-Zarit, from 2.49 ± 1.75 to 2.06 ± 1.67 (p = 0.0002); and in the Barthel index, from 66.42 ± 12.67 to 84.81 ± 23.70 (p < 0.001).

CONCLUSION

Patients who received a rehabilitation program by the CSRT have an improvement in their social participation, and their informal caregivers have a reduction in their burden.

Factors impacting the access and use of formal health and social services by caregivers of stroke survivors: an interpretive description study

BACKGROUND

Evidence has shown that family and friend caregivers of stroke survivors are significantly and negatively impacted by caregiving. The negative effects of caregiving may persist over time suggesting that caregivers might benefit from ongoing engagement with supportive services. However, little is known about caregivers' use of formally funded health and social services, or the factors influencing their access to and use of these services. The aim of this study is to increase understanding of the factors that influence stroke caregivers' access and use of formal health and social services, from the perspective of stroke caregivers and healthcare providers.

METHODS

A qualitative study was conducted with stroke caregivers and health providers in Ontario, Canada using interpretive description. In-depth interviews were conducted with caregivers of survivors who experienced a stroke between six months to five years previous and healthcare providers who support caregivers and stroke survivors. All participants provided written informed consent. Interview data were analyzed using constant comparison to identify codes and develop key thematic constructs.

RESULTS

A total of 40 interviews were conducted with 22 stroke caregivers at an average 30-months post-stroke and 18 health providers. Factors that influenced stroke caregivers' access and use of services included: finances and transportation; challenges caregivers faced in caring for their health; trust that they could leave their family member and trust in health providers; limited information pertaining to services and a lack of suitable services; and the response of their social networks to their caregiving situation.

CONCLUSION

Stroke caregivers experience significant challenges in accessing and using formal health and social services. These challenges could be addressed by increasing availability of subsidized community-based supports such as respite and counselling tailored to meet the ongoing needs of caregivers. Systemic change is needed by the health system that readily includes and supports caregivers throughout the stroke recovery continuum, particularly in the community setting.

A Biopsychosocial Intervention for Stroke Carers (BISC): development and description of the intervention

Objective

Family members of stroke survivors are often not supported for their caring role, with many reporting adjustment difficulties. This paper describes the development and content of a group-based intervention for informal carers of stroke survivors.

Method

The intervention is based on the theoretical foundation of the biopsychosocial model with the aim to understand and address the physical, psychological and social factors of caring for stroke survivors. Findings from a comprehensive literature review and a qualitative study with carers and stroke professionals were synthesized to guide the intervention development. The Template for Intervention Description and Replication (TIDieR) checklist was used as a framework to describe the intervention.

Results

The intervention integrates cognitive-behavioural approaches via the identification of the biopsychosocial (physical, emotional, social) factors that can have an impact on the well-being of carers. It includes education on stroke-specific topics and advice on coping strategies. It consists of six structured two-hour group sessions facilitated in a community setting. It provides information and support on adjusting to the caring role in the first year post-stroke. Intervention materials were designed for addressing carers’ specific needs using psychological techniques, such as problem-solving, goal setting and relaxation exercises.

Conclusion

We have underlined the importance for describing and reporting the process of intervention development for complex interventions in the context of stroke rehabilitation. An intervention addressing the needs of informal stroke carers (Biopsychosocial Intervention for Stroke Carers; BISC) has been developed and described. BISC was further evaluated in a single-centre feasibility randomized controlled trial.

Effect of transitional care stroke case management interventions on caregiver outcomes: the MISTT randomized trial

This study reports on outcomes for 169 caregivers enrolled in the Michigan Stroke Transitions Trial (MISTT), an RCT of social work case management for stroke patients returning home. A mixed-model approach examined the mean change from 7- to 90-days post-discharge with group-by-time interactions for differences between treatment groups. Caregivers reported few life changes or depressive symptoms from caregiving. There was no significant change over time or treatment effects. Negative aspects of stroke caregiving may take longer to develop. Focused caregiver assessment at discharge and a better understanding of how caregiving develops over time may improve the type and timing of support.

Examining the Influence of Social Interactions and Community Resources on Caregivers' Burden in Stroke Settings: A Prospective Cohort Study

Since the introduction of the integrated care model, understanding how social interactions and community resources can alleviate caregivers’ burden is vital to minimizing negative patients’ outcomes. This study (n = 214) examined the associations between these factors and caregivers’ burden in stroke settings. It used 3-month and 1-year post-stroke data collected from five tertiary hospitals. Subjective and objective caregivers’ burdens were measured using Zarit burden interview and Oberst caregiving burden scale respectively. The independent variables examined were quality of care relationship, care management strategies for managing patients’ behaviour, family caregiving conflict, formal service usage and assistance to the caregiver. Significant associations were determined using mixed effect modified Poisson regressions. For both types of burden, the scores were slightly higher at 3 months as compared to 1 year. Poorer care-relationship (relative risk: 0.81, 95% confidence interval (CI): 0.70–0.94) and adopting positive care management strategies (relative risk: 1.05, 95% CI: 1.02–1.07) were independently associated with a high subjective burden. Providing assistance to caregivers (relative risk: 2.45, 95% CI: 1.72–3.29) and adopting positive care management strategies (relative risk: 1.03, 95% CI: 1.02–1.04) were independently associated with a high objective burden. Adopting positive care management strategies at 3 months had a significant indirect effect (standardised β: 0.11, 95% CI: 0.01 to 0.20) on high objective burden at one year. Healthcare providers should be aware that excessive care management strategies and assistance from family members may add to caregivers’ burden.

Support system diversity among family caregivers of stroke survivors: a qualitative study exploring Asian perspectives

BACKGROUND

Caregiving is a global phenomenon which is bound to increase in tandem with the aging population worldwide. Stroke is a condition common in older people that requires complex caregiving necessitating provision of adequate support to the caregivers. Past literature consists of limited accounts of types and organization of support arrangements needed by different caregivers. We aimed to describe the support system of caregivers of stroke survivors in Singapore, highlighting differences across the different caregiver identities (i.e. spouse, adult-child, etc.).

METHODS

We conducted a qualitative descriptive study in the community setting involving 61 purposively sampled and recruited stroke survivors and caregivers. Semi-structured interviews were conducted, and transcripts were analysed using thematic analysis.

RESULTS

Our findings were summarized across the following 4 themes: 1) cultural influence and caregiving; 2) caregiver support system with the following sub-themes: 2.1) dyadic caregiver support type, 2.2) extended caregiver support type, 2.3.) distributed caregiver support type and 2.4) empowering caregiver support type; 3) breaks in care of stroke survivor and 4) complex relationship dynamics. We operationalized the caregiver support system as comprising of type, people and activities that enable the caregiver to participate in caregiving activities sustainably. While spouse caregivers preferred dyadic and extended support systems positioning themselves in a more central caregiving role, adult-child caregivers preferred distributed support system involving family members with paid caregivers playing a more central role.

CONCLUSIONS

Our findings highlight caregiver identity as a surrogate for the differences in the caregiver support systems. Practical implications include imparting relationship-building skills to the stroke survivor-caregiver dyads to sustain dyadic support system and educating clinicians to include differences in caregiving arrangements of stroke survivors in practising family-centred care.