Home rehabilitation project for home-bound physically disabled people in Yokohama

Objective: To evaluate the effectiveness of home-visit rehabilitation.

Design: Before/after trial.

Setting: Home-visit rehabilitation in Yokohama city.

Subjects: Four hundred and seventy-five of 601 cases that received services during 1992, and 141 of 186 cases that received sequential visits.

Interventions: Comprehensive home-visit rehabilitation.

Main outcome measures: (1) Carer's response on change in care burden; (2) improvement in personal care performance.

Results: Care burden decreased in 40.8% of 475 subjects. All of the 141 cases that received sequential visits gained proficiency in personal care.

Conclusion: Improved performance of daily activities and reduction of care burden were found for most subjects after the rehabilitation visits.

[Changes in therapy aims and palliative treatment for severe stroke]

Recent years have seen considerable advances in acute stroke treatment. Patients who survive the acute phase following major stroke often retain severe limitations of motor, cognitive, and communicative functions. In such patients whose death is imminent, curative therapies should be avoided. Instead, the goal of any therapy should shift to palliative treatment and concentrate on reducing causes of suffering. Palliative methodologies and concepts are already well established in neurology, e.g. for amytrophic lateral sclerosis. Particularly those stroke patients who remain stable for a long period with massive neurological deficits require interdisciplinary palliative care that goes beyond mere reduction of symptoms and seeks a response to possible complications and the question of maintaining life-preserving measures. Not only medical indications but also the expressed or presumed will of the patient must be included in such considerations. This article describes and elucidates basic questions of palliative medicine and symptomatic palliative treatment concepts for stroke patients.

The impact of stroke on the well-being of the patient's spouse: an exploratory study

AIMS

The aim of this study was to investigate the impact of stroke on the patient's spouse, paying particular attention to psychiatric morbidity and the strain of caring, and correlating these with the degree of disability of the patient. The impact of impairment of speech was also investigated.

BACKGROUND

The impact of a stroke is not limited to the person who suffers it but also to the family, with the patient's spouse being particularly vulnerable. The literature suggests that the consequences for the spouse can be physical, psychological, economic and social.

METHODS

A quantitative approach was employed to investigate 44 couples who volunteered to participate in the study. A small battery of validated instruments was used to describe the patient's degree of disability, and psychiatric morbidity and the strain of caregiving in the spouse. Pearson's Correlation and Mann-Whitney U-test were used in data analysis.

RESULTS

The spouses were found to have a greater degree of psychiatric morbidity than a reference group and a large proportion of them found caregiving to be stressful. Psychiatric morbidity and strain in the spouses were not directly proportional to the extent of the patient's disability. Spouses whose partners' speech was affected by the stroke were more likely to experience strain than those who were unaffected in this way.

CONCLUSIONS

This study contributes to our knowledge of the relationship between patients' physical disability and the level of strain and psychiatric morbidity in spouses. The relationship is a complex one, in which it is not possible to predict with confidence which spouses will be most vulnerable.

RELEVANCE TO CLINICAL PRACTICE

Caring for a patient following a stroke is very stressful, particularly in cases where the patient's speech is affected and there is also likely to be a significant effect on the psychological well-being of the spouse. This information is relevant to all nurses caring for patients with stroke and the patients' spouses.

Quantitative und qualitative Diagnostik von Belastungen und Belastungsverarbeitung bei pflegenden Angehörigen

Zusammenfassung: Gegenstand der vorliegenden Arbeit ist die diagnostische Erfassung von subjektivem Belastungserleben und Belastungsverarbeitung bei pflegenden Angehörigen von älteren Menschen, die insbesondere für die Interventionsforschung eine hohe Relevanz besitzt. Statt der Verwendung globaler Belastungsmaße wird eine multidimensionale Erfassung des Belastungserlebens und der Belastungsverarbeitung mittels standardisierter Messinstrumente empfohlen. Anhand von Daten zur Belastung von Angehörigen von Demenz- und Schlaganfallpatienten wird demonstriert, dass eine reliable Erfassung des Belastungserlebens mittels allgemein-klinischer Verfahren (BDI, GBB-24, SF-12, WHOQOL-BREF) bei diesen spezifischen Gruppen möglich ist. Die Daten können somit als Referenzwerte für diese Subgruppen angesehen werden. Im Hinblick auf die Entwicklung diagnostischer Standards zur multimodalen Erfassung von Belastungserleben sollten sie jedoch ergänzt werden durch Daten an größeren Stichproben einerseits und durch Stichproben von Angehörigen anderer Patientengruppen andererseits. Es wird außerdem gezeigt, dass mittels halbstrukturierter Interviews qualitative Maße des subjektiven Belastungserlebens und der Belastungsverarbeitung gewonnen werden können und eine wichtige Ergänzung zu den quantitativen Belastungsmaßen darstellen.

Needs of carers of severely disabled people: are they identified and met adequately?

OBJECTIVE

To examine the unmet needs of informal carers of community dwelling disabled people and to compare their perspectives to those of disabled people and nominated professionals. It was hypothesised that a poor recognition of carers' needs could have implications for carers' well- being and thus their ability to maintain their caring role. Need was defined as a service or a resource that would confer a health or rehabilitation gain.

DESIGN

Face to face interviews with carers and disabled participants, telephone interviews with professionals (Southern England). Disabled participants had been selected randomly from two disability registers.

MAIN OUTCOME MEASURES

The Southampton Needs Assessment Questionnaire (carers version), SF-36 (carers' health status).

RESULTS

Carers experienced similar health status to people in the general population. The most frequently carer-reported unmet needs were for short breaks, domestic help and respite care. Carers who had reported unmet need for short breaks had significantly poorer levels of mental health and vitality (SF-36) than carers who had not reported this. Similar numbers of unmet carers' needs were reported by disabled participants, professionals and carers themselves. In terms of type of unmet needs, poor concordance between carers and disabled participants occurred in 52% of cases: carers reported more unmet needs than disabled participants for short breaks and domestic help. Poor concordance scores between carers and professionals occurred in 59% of cases: carers reported more unmet needs for short breaks than professionals and professionals reported more unmet needs for formal respite care.

CONCLUSION

In line with recent legislation, carers' needs must be independently addressed and services, especially for flexible community support such as short break services, must be developed specifically to meet the needs of carers. Further research is warranted to evaluate whether recent legislation for carers has any effect on carers' well-being and ability to cope with their caring role.

The impact of stroke on informal carers: a literature review

Stroke incidence is set to rise in Western societies as population projections predict an increase in the proportion of older people. Most of these stroke survivors are supported by close kin members who play an important role in the rehabilitation and care of this group. The objective of this review was to establish the following: (a) to evaluate the impact of the stroke on the informal carers' quality of life, (b) to identify factors which help carers to cope with their caring role, (c) to evaluate health service provision for stroke carers. A systematic literature search using BIDS-EMBASE, MEDLINE and PSYCHLIT, identified 31 relevant studies. These showed that most studies concentrated on carers' psychological health and the negative impact that the stroke had. Carers ability to cope with the stroke was enhanced both by the use of positive coping strategies and more concrete measures e.g. more stroke information. Furthermore, whilst most carers were generally satisfied with health services, the few interventions directed at improving carer outcomes showed mixed results. The studies reviewed had many limitations; few gave definitions of 'informal' carer and there was a predominant use of cross-sectional studies and non-standardised outcome measures. Future studies should broaden their research question to evaluate quality of life, using standardised measures to do this and employing either a longitudinal or randomised control design to improve the robustness of results. More studies are also needed evaluating the effectiveness of health services on carers' quality of life.

Percutaneous endoscopic gastrostomy: psychological effects

A mainly qualitative study, with some quantitative measurement tools, was undertaken to explore the psychological effects of percutaneous endoscopic gastrostomy (PEG) feeding on both patients and carers. A significant level of depression and stress was found in patients whose lifestyle had changed greatly; this was due partly to having to use a PEG and part to the underlying disease. Patients were, at the same time, grateful for the benefits to their nutritional state of having a PEG. A high level of stress was experienced by the relatives of patients whose functional and/or mental abilities had significantly changed for the worse and who had had a PEG tube placed. A need for more initial factual information and for ongoing practical and psychological support for both patients and carers was identified.

Poststroke depression: prevalence, course, and associated factors

Despite the considerable amount of research that has been undertaken on poststroke depression, a review of the literature demonstrates that there are many inconclusive findings in the area. In particular, the causes and course of the disorder remain to be firmly established. While studies of prevalence differ with respect to the nature and timing of their assessment procedures, most conclude that poststroke depression has a negative impact on the rehabilitation of the stroke patient. Very little research is available on te relationship between poststroke depression and care-giver burden. However, recent studies have adopted more rigorous methodological procedures, allowing some insights into the complex mixture of factors which determine the occurrence of poststroke depression.