Caregivers' Grief in Acquired Non-death Interpersonal Loss (NoDIL): A Process Based Model With Implications for Theory, Research, and Intervention

The number of family members caring and caregiving for a loved one undergoing physical and mental changes continues to increase dramatically. For many, this ongoing experience not only involves the “burden of caregiving” but also the “burden of grief” as their loved-one’s newfound medical condition can result in the loss of the person they previously knew. Dramatic cognitive, behavioral, and personality changes, often leave caregivers bereft of the significant relationship they shared with the affected person prior to the illness or injury. This results in what we term conditions of acquired “non-death interpersonal loss” (NoDIL). Current approaches to these losses use an amalgam of models drawn from both death and non-death loss. Despite their utility, these frameworks have not adequately addressed the unique processes occurring in the interpersonal sphere where the grieving caregiver needs to reach some modus vivendi regarding the triad of “who the person was,” “who they are now,” and “who they will yet become.” In this paper we propose a process-based model which addresses cognitive-emotional-behavioral challenges caregivers meet in the face of their new reality. These require a revision of the interpersonal schemas and the relationships that takes into account the ongoing interactions with the affected family member. The model and its utility to identify adaptive and maladaptive responses to NoDIL is elaborated upon with clinical material obtained from caregivers of people diagnosed with major neuro-cognitive disorder and pediatric traumatic brain injury. The article concludes with implications for theory, research and clinical intervention.

Stress and inflammation - The need to address the gap in the transition between acute and chronic stress effects

Stress responses help us navigate our environment and respond appropriately to threats. Stress systems communicate threats to the entire organism, and as such, also stimulate inflammatory mechanisms. This modulation might serve protective functions in the short term, but sustained low-grade inflammation has severe long-term health consequences. While we have reached a reasonable level of understanding of acute, as well as chronic stress effects on inflammatory mechanisms, there is a significant gap in our understanding of the transitional phase between acute and chronic stress. The purpose of this review is to first summarize current knowledge of our understanding of acute stress effects on inflammation, as well as of chronic stress effects on inflammation, and to then analyze the state of knowledge about the transitional phase between acute and chronic stress. Research discussed here shows that we are beginning to understand the early phase of repeated acute stress, but lack information on longer term exposure to repeated acute stress experiences. More research is needed to bridge this important gap und our conceptualization and understanding of the stress and health relationship.

Understanding Health-related Quality of Life in Caregivers of Civilians and Service Members/Veterans With Traumatic Brain Injury: Establishing the Reliability and Validity of PROMIS Mental Health Measures

OBJECTIVE

To provide important reliability and validity data to support the use of the Patient-Reported Outcomes Measurement Information System (PROMIS) mental health measures in caregivers of civilians or service members/veterans (SMVs) with traumatic brain injury (TBI).

DESIGN

Patient-reported outcome surveys administered through an electronic data collection platform.

SETTING

Three TBI model systems rehabilitation hospitals, an academic medical center, and a military medical treatment facility.

PARTICIPANTS

Caregivers (N=560) of individuals with a documented TBI (344 civilians and 216 military).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

PROMIS anxiety, depression, and anger item banks.

RESULTS

Internal consistency for all the PROMIS Mental Health item banks was very good (all α>.86) and 3-week test-retest reliability was good to adequate (ranged from .65 to .85). Convergent validity and discriminant validity of the PROMIS measures were also supported. Caregivers of individuals who were low functioning had worse emotional health-related quality of life (HRQOL) (as measured by the 3 PROMIS measures) than caregivers of high-functioning individuals, supporting known groups validity. Finally, levels of distress, as measured by the PROMIS measures, were elevated for those caring for low-functioning individuals in both samples (rates ranged from 26.2% to 43.6% for caregivers of low-functioning individuals).

CONCLUSIONS

Results support the reliability and validity of the PROMIS anxiety, depression, and anger item banks in caregivers of civilians and SMVs with TBI. Ultimately, these measures can be used to provide a standardized assessment of HRQOL because it relates to mental health in these caregivers.

Salivary Biomarkers in Psychoneuroimmunology

As molecular biology advances, an increasing number of proteins are becoming detectable at very low levels in different biological tissues. In this regard, saliva holds vast promise. Unlike blood, saliva can be sampled 1) non-invasively; 2) across all ages (newborn to elderly); 3) in the field; 4) by study participants; and 5) many times per day. With respect to psychoneuroimmunology (PNI), physiological measures of stress such as cortisol have been well characterized. Alpha amylase provides another physiological index of stress; it is a measure of autonomic nervous system activation and is quantifiable in saliva. Other salivary measures, such as inflammatory biomarkers and immunoglobulin A (IgA), provide valuable information pertaining to the effects of stress on inflammation, mucosal immunity, and oral health. Importantly, due to various methodological issues and a lack of strong correlation between saliva and blood measures, investigators should proceed with caution in drawing conclusions from measures of salivary inflammation that pertain to systemic immunity or generalized health.

Perceived health, caregiver burden, and quality of life in women partners providing care to Veterans with traumatic brain injury

Families of Veterans with traumatic brain injury (TBI) are often faced with providing long-term informal care to their loved one. However, little is known about how their perceived health and caregiving burden contribute to their quality of life (QOL). The purpose of this descriptive study was to describe perceived health, somatic symptoms, caregiver burden, and perceived QOL and to identify the extent to which these variables are associated with QOL in female partners/spouses of Veterans with TBI. Participants completed a written questionnaire including the Patient Health Questionnaire-15, Caregiver Reaction Assessment, Quality of Life Index, and the general health subscale of the 12-Item Short Form Survey version 2. Caregivers reported moderate levels of QOL, and over a quarter of the sample reported high levels of somatic symptoms, particularly fatigue and sleep disturbance. Age, perceived general health, somatic symptoms, the five subscales of caregiver burden (self-esteem, disrupted schedule, effect on finances, lack of family support, and effect on health) predicted QOL and explained 64% of its variance (adjusted r² = 0.64, F(8,31) = 9.59). However, only somatic symptoms and the caregiver burden subscales of self-esteem and effect on finances were significant predictors in the model. These findings have implications for development of family-centered interventions to enhance the QOL of informal caregivers of Veterans with TBI.