Determinants of well-being in primary caregivers of spinal cord injured persons

Association between Social Support and Depressive Symptoms in Informal Caregivers of Adult and Older Dependents: A Systematic Review and Meta-Analysis

Social support is an important determinant of a carer's mental health. In recent decades, despite many studies reporting on the relationship between social support and depressive symptoms in informal caregivers of adult and older dependents, there are no systematic reviews synthesizing the available evidence. The purpose of the present study was to perform a systematic review and meta-analysis on the relationship between social support and depressive symptoms in informal caregivers of adults and older dependent people. We searched PubMed, CINAHL (EBSCO), PsycINFO (ProQuest), and Scopus, up to 15 January 2023 for studies. We applied no date or language limits to our search. A random-effects model was used to pool effect estimates. The included studies were also independently assessed for quality. Publication bias was evaluated by funnel plots, Egger's regression test, and the Trim and Fill method. Ninety-three studies were included in the review, reporting on a total of 15,431 informal caregivers. We found a moderate negative association between perceived social support and caregiver depressive symptoms (78 studies; r = -0.35, 95% CI = -0.39, -0.31; low heterogeneity and low risk of publications bias) and a small negative association between received social support and caregiver self-reported depressive symptoms (12 studies; r = -0.14, 95% CI = -0.20, -0.07; low heterogeneity and low risk of publications bias). Our results indicate that social support is a clinically relevant construct for carer well-being and an important protective factor for depressive symptoms in informal caregivers of adult and older dependents.

Family caregiving research: Reflecting on the past to inform the future

OBJECTIVE

Family caregiving research has evolved since its inception in the late 1970s. The objective of this brief report was to summarize the research areas and findings to date with the goal of highlighting directions for future research.

DESIGN

Narrative review.

SETTING

Not applicable.

PARTICIPANTS

Published scientific articles in neurological populations including spinal cord injury, traumatic brain injury, and stroke.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Not applicable.

RESULTS

Caregiving research began with a description of the impact of providing care on caregiver health and wellbeing. Intervention research followed to support caregivers in their role and improve caregiving outcomes. Recent reviews conclude a "one size fits all" intervention will not be sufficient to support caregivers. New research suggests caregivers have different patterns of adjustment to the caregiving role highlighting heterogeneity in the caregiving population. Research is also advancing to support patients and families as they transition across care environments by enhancing the timing of intervention delivery. Health care systems do not routinely adopt evidence-based caregiver interventions. As a result, recent research has begun to identify factors that influence the adoption of evidence-based caregiver interventions by health care systems. Ultimately, family centered care that addresses the needs of not only the patient but also the caregiver may be the best way to meet the needs of a heterogeneous group of caregivers across the care continuum.

CONCLUSIONS

Family caregivers make an important contribution to the health and wellbeing of individuals with spinal and other neurological conditions. Ultimately, system changes, like family centered care, may be best suited to meet the complex needs of this heterogeneous group of caregivers.

Spinal Cord Injury Veterans' Disability Benefits, Outcomes, and Health Care Utilization Patterns: Protocol for a Qualitative Study

BACKGROUND

An estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources (eg, assistive devices and personal aide) and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI.

OBJECTIVE

The aim of this study is to compare the ways in which Veterans Affairs' (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers.

METHODS

This cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System.

RESULTS

This study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019.

CONCLUSIONS

The factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14039.

Family caregivers of individuals with spinal cord injury: exploring the stresses and benefits

STUDY DESIGN

Cross-sectional, focus group.

OBJECTIVES

To explore positive and negative issues reported by family caregivers of people with spinal cord injury (SCI) to develop a relevant and valid tool to assess caregiver distress and benefit for this unique population.

METHODS

Seventy-three family caregivers of people with SCI participated in 16 focus groups. We audio-recorded all focus group discussions and transcribed the recordings verbatim. Qualitative analysis of the transcripts was performed to identify major themes and subthemes relating to family caregiving activities.

RESULTS

Positive themes were disproportionately limited in comparison with negative themes. Positives included changes in self-awareness, enhanced family cohesiveness and feeling appreciated. Negative themes included physical and emotional strain, dissatisfaction with hired carers and strain on family relationships. Health-related themes included fatigue and lack of sleep. Caregivers identified sources of strength that helped them manage stresses including faith and support from friends and co-workers.

CONCLUSION

The numerous themes help lay the groundwork to develop a valid and reliable assessment tool to assist health-care providers in treatment planning and the provision of long-term assistance to people with SCI by enhancing areas of strengths and addressing factors that contribute to burden and distress for family caregivers.

Psychological distress, quality of life, and burden in caregivers during community reintegration after spinal cord injury

OBJECTIVES

To examine relations between psychological distress, health-related quality of life (HR-QOL), and burden among caregivers of people with traumatic spinal cord injury (SCI) over time, and to determine whether the data are more consistent with a wear and tear or adaptation trajectory.

DESIGN

Prospective longitudinal cohort study with measurements at 4 time points (6wk prior to discharge from subacute inpatient rehabilitation and 6wk, 1y, and 2y postdischarge to community).

SETTING

Rehabilitation units.

PARTICIPANTS

Participants (N=44; spouses, parents, others) nominated as a primary caregiver by the person with SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

General Health Questionnaire-28 (GHQ-28), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Caregiver Strain Index (CSI) assessed the extent of psychological distress, HR-QOL, and burden, respectively, among caregivers. Functional status and community participation/care needs of the persons with SCI were assessed by the FIM and Craig Handicap Assessment and Reporting Technique, respectively.

RESULTS

Multilevel piecewise models showed that psychological distress (GHQ-28 score) decreased significantly after discharge (slope estimate =-.03, P<.008). At the predischarge time point, the caregivers' mental component summary score on the SF-36 was significantly lower than Australian national norms. The scores improved from predischarge to 6 weeks postdischarge (slope estimate =.39, P<.001), but they did not change significantly across the following 2 time points (slope estimate =.02, P=.250). At all 3 postdischarge time points, the mental component summary scores were not significantly different to national norms. In contrast, the physical component summary score of the SF-36 did not significantly change across the predischarge and 6-week postdischarge time points (slope estimate =-.14, P=.121) and the 3 postdischarge time points (slope estimate <.01, P=.947). Scores at all 4 time points were not significantly different to the national norms. Caregiver burden showed no significant change over the study period (predischarge to 6wk postdischarge slope estimate =.02, P=.426; 3 postdischarge time point slope estimates <-.01, P=.334). Reflecting this, 42% of caregivers met CSI caseness criterion at the first time point, and 46% met the criterion at the fourth (2y) time point. Higher burden was significantly correlated with increased hours of care being provided by the caregiver and lower FIM scores and lower community participation (for the person with SCI) at each time point. Psychological distress correlated with caregiver burden at 6 weeks and 1 year postdischarge but not at 2 years postdischarge.

CONCLUSIONS

The trajectory of scores for psychological distress and HR-QOL was consistent with caregiver adaptation to the challenge of providing support to a person with SCI in the early postdischarge period. Caregiver burden did not display similar reductions but did not worsen over the study period.

Comparison of utility weighted DMFT with patient-reported oral well-being

This study investigated a method of measuring oral health, as opposed to measuring disease. The objective was to compare DMF score and whole mouth utility scores to a patient-reported outcome measure (PROM). Disutility values for lost and restored teeth were used to weight the decayed, missing and filled teeths(DMFTs) of 10 adult patients. This gave two whole mouth utility scores (WMU). These scores were then compared with a patient-reported oral health outcome measure recorded by the use of a visual analogue scale (VAS). The anchors for the VAS were 'my mouth could not be worse' and 'my mouth could not be better'. There was a positive correlation (r = 0.6457) between WMU1 and the patient-reported outcome measure (P < 0.05) and a negative correlation (r = -0.8383) between WMU1 and DMFT which was significant at the P < 0.01 level. There was a statistically significant positive correlation of r = 0.7926 between WMU2 and the patient-reported outcome measure (P < 0.01) and a negative correlation (r = -0.9393) between WMU2 and DMFT (P < 0.01). The Pearson's correlation between DMFT and the patient-reported outcome measure was -0.8757, which was significant at the 0.01 level. Patient reports of their perceived level of health correlate well with DMFT scores. Weighting DMFT scores according to the differential values assigned to missing, or missing and filled, teeth does not increase the degree of correlation between the measure and the patients' personal quantification of their oral health. Decayed, missing and filled teeth therefore seems to adequately capture the patient's sense of well-being.

Tooth loss and oral health-related quality of life: a systematic review and meta-analysis

BACKGROUND

It is increasingly recognized that the impact of disease on quality of life should be taken into account when assessing health status. It is likely that tooth loss, in most cases being a consequence of oral diseases, affects Oral Health-Related Quality of Life (OHRQoL). The aim of the present study is to systematically review the literature and to analyse the relationship between the number and location of missing teeth and oral health-related quality of life (OHRQoL). It was hypothesized that tooth loss is associated with an impairment of OHRQoL. Secondly, it was hypothesized that location and distribution of remaining teeth play an important role in this.

METHODS

Relevant databases were searched for papers in English, published from 1990 to July 2009 following a broad search strategy. Relevant papers were selected by two independent readers using predefined exclusion criteria, firstly on the basis of abstracts, secondly by assessing full-text papers. Selected studies were grouped on the basis of OHRQoL instruments used and assessed for feasibility for quantitative synthesis. Comparable outcomes were subjected to meta-analysis; remaining outcomes were subjected to a qualitative synthesis only.

RESULTS

From a total of 924 references, 35 were eligible for synthesis (inter-reader agreement abstracts κ = 0.84 ± 0.03; full-texts: κ = 0.68 ± 0.06). Meta-analysis was feasible for 10 studies reporting on 13 different samples, resulting in 6 separate analyses. All studies showed that tooth loss is associated with unfavourable OHRQoL scores, independent of study location and OHRQoL instrument used. Qualitative synthesis showed that all 9 studies investigating a possible relationship between number of occluding pairs of teeth present and OHRQoL reported significant positive correlations. Five studies presented separate data regarding OHRQoL and location of tooth loss (anterior tooth loss vs. posterior tooth loss). Four of these reported highest impact for anterior tooth loss; one study indicated a similar impact for both locations of tooth loss.

CONCLUSIONS

This study provides fairly strong evidence that tooth loss is associated with impairment of OHRQoL and location and distribution of tooth loss affect the severity of the impairment. This association seems to be independent from the OHRQoL instrument used and context of the included samples.

Aging and disability: biopsychosocial perspectives

Understanding the complex trajectories of disability and aging requires a biopsychosocial approach that considers disability in the broader context of later adulthood. Although disability service researchers and gerontologists have many shared interests and a similar mission, the fields are relatively new to one another and have had little historical interaction. The purpose of this article is to increase and improve collaboration among investigators in these fields by providing some background in social gerontology to the disability researcher, and by applying key theories in aging to the issue of growing older with physical disability. The article discusses particular problem areas for older adults, including social support, and also discusses the parallel paradoxes of aging and disability.

Leisure satisfaction and psychiatric morbidity among informal carers of people with spinal cord injury

STUDY DESIGN

Cross sectional survey.

OBJECTIVE

To examine the nature and prevalence of common mental disorders among informal carers of people with Spinal Cord Injury (SCI) and the association with their leisure satisfaction.

SETTING

Christian Medical College, Vellore, Tamilnadu, India.

METHODS

A cross-sectional survey of informal carers of people SCI at the Department of Physical Medicine and Rehabilitation. Fifty-three informal carers of people with SCI were interviewed using the Revised Clinical Interview Schedule to assess psychiatric morbidity, and using the Leisure Satisfaction Scale to measure leisure and contentment. Data on carers with psychiatric morbidity were compared to those without common mental disorders using univariate and multivariate statistics.

RESULTS

Study reported a high morbidity (53%), with most consistent diagnoses of depression and anxiety. Carers who were spouses, women, currently married and those with lower education had greater psychiatric morbidity and lesser leisure satisfaction, even after adjusting for age and education using logistic/linear regression. Age, occupation, residence, socioeconomic status, type and duration of SCI were not associated with either morbidity or leisure satisfaction.

CONCLUSION

Many carers of people with SCI suffer from psychiatric morbidity and also have low scores on leisure satisfaction.

Re-examining the psychology of spinal cord injury: a meaning centered approach from a cultural perspective

OBJECTIVES

To examine the impact of SCI from a non-Western cultural perspective.

SETTING

India.

METHODS

A philosophical approach.

CONCLUSION

Management of the individual with spinal cord injury needs to take in to account the individual's beliefs and cultural context.

Quality of life of primary caregivers of spinal cord injury survivors living in the community: controlled study with short form-36 questionnaire

OBJECTIVE

To compare the quality of life scores of primary caregivers of spinal cord injury survivors living in the community with healthy age matched-population based controls and to determine the relationship between some severity parameters related with spinal cord injury and the quality of life scores of primary caregivers.

SETTING

University hospital, rehabilitation centre.

METHODS

Fifty primary caregivers of spinal cord injured patients living in the community and 40 healthy age-matched controls completed SF-36 (short form-36) questionnaire forms. Questionnaires were administered by interviewers who were physiatrists and the authors of the present study. All the patients were rehabilitated by the authors and data about the duration of injury, lesion levels, ASIA scores, degree of spasticity, presence of bladder and bowel incontinence and pressure sores were gathered from the hospital recordings and/or by physical examinations during control visits when the primary caregivers were administered the questionnaires.

RESULTS

Quality of life scores measured by SF-36 were significantly low in the primary caregivers group compared to age-matched healthy population based controls. No significant relation was demonstrated between the quality of life scores of primary caregivers and parameters such as the duration of injury, lesion levels, ASIA scores, degree of spasticity, bladder and/or bowel incontinence and pressure sores respectively.

CONCLUSION

According to the results of the present study, being a primary caregiver of a spinal cord injured victim significantly interferes with quality of life; some severity parameters related to the injury however do not seem to have an additional impact on the primary caregiver's life quality.

Mood and blood pressure responses in black female caregivers and noncaregivers

BACKGROUND

Substantial interaction between mood and blood pressure, especially in the context of caregiving for a dependent elder, could increase the risk in the already at-risk population of black women for either higher blood pressure or the onset of hypertension.

OBJECTIVES

To examine the relationship between mood symptoms and daytime ambulatory blood pressures during a 12-hour period in Black female caregivers and noncaregivers.

METHOD

A prospective cohort design was employed to study black females 18 years of age or older identified by randomly selected elders as the provider or potential provider of 5 or more hours of care per week to the elder. Mood symptoms were measured on visual analogue scales by the subjects in a diary attached to a retractable clip key ring worn by the subject. Blood pressure responses were measured with automated portable blood pressure monitors every 30 minutes. Additional risk and treatment factors were considered for descriptive purposes.

RESULTS

The two groups were equivalent on all hypertension risk and treatment factors except alcohol use (more noncaregivers consumed alcohol). Among caregivers, anger and mean diastolic blood pressure (DBP) were negatively related (parameter = -0.64, SE = .23, p = .01) and the negative relationship between anger and systolic blood pressure approached significance (parameter = -0.81, SE = 0.65, p = 0.10). Anxiety and sadness were not significant predictors.

CONCLUSION

Among black caregivers, elevated anger was associated with significant decreases in DBP, while lowered anger was associated with significant increases in DBP. Whether lower anger scores reflect a low level of perceived anger or suppressed anger among black caregivers should be explored in future studies.

Rehabilitation following spinal injury: the nursing response

Spinal cord injury is one of the most unexpected and devastating of events that typically affects young people, often males. Thus it stands in stark contrast to both multiple sclerosis and arthritis, the conditions considered in the previous two articles of this series. The differences do not end here as spinal injury is relatively stable once the initial phase has passed, whereas both multiple sclerosis and arthritis are progressive. However, despite this variation the literature suggests that rehabilitation in all three conditions raises similar concerns. This article focuses on these concerns and how nurses can respond to them.

Literature review of social support and caregiver burden, 1980 to 1995

PURPOSE

To critique social support and caregiver burden studies for (a) explication of constructs, (b) associations between constructs, (c) statistical conclusion validity, and (d) generalizability. Social support moderates caregiver burden, yet studies using different conceptualizations raise questions about validity. FRAMEWORK AND SCOPE: Cooper's (1984) methodology for an integrated literature review was used to examine 50 studies (1980-1995) involving adult caregivers of older family members.

FINDINGS

Inadequate explication of social support, potential spuriousness and reverse causation, threats to statistical conclusion validity, and lack of generalizability were found.

CONCLUSIONS AND IMPLICATIONS

Progress has been made in caregiving and social support research, yet many problems remain. Future research should include multiple measures of support, controls for spuriousness and reverse causation, valid and reliable instruments, and samples of diverse populations.

Spouses of spinal cord injury survivors: the added impact of caregiving

OBJECTIVE

To better understand the needs of spouses who provide care to spinal cord injury (SCI) survivors, by comparing their self-perceptions and complaints with those of their partners with disabilities and with those of spouses who do not provide care.

DESIGN

Survey, including demographics, health concerns questionnaire, and administration of the Center for Epidemiologic Studies Depression Scale (CES-D), the Perceived Stress Scale (PSS), the Life Satisfaction Index (LSI-Z), and the Quality of Life and Individual Needs Questionnaire.

SETTING

Two British SCI treatment centers, serving a defined population-based catchment area.

PARTICIPANTS

One hundred twenty-four spouses of a longitudinally followed sample of SCI survivors, all of whom had been injured 23 or more years when the study was conducted in 1993.

OUTCOME MEASURES

Scores on the above standardized tests, and responses to survey questions.

RESULTS

Spouses had more depressive affect (p < .001) than their partners with disabilities, as measured by the CES-D. On the PSS, they exhibited no significant differences. Compared with spouses who were not caregivers, the caregiving spouses reported more physical stress (p = .005), emotional stress (p = .011), burnout (p = .007), fatigue (p = .002), and anger and resentment (p = .029). On the CES-D, they had more symptoms of depressive affect (p = .004) and somatic depression (p = .005).

CONCLUSIONS

Spouses of long-term SCI survivors who fulfill a caregiving role report more symptoms of stress and depression than their partners with disabilities and other spouses who are not caregivers.

Caring for the caregivers: the hidden victims of illness and disability

As advances in medical care extend the life expectancy of the elderly as well as those with disabling and chronic conditions, new sets of problems often emerge. One such problem is the constantly growing population of those providing care for spouses who, due to a disability, chronic illness, medical condition, or simply the frailty of old age, can no longer totally care for themselves. Well spouses who provide care are at risk for numerous physical, mental, emotional, social, and financial problems of their own. The literature points to several issues that emerge from the caregiving experience, as well as appropriate and effective responses to these issues. Nurses are in a position to identify at-risk caregivers and to advise them of their increased risk of physical and emotional problems. Addressing caregivers' needs helps to ensure that better care will be given to those dealing with or recovering from chronic illness, disability, or medical condition and, thus, that there will be improved results.

Psychosocial outcome following spinal cord injury

Studies have indicated that loss of social contact remains the primary complaint of people with head injuries many years after discharge. In an attempt to disentangle specific and nonspecific effects of head injury a study was undertaken to compare a group of 15 men with severe closed head injuries and their wives, with a group of 15 men with complete, traumatic spinal cord injuries and their partners (n = 60). Time since discharge extended from 4 months to several years. This paper focuses primarily upon the results and implication of the responses from the group of men with spinal cord injuries and their partners. The Interview Schedule for Social Interaction was correlated with the Leeds Scale for the Self Assessment of Anxiety and Depression. All groups reported low availability and adequacy of social integration and exhibited high levels of depression. The group of men with spinal cord injuries had the lowest scores for the availability of social integration, indicating that the social isolation which has previously been identified amongst people with head injuries may not be attributable solely to brain damage.

Quality of life after spinal cord injury: a literature critique and meta-analysis (1983-1992)

Research articles cross-indexed in Index Medicus under the subject headings "quality of life" (QOL) and "spinal cord injury" (SCI) were examined in order to compare their relative merits in terms of research design, sampling techniques and the type of QOL criteria included. Of 3,710 citations indexed for the ten year period 1983 through 1992 under "quality of life," thirty-two research articles (< 1 percent) were cross-indexed with the subject heading "spinal cord injury." The modal design was a descriptive survey or case study (n = 23 or 72 percent). None of them were randomized clinical trials. Because of limited rigor of research design and poor validity of measurements, conclusions about the ability of rehabilitative care to improve the QOL for SCI persons could not be drawn from the studies reviewed. Meta-analysis indicated that severity of injury is associated with QOL, with more severe injury being correlated with poorer quality. The critique concludes that QOL research with SCI persons needs to be better designed and should include more uniform and valid criteria.

Caring for individuals using home ventilators: an appraisal by family caregivers

This article describes a study of the effects of caregiving on family members who assumed primary responsibility for managing the care of ventilator-assisted individuals in the home. Thirteen caregivers were interviewed and five variables associated with their role were assessed: caregiving tasks, burden of caregiving, impact of caregiving, mastery of the caregiving role, and satisfaction with caregiving. Data were collected using the Caregiving Appraisal Scale (CAS), a list of caregiving tasks, and a semistructured interview. Caregivers assumed multiple responsibilities for individuals who were completely ventilator-dependent (n = 5), partially ventilator-dependent (n = 3), or nocturnally ventilated (n = 5). Caregivers reported feeling moderate levels of both the burden and the negative impact of caregiving but a positive sense of mastery and satisfaction. They described problems with home healthcare nurses, insurance coverage, and equipment suppliers. Lack of preparation, in terms of education provided by healthcare professionals, limited their ability to manage these problems quickly and effectively. Caregivers suggested that healthcare providers expand discharge planning to include provision of problem-solving strategies.

The stress process in family caregivers of persons receiving chemotherapy

The purpose of this analysis was to explore strain and depression among family caregivers of persons receiving chemotherapy for cancer using the Pearlin Stress Process Model. Seventy-five family caregivers of persons receiving chemotherapy participated, completing the Caregiver Strain Index and the Depression Subscale of the Profile of Mood States within 3 weeks of the initiation of chemotherapy. Hierarchical regression analyses indicated that 44% of the variance in strain and 40% of the variance in depression were explained by the antecedent variables of caregiver age and gender, patient age and gender, patient functional status, the presence of recurrent disease, perceived efficacy of coping strategies, and perceived adequacy of social support. Further analysis aimed at delineating the mechanisms through which coping and social support operate in the model found no evidence for a moderating or stress-buffering effect. However, coping mediated the relationship between strain and depression and social support mediated the relationship between functional status and depression.