Quality of life, caregiver burden and mental health disorders in primary caregivers of patients with Cirrhosis

Burden, stress and depression in caregivers of cirrhosis patients before and after liver transplantation

BACKGROUND

Family caregivers of cirrhosis patients (CPs) often experience burden, stress, and depression. Investigating whether these conditions improve following the patient undergoing liver transplantation (LT) is crucial, as it would elucidate the comprehensive benefits of the procedure and demonstrate the positive impacts not only on the patients but also on their caregivers and society.

AIM

To compare the levels of burden, stress and depression among family caregivers of cirrhotic and liver transplant patients.

METHODS

This cross-sectional observational study evaluated caregivers of CPs and LT recipients at a quaternary Brazilian hospital. Instruments included identification cards, interview scripts, the caregiver burden scale Inventory, Lipp’s Stress Symptom Inventory, and the Beck Depression Inventory-Second Edition. Psychometric analyses involved confirmatory factor analysis and calculation of McDonald’s omega and composite reliability. Factor scores were compared with the Mann-Whitney U test, with effect size as the rank-biserial correlation coefficient (r). Statistical analysis was performed with R software (P < 0.05).

RESULTS

Seventy-seven CP caregivers and 65 LT recipient caregivers were included. Most were female (CP: 85.7% vs LT: 84.6%) and the patients’ spouses (76.6% vs 63.1%). The median age and caregiving duration were 55.4 (23.3-76.3) vs 54.6 (25.7-82.1) and 3.9 (1-20) vs 8 (1.5-24) years, respectively (P = 0.001). LT caregivers were less likely to be at risk of overload (21.5% vs 49.4%), to be under stress (33.8% vs 36.4%) and to show symptoms of depression (15.4% vs 35.1%). Compared with LT caregivers, CP caregivers had greater median factor scores for burden (general tension, P = 0.012; isolation, P = 0.014; disappointment, P = 0.004), depression (P = 0.008), and stress (P = 0.047), with small to moderate effect sizes. The disappointment (r = 0.240) and depression (r = 0.225) dimensions had the largest effect sizes.

CONCLUSION

Family caregivers of LT recipients are less likely to exhibit symptoms of burden, stress, and depression, suggesting that the benefits of LT extend to the patients’ family members.

Psychological Distress Is Prevalent and Interdependent Among Patients With Decompensated Cirrhosis and Their Caregivers

INTRODUCTION

Little is known about the interdependence of psychological distress among patients with decompensated cirrhosis and their caregivers.

METHODS

In this cross-sectional study, we examined the interdependence of psychological distress (Hospital Anxiety and Depression Scale) among 127 patient-caregiver dyads using Actor-Partner Interdependence Modeling.

RESULTS

Among dyads, 26% had both partners reporting clinically significant anxiety and 18% reporting clinically significant depression. Caregiver anxiety significantly predicted patient depression (standardized β = 0.18, P = 0.03).

DISCUSSION

Psychological distress was prevalent and interdependent among dyads. These results underscore the need to develop interventions to reduce psychological distress in both patients with decompensated cirrhosis and their caregivers.

Informal Family Care Partner Well-Being Is Diminished in End-Stage Liver Disease

BACKGROUND

Chronic liver disease is a significant global neglected public health problem. End-stage liver disease is associated with substantial symptom complexity, disability, and care needs that require assistance from informal family care partners. Research on these care partners' caregiver burden or strain, symptoms, and quality of life is sparse and has not focused on these variables as co-occurring or in the context of the quality of the relationship care partners have with the patients.

OBJECTIVES

The purpose of this study was to provide a collective presentation of patterns and determinants of well-being as measured by caregiver strain, depression, sleep, and quality of life in a cohort of informal family care partners for adult outpatients with end-stage liver disease.

METHODS

Care partners (aged >18 years) were recruited from two liver clinics within two tertiary healthcare systems and invited to complete a cross-sectional survey. They completed the Multidimensional Caregiver Strain Index, Patient Health Questionnaire, Pittsburgh Sleep Quality Index, Short Form Health Survey, and Mutuality Scale. Descriptive statistics and latent class mixture modeling were used to analyze these data.

RESULTS

The sample was predominantly female and White. The well-being of care partners was diminished. Three distinct classes of well-being were identified: mildly diminished (53.2%), moderately diminished (39.0%), and severely diminished (7.8%). Those at a greater risk of worse well-being were younger and spouses and had poorer relationship quality with the patients.

DISCUSSION

To improve the well-being of care partners in moderately and severely diminished classes, assessing and addressing caregiver strain and co-occurring symptoms is essential. Addressing the strain and symptoms has the potential to maintain or optimize care partners' ability to provide care to patients. Future researchers should include longitudinal and dyadic studies to examine how patients' disease progression and symptoms may affect family care partners' well-being and vice versa.

Social Impact of Hepatic Encephalopathy

Hepatic encephalopathy is a medical condition that stems from liver dysfunction, leading to the accumulation of toxins in the bloodstream. This can result in cognitive impairments, mood changes, and motor dysfunction. Its social impact includes challenges in employment, relationships, and daily functioning for affected individuals. Stigma and misunderstanding around the condition can further exacerbate the difficulties faced by both patients and their caregivers. Efforts to raise awareness, improve medical management, and provide support systems can help mitigate the social impact of hepatic encephalopathy.

Mediating effect of social support between caregiver burden and quality of life among family caregivers of cancer patients in palliative care units

PURPOSE

To identify factors influencing the quality of life of family caregivers with terminal cancer in Chinese palliative wards and to test whether social support mediates the relationship between caregiver burden and caregiver quality of life.

METHODS

A cross-sectional study design was used. Sociodemographic data were collected and the Quality of Life Scale, the Caregiver Burden Scale, and the Social Support Rating Scale were administered to Chinese family caregivers from December 2021 to December 2022. The factors influencing quality of life and caregiver burden were examined using the Mann‒Whitney U test and the Kruskal‒Wallis H test. The mediating role of social support was assessed using the bootstrap method.

RESULTS

Family caregivers' quality of life in Chinese terminal cancer palliative units was related to caregivers' daily care time, the caregiver-patient relationship, and patient age. Caregiver quality of life was negatively associated with caregiver burden and positively associated with social support. In addition, social support mediated the relationship between caregiver burden and caregiver quality of life.

CONCLUSION

Social support mediated the impact of caregiver burden on caregiver quality of life. Family, society, and palliative care institutions should be integrated to take actions to reduce family caregiver burden, increase social support, and transfer the positive aspects of specific cultural contexts to the culture of palliative care in general to collaboratively cope with various problems related to end-stage cancer.

Palliative clinical trials in advanced chronic liver disease: Challenges and opportunities

Patients with advanced chronic liver disease have a complex symptom burden and many are not candidates for curative therapy. Despite this, provision of palliative interventions remains woefully inadequate, with an insufficient evidence base being a contributory factor. Designing and conducting palliative interventional trials in advanced chronic liver disease remains challenging for a multitude of reasons. In this manuscript we review past and ongoing palliative interventional trials. We identify barriers and facilitators and offer guidance on addressing these challenges. We hope that this will reduce the inequity in palliative care provision in advanced chronic liver disease.

CAREGIVER Randomized Trial of Two Mindfulness Methods to Improve the Burden and Distress of Caring for Persons with Cirrhosis

BACKGROUND

Patient caregivers experience burden and distress that negatively impacts health-related quality of life (HRQOL). Mindfulness may alleviate caregiver burden but randomized trials of mindfulness activities on caregiver burden and distress are lacking.

METHODS

Caregivers for patients with advanced liver disease were recruited from the Universities of Michigan and Pennsylvania (12/2019-12/2021) and followed for 8 weeks. Participants were randomized 1:1:1 to: written emotional disclosure for 4 weeks, resilience training for 4 weeks, or control (no active intervention). All completed assessments at baseline, week 4 and 8. The primary outcome was change in the Zarit Caregiver Burden Index-12 (ZBI) at week 8. Secondary outcomes included changes at week 4 and 8 in the ZBI, distress thermometer (DT), HRQOL visual analog scale (VAS), and caregiver captivity index (CCI).

RESULTS

Eighty seven caregivers were enrolled, 59(72%) completed the study. In unadjusted analyses at week 4, the burden measured by ZBI was not significantly different between arms, increasing by 0.6 ± 5.7 and 2.5 ± 5.2 points, for the written emotional disclosure and resilience training study arms, respectively, and by 2.9 ± 6.1 points in the control arm. At week 8, the non-significant ZBI change was - 1.0 ± 8.9, 2.8 ± 6.1, and 1.5 ± 7.4 for written emotional disclosure, resilience training, at week 8, respectively. The DT and VAS worsened in all arms, however, it worsened the least in the written emotional disclosure arm. In analyses adjusted for differences in baseline characteristics, the ZBI declined by - 4.21 ± 2.03(p = 0.04) in the emotional disclosure arm at week 4. This decrease was attenuated week 8, - 1.13 ± 2.6(p = 0.67). There were no significant differences in secondary outcomes save for resilience training reducing the CCI at week 4 by 1.36 ± 0.67(p = 0.04).

CONCLUSION

Written emotional disclosure may reduce caregiver burden in the short term among caregivers for patients with cirrhosis.

REGISTRATION

NCT04205396.

Does the Nae Umeed group intervention improve mental health and social participation? A pre-post study in Uttarakhand, India

There are few evidence-based interventions to support caregiver mental health developed for low- and middle-income countries. Nae Umeed is a community-based group intervention developed with collaboratively with local community health workers in Uttarakhand, India primarily to promote mental wellbeing for caregivers and others. This pre-post study aimed to evaluate whether Nae Umeed improved mental health and social participation for people with mental distress, including caregivers. The intervention consisted of 14 structured group sessions facilitated by community health workers. Among 115 adult participants, 20% were caregivers and 80% were people with disability and other vulnerable community members; 62% had no formal education and 92% were female. Substantial and statistically significant improvements occurred in validated psychometric measures for mental health (12-Item General Health Questionnaire, Patient Health Questionnaire-9) and social participation (Participation Scale). Improvements occurred regardless of caregiver status. This intervention addressed mental health and social participation for marginalised groups that are typically without access to formal mental health care and findings suggest Nae Umeed improved mental health and social participation; however, a controlled community trial would be required to prove causation. Community-based group interventions are a promising approach to improving the mental health of vulnerable groups in South Asia.

Correlations between caregiver competence, burden and health-related quality of life among Chinese family caregivers of elderly adults with disabilities: a cross-sectional study using structural equations analysis

OBJECTIVE

To examine the relationship between caregiver competence and health-related quality of life (HRQoL) among family caregivers of disabled elderly adults, and to evaluate the role of caregiver burden as a potential mediator of that relationship.

DESIGN

Cross-sectional study.

SETTING

Two general hospitals in Shanghai, China.

PARTICIPANTS

Study participants were 135 family caregivers of disabled elderly adults listed on a roster for outpatient and emergency services utilisation from January to March 2022.

DATA ANALYSIS AND OUTCOME MEASURES

We used stratified linear regression and structural equation model analysis. HRQoL was the main outcome, measured using the Medical Outcomes Study 36-Item Short form Health Survey. Caregiver competence was assessed using the Family Caregiver Task Inventory, and caregiver burden was assessed with the Zarit Burden Interview.

RESULTS

Caregivers of moderately and severely disabled elderly adults showed poorer scores in Physical Component Summary (F=20.463, p<0.05) and Mental Component Summary (F=17.062, p<0.05) compared with caregivers of older adults with mild disabilities. At the same time, those caregivers showed higher scores on the caregiving burden (F=19.533, p<0.05) and caregiving difficulties (F=16.079, p<0.05). A structural equation model was performed and successfully adjusted (χ²/df=1.175, p=0.261, NFI=0.970, RFI=0.949, IFI=0.995, CFI=0.995, GFI=0.963, TLI=0.992, AGFI=0.920, RMSEA=0.036). The total effect of Family Caregiver Task Inventory scores on HRQoL scores was -0.980, with a direct effect of -0.645. The mediating effect on HRQoL scores through the intermediate variable of caregiver burden scores was -0.335.

CONCLUSIONS

Family caregivers' HRQoL is closely related to caregiver difficulties and burdens. Early identification and targeted measures are needed to reduce the burden and problems in caregiving.

Effects of a Social Media-Based Mind-Body Intervention Embedded With Acupressure and Mindfulness for Stress Reduction Among Family Caregivers of Frail Older Adults: Pilot Randomized Controlled Trial

BACKGROUND

Family caregivers of frail older adults experience high levels of stress. Mind-body interventions (MBIs) focused on caregiver stress are often limited in teaching approaches, difficult to practice, and costly. A social media-based MBI embedded with mindfulness meditation (MM) and self-administered acupressure (SA) may be effective for family caregivers, offer greater usability, and lead to greater adherence.

OBJECTIVE

The aim of this study was to test the feasibility and preliminary effects of a social media-based MBI embedded with MM and SA on family caregivers of frail older adults and to investigate the preliminary effects of the intervention using a pilot randomized controlled trial.

METHODS

A 2-arm randomized controlled trial design was adopted. Family caregivers of frail older adults (n=64) were randomized into either the intervention group (n=32), receiving 8 weeks of social media-based MM and SA, or the control group (n=32), receiving brief education on caregiving for people with frailty. The primary outcome (caregiver stress) and secondary outcomes (caregiver burden, sleep quality, and mindfulness awareness and attention) were measured using a web-based survey at baseline (T0), immediately after the intervention (T1), and at the 3-month follow-up (T2).

RESULTS

The feasibility of the intervention was established with a high attendance rate (87.5%), high usability score (79), and low attrition rate (1.6%). The generalized estimating equation results showed that participants in the intervention group at T1 and T2 experienced a significant improvement in stress reduction (P=.02 and P=.04, respectively), sleep quality (P=.004 and P=.01, respectively), and mindful awareness and attention (P=.006 and P=.02, respectively) compared with the control group. There were no substantial improvements in caregiver burden at T1 and T2 (P=.59 and P=.47, respectively). A focus group session conducted after the intervention had 5 themes: impact on the family caregivers, difficulty in practicing the intervention, the strength of the program, the limitations of the program, and perception of the intervention.

CONCLUSIONS

The findings support the feasibility and preliminary effects of social media-based MBI embedded with acupressure and MM on reducing stress among family caregivers of frail older people and enhancing sleep quality and mindfulness levels. A future study with a larger and more diverse sample is proposed to evaluate the longer-term effects and generalizability of the intervention.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100049507; http://www.chictr.org.cn/showproj.aspx?proj=128031.

Financial burden in adults with chronic liver disease: A scoping review

The economic burden of chronic liver disease is rising; however, the financial impact of chronic liver disease on patients and families has been underexplored. We performed a scoping review to identify studies examining financial burden (patient/family health care expenditures), financial distress (material, behavioral, and psychological consequences of financial burden), and financial toxicity (adverse health outcomes of financial distress) experienced by patients with chronic liver disease and their families. We searched MEDLINE, Embase, Cochrane Library, and the Web of Science online databases for articles published since the introduction of the Model for End-Stage Liver Disease score for liver transplantation allocation in February 2002 until July 2021. Final searches were conducted between June and July 2021. Studies were included if they examined the prevalence or impact of financial burden or distress among patients with chronic liver disease and/or their caregivers. A total of 19 observational studies met inclusion criteria involving 24,549 patients and 276 caregivers across 5 countries. High rates of financial burden and distress were reported within the study populations, particularly among patients with hepatic encephalopathy, hepatocellular carcinoma, and liver transplantation recipients. Financial burden and distress were associated with increased pre- and posttransplantation health care utilization and poor health-related quality of life as well as caregiver burden, depression, and anxiety. None of the included studies evaluated interventions to alleviate financial burden and distress. Observational evidence supports the finding that financial burden and distress are underrecognized but highly prevalent among patients with chronic liver disease and their caregivers and are associated with poor health outcomes. There is a critical need for interventions to mitigate financial burden and distress and reduce financial toxicity in chronic liver disease care.

The emotional burden of caregiving for patients with cirrhosis

Caregivers for patients with cirrhosis face immense physical and psychological strain that negatively impact quality of life and ability to care for oneself. The aim is to explore the caregiver experience for patients with cirrhosis, identify prominent stressors, and understand the multidimensional contributors to caregiver burden, to help tailor effective interventions. The caregivers of 25 patients with decompensated cirrhosis underwent semistructured in-person interviews and completed written exercises targeting emotional disclosure or resilience training that were analyzed for dominant emotions and themes. Burden was quantified using the Zarit Burden Interview-12 (ZBI, range 0-48), Distress Thermometer (0-10), and Caregiver Captivity Index (0-4). Quality of life was assessed with a visual analog scale (0-100). Median ZBI was moderate (14 [10-19]), as was distress (5 [2-7]), and captivity (2 [1-4]). Quality of life was fair (80 [70-85]). Dominant emotions included anxiety, guilt, fear, frustration, captivity, and resentment. Prominent themes included lack of time for self-care, hierarchy of caregiver role, support from versus frustration with medical professionals, social support, spirituality and religion, and disease-related restrictions. Hepatic encephalopathy, and need to follow strict nutrition and diet recommendations, are frequent sources of disease-related caregiver burden. The health care system confers some degree of burden, especially when doubts arise regarding physician competence. Conclusion: Caregiver burden is significant. The impact of interventions to alleviate caregiver burden should be explored, so that their appreciated efforts do not have such detrimental effects on their quality of life.

Palliative care experience and perceived gaps in training among transplant hepatology fellows: A national survey

Despite the likely benefits of palliative care (PC) for patients with cirrhosis, physician experiences and perspectives about best practices are variable. We aimed to assess PC experience and gaps in training among transplant hepatology fellows. We conducted a national survey of all transplant hepatology fellows enrolled in accredited fellowship programs during the 2020-2021 academic year. We assessed the frequency of PC provision and comfort with physical and psychological symptom management, psychosocial care, communication skills, advance care planning, and end-of-life care. A total of 45 of 56 (79%) of transplant hepatology fellows responded to the survey; 50% (n = 22) were female. Most trained at centers performing over 100 transplants per year (67%, n = 29) distributed evenly across geographic regions. Most fellows (69%, n = 31) had a PC or hospice care rotation during residency, and 42% (n = 19) of fellows received education in PC during transplant hepatology fellowship. Fellows reported feeling moderately to very comfortable with communication skills such as breaking bad news (93%, n = 41) and leading family meetings (75%, n = 33), but nearly one-third (30%, n = 13) reported feeling not very or not at all comfortable assessing and managing anxiety and depression (30%, n = 13) and spiritual distress (34%, n = 15). Nearly one-quarter (22%, n = 10) had never discussed or documented advance care plans during fellowship. Fellows wished to receive future instruction on the assessment and management of physical symptoms (68%, n = 30) and anxiety and depression (64%, n = 28). Conclusion: Our survey highlights gaps in PC experience and education during transplant hepatology fellowship, lack of comfort in managing psychological distress and advance care planning, and desire to improve skills, particularly in symptom management. Future studies should investigate how to enhance transplant hepatology competencies in these PC domains and whether this impacts clinical care, advance care planning, or patient experience.

Intensity of care and perceived burden among informal caregivers to persons with chronic medical conditions: a systematic review and meta-analysis

PURPOSE

Informal caregivers provide ongoing assistance to a loved one with a health condition. No studies have compared caregiving intensity and perception of burden across chronic medical conditions.

MATERIALS AND METHODS

Databases were searched from inception through 11 September 2020 to identify studies that included the Level of Care Index or the Zarit Burden Inventory (ZBI) among caregivers for people with chronic diseases. Pooled mean ZBI scores and 95% confidence intervals by medical condition were calculated using a random effects model and heterogeneity with I².

RESULTS

Ninety-seven included articles reported on 98 unique samples across 21 chronic diseases. No study used the Level of Care Index. Among 12 disease groups with more than one study, heterogeneity was too high (I² range: 0-99.6%, ≥76.5% in 11 groups) to confidently estimate burden. The percent of studies rated high risk of bias ranged from 0% to 98%, but all external validity items were rated as high-risk in >50% of studies.

CONCLUSIONS

Findings highlight the need for studies on caregiver burden to improve sampling techniques; better report sampling procedures and caregiver and care recipient characteristics; and develop a standard set of outcomes, including a measure of caregiving intensity. Systematic Review Registration: CRD42017080962IMPLICATIONS FOR REHABILITATIONThe amount of burden reported by caregivers to loved ones is associated with reduced physical and mental health.We found considerable heterogeneity in perceived burden reported by informal caregivers across different studies within disease groups, which is likely related to methodological issues, including sampling techniques.Health care providers who use research on caregiver burden should assess how representative study samples may be and exercise caution in drawing conclusions.

Hospice care for end stage liver disease in the United States

INTRODUCTION

Patients with end-stage liver disease (ESLD) have impaired physical, psychological, and social functions, which can diminish patient quality of life, burden family caregivers, and increase health-care utilization. For those with a life expectancy of less than six months, these impairments and their downstream effects can be addressed effectively through high-quality hospice care, delivered by multidisciplinary teams and focused on the physical, emotional, social, and spiritual wellbeing of patients and caregivers, with a goal of improving quality of life.

AREAS COVERED

In this review, we examine the evidence supporting hospice for ESLD, we compare this evidence to that supporting hospice more broadly, and we identify potential criteria that may be useful in determining hospice appropriateness.

EXPERT OPINION

Despite the potential for hospice to improve care for those at the end of life, it is underutilized for patients with ESLD. Increasing the appropriate utilization of hospice for ESLD requires a better understanding of patient eligibility, which can be based on predictors of high short-term mortality and liver transplant ineligibility. Such hospice criteria should be data-driven and should accommodate the uncertainty faced by patients and physicians.

Creating Effective Models for Delivering Palliative Care in Advanced Liver Disease

Purpose of Review

The current healthcare system is not fully equipped to provide comprehensive support for patients with advanced liver disease (ALD) and their caregivers resulting in concomitant suffering and reduced quality of life (QoL). Integration of palliative care (PC) within routine care has demonstrated benefits in improving symptoms and QoL and reducing healthcare utilization for other serious illnesses but has been underutilized or delayed for ALD care. The purpose of this article is to outline the domains and benefits of PC and discuss the misconceptions and barriers for PC integration, and healthcare delivery models supporting PC integration within ALD care.

Recent Findings

PC has eight key domains related to physical and mental health, goals for future care, and care of the caregivers. PC offers benefits to improve health outcomes and patient satisfaction and reduce healthcare utilization. To date there have been successful models of PC that are primarily hospital- or community-based; successful models have been PC specialist- or primary/generalist-led.

Summary

Concurrent PC within oncology has formed the basis for most evidence-based guidelines. PC integration within ALD care is still in its infancy. While amassing evidence in ALD, hepatology organizations can promote consensus-based integrated PC models that can guide research and practice efforts to increase supportive care for these patients in need and their family caregivers.