Recovering together: building resiliency in dyads of stroke patients and their caregivers at risk for chronic emotional distress; a feasibility study

Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma

BACKGROUND

Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma.

METHODS

Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences.

RESULTS

We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress.

CONCLUSIONS

In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.

Feasibility, usability, and acceptability of psychoeducational videoconferencing interventions for informal caregivers: A systematic review of randomized controlled trials

Psychoeducational videoconferencing interventions bypass traditional in-person barriers to attendance and are effective in improving caregiving skills, self-care, and wellness among informal caregivers. Information on their feasibility, usability, and acceptability from the caregivers' perspective is needed to inform future designs and developments. This systematic review follows PRISMA 2020 guidelines to integrate this information. Five databases were systematically searched for relevant randomized control trials published between January 2012 and December 2022. Reference lists were cross-checked for additional studies. Relevant studies were appraised and had their data extracted. This review contains 14 randomized controlled trials. Retention rates ranged from 55.56% to 100%, and major reasons for withdrawing include deteriorating patient health, lack of interest, and technical difficulties (feasibility). Caregivers found the videoconference technology usable, although participants in one intervention experienced poor connectivity and persistent technical issues (usability). Most caregivers were satisfied with videoconferencing interventions, found their content applicable to their situation, and appreciated their structure (acceptability). Those in videoconferencing group interventions were satisfied with small caregiver group sizes (acceptability). Adding respite care to interventions and incorporating short and regular videoconferencing sessions may improve feasibility. Ensuring small group sizes in videoconferencing group interventions and using participatory design may enhance acceptability. Advocacy is needed for employees identifying as informal caregivers to receive employer support and for quality connectivity within underserved areas. This may improve the feasibility and usability of interventions, allowing caregivers to receive the support they need. In future studies, power analyses and recruiting more caregivers may better assess feasibility.

Physical Activity Together for Multiple Sclerosis (PAT-MS): A randomized controlled feasibility trial of a dyadic behaviour change intervention

Background

Many people with advanced multiple sclerosis (MS) and their care-partners do not engage in sufficient physical activity (PA) for health benefits. We developed "Physical Activity Together for MS (PAT-MS)", a 12-week dyadic behavioural intervention, to promote PA among these dyads. Herein, we evaluated the feasibility of PAT-MS before a definitive trial.

Methods

A randomized controlled feasibility trial, with 1:1 allocation into the intervention or wait-list control condition. Predefined progression criteria included rates of recruitment, retention, safety, participant satisfaction and adherence. Changes in self-reported and accelerometer-measured PA were assessed at baseline and post-intervention using mixed-factor ANOVAs. Effects sizes were calculated as Cohen's d.

Results

The recruitment rate (i.e., 20 participants in 10 months) was not acceptable. However, retention (80%) was acceptable. No serious adverse events were reported. There were high levels of participant satisfaction with the intervention (content (median = 6 out of 7), facilitator (median = 7 out of 7), and delivery (median = 5 out of 7)) and adherence (92% of the group sessions, 83% of the individual support calls, and 80% of the practice activities were completed). There were statistically significant time-by-condition interactions on self-reported PA, steps/day, and %wear time and minutes in sedentary behaviour, and moderate-to-vigorous PA from baseline to post-intervention in people with MS and their family care-partners.

Conclusion

PAT-MS appears feasible, safe, and efficacious for PA promotion in MS dyads. We established effect size estimates to power a future definitive trial and identified necessary methodological changes to increase the efficiency of study procedures and improve the quality of the intervention.

Trial registration

ClinicalTrials.gov NCT04267185; Registered February 12, 2020, https://clinicaltrials.gov/ct2/show/NCT04267185.

Family experiences and health outcomes following a loved ones' hospital discharge or death after cardiac arrest: A scoping review

Aim

Synthesise the existing literature on experiences and health outcomes of family members of adult cardiac arrest patients either after hospital discharge or death and identify gaps and targets for future research.

Methods

Following recommended scoping review guidelines and reporting framework, we developed an a priori protocol and searched five large biomedical databases for all relevant studies published in peer-reviewed journals in the English language through 8/8/2022. Studies reporting either on the experiences or health outcomes of family members of adult cardiac arrest patients who survived to hospital discharge (i.e., co-survivors) or bereaved family members were included. Study characteristics were extracted and findings were reviewed for co-survivors and bereaved family members. We summarised practice recommendations and evidence gaps as reported by the studies.

Results

Of 44 articles representing 3,598 family members across 15 countries and 5 continents, 89% (n = 39) were observational. Co-survivors described caregiving challenges and difficulty transitioning to life at home after hospital discharge. Co-survivors as well as bereaved family members reported significant and persistent psychological burden. Enhanced communication, information on what to expect after hospital discharge or the death of their loved ones, and emotional support were among the top recommendations to improve family members' experiences and health outcomes.

Conclusion

Family members develop significant emotional burdens and physical symptoms as they deal with their loved ones' critical illnesses and uncertain, unpredictable recovery. Interventions designed to reduce family members' psychological distress and uncertainty prevalent throughout the illness trajectory of their loved ones admitted with cardiac arrest are needed.

The effects of a family-focused dyadic psychoeducational intervention for stroke survivors and their family caregivers: A randomised controlled trial

BACKGROUND

Stroke can cause a variety of physical and psychosocial disturbances for both survivors and their family caregivers (i.e., stroke dyads). Dyadic psychoeducation appears to be a promising approach for providing knowledge of stroke and self-care or caregiving skills to improve stroke dyads' health outcomes. Therefore, a family-focused psychoeducation intervention was designed and tested to improve the health outcomes of stroke dyads.

OBJECTIVE

To examine the effects of a family-focused dyadic psychoeducational intervention on the functional and psychosocial outcomes of stroke survivors and family caregivers.

DESIGN

A single-blinded, parallel-group randomised controlled trial with repeated-measures design.

SETTINGS

Two general hospitals and one rehabilitation facility in Jinan, China.

PARTICIPANTS

Stroke survivors and family caregivers (N = 162 dyads).

METHODS

The dyads were randomly allocated to either psychoeducation or control group with usual care only (N = 81 dyads per group). The intervention included three structured face-to-face education sessions (one hour per session) in hospital pre-discharge and four weekly telephone counselling calls post-discharge. Study outcomes included survivor functioning and caregiver burden (primary outcomes), and other secondary outcomes (i.e., caregiving competence, dyads' coping, depressive and anxiety symptoms, family functioning, and dyadic relationship, as well as survivor healthcare utilisation and caregiving-related injury). Data were collected at baseline (T₀) and immediately (T₁) and 3 months post-intervention (T₂). The intervention effects were estimated using generalised estimating equation models.

RESULTS

Participants in the psychoeducation group revealed significantly greater reductions on caregiver burden than the control group at T₁ (β = -6.01, p = 0.026) and T₂ (β = -6.73, p = 0.039), but non-significant effects on survivor functioning, except in emotion domain at T₁ (β = 7.22, p = 0.015). In addition, the intervention demonstrated significantly greater improvements on caregiving competence (β = 0.98, p = 0.013; β = 1.58, p < 0.001), survivors' depressive symptoms (β = -1.56, p = 0.007; β = -2.06, p = 0.005), and dyadic relationship (β = 0.26, p = 0.012; β = 0.27, p = 0.022) at T₁ and T₂, as well as on survivor coping at T₂ (β = 6.73, p = 0.008).

CONCLUSIONS

Our study added values on the benefits of family-focused dyadic psychoeducation to routine stroke rehabilitation and family care. Future research can evaluate its long-term effects for families of stroke survivors with diverse socio-demographic and stroke-related characteristics.

REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100042684). Recruitment: March to June 2021.

Efficacy of resilience interventions for dyads of individuals with brain injury and their caregivers: A systematic review of prospective studies

BACKGROUND

Acquired brain injury (BI) is associated with negative mental health outcomes for both people with BI, their caregivers (CG), and patient-CG dyads, which may be mitigated through increased resilience. However, little is known regarding the efficacy of resilience interventions focused on CGs of individuals with BI, as well as dyads, which may be instrumental for positive outcomes.

OBJECTIVE

To systematically review the evidence of the efficacy of resilience interventions focused on CGs and/or dyads of individuals with BI.

METHODS

A search of MEDLINE, Embase, APA PsycINFO, CINAHL with Full Text, Scopus, SCIE, and ESCI was conducted. Each title and abstract were screened by two authors independently. Each full text review, study data extraction, and study quality assessment was performed independently by two authors. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool.

RESULTS

Out of 11,959 articles retrieved, 347 full text articles were assessed for review and 18 met inclusion criteria for data extraction and quality assessment. Resilience interventions were stratified into 5 different categories based on the type of intervention.

CONCLUSION

This systematic review suggests that dyadic/CG resilience interventions may improve mental health related outcomes, but conclusions were limited secondary to heterogenous outcomes and lack of a standardized resiliency construct. Future efforts are compulsory to create a standardized resiliency construct and associated outcomes focused on persons with BI, their CGs, and dyads.

Feasibility and acceptability of the Resilient Living program among persons with stroke or brain tumor and their family caregivers

BACKGROUND

Practice guidelines and research results emphasize the need for dyadic interventions targeting psychosocial outcomes such as depression, anxiety, social function, physical function, and health-related quality of life. Resilience interventions have been proposed as one strategy to influence these outcomes.

OBJECTIVE

The objective of this observational pilot study was to determine the feasibility and acceptability of the Resilient Living program among persons with stroke or brain tumor (BT) admitted for comprehensive acute inpatient rehabilitation and/or their family caregivers. A secondary aim was to gather preliminary data to assess the effects of the program on quality of life, stress, anxiety, physical function, sleep disturbance, fatigue, resilience, dyadic coping, and caregiver role overload.

METHODS

The Resilient Living program is a psychosocial intervention with a focus on building resilience skills. Feasibility and acceptability outcomes were assessed at the end of the study. Quantitative outcome measures were collected at baseline, 12 weeks, and 6 months post the intervention.

RESULTS

Eight patients and eight caregivers completed the study. The intervention was feasible with this population. Participants found the intervention useful and appreciated the flexibility of an online program; however, finding time to engage in it was challenging. Recruitment of eligible patients with acquired brain disorders and their caregivers as a dyad was challenging.

CONCLUSION

The study confirms prior research suggesting that interventions targeting resilience are feasible, but larger studies with more rigorous methods are needed to appreciate the influence of resilience interventions in persons with brain disorders and their caregivers. Further research is needed to identify the characteristics of those most likely to benefit from resilience interventions and the optimal timing of such interventions.

The Recovering Together study protocol: A single-blind RCT to prevent chronic emotional distress in patient-cargiver dyads in the Neuro-ICU

INTRODUCTION

Patients admitted to the Neuroscience Intensive Care Unit (Neuro-ICU) with acute neurological illnesses (ANI; e.g., stroke, tumor, TBI) and their informal caregivers experience high rates of anxiety, depression, and posttraumatic stress. To address this need, we previously developed the Recovering Together (RT) dyadic intervention to help prevent chronic emotional distress in both patients and caregivers. Currently, we are conducting a fully-powered, single-blind randomized clinical trial (RCT) to evaluate the efficacy of RT versus an attention matched health education control. Here, we describe the protocol and current status of this RCT.

METHODS

We aim to recruit 194 at risk patient-caregiver dyads from the Neuro-ICU at MGH. Eligible dyads include patients diagnosed with ANI, cognitively intact, at least one partner endorses emotional distress (on Hospital Anxiety and Depression Scale), English speaking, age 18 or older. Dyads are randomized to the intervention (RT-1) or control condition (RT-2) (both six sessions). RT-1 teaches resiliency (e.g., coping, mindfulness) and interpersonal skills. RT-2 provides education on health-related topics (e.g., stress, self-care, adhering to medical recommendations). Blinded research assistants collect measures at baseline, post-intervention, and three months follow-up. We will conduct mixed linear, mediation, and actor-partner interdependence models to examine changes in dyads' outcomes across time.

RESULTS

We have recruited 41 dyads and aim to recruit 194 total.

DISCUSSION

If successful, we plan to test RT in a large-scale, multisite hybrid effectiveness-implementation study in Neuro-ICUs across the country. Enhancing psychosocial supports for patients and families could improve health outcomes, healthcare efficiency, and the culture of these units.

Psychological Distress After Sudden Cardiac Arrest and Its Impact on Recovery

PURPOSE OF REVIEW

To summarize the prevalence, correlates, and health consequences of poor mental health in the increasingly sizable population of survivors of Sudden cardiac arrest (CA) and to describe current intervention research in this area.

RECENT FINDINGS

After CA many patients report high psychological distress, including depression, generalized anxiety, and posttraumatic stress. Emerging evidence suggests that distressed patients' attention may narrow such that anxious awareness of afferent cardiac signals e.g., changes in heart rate or blood pressure, becomes predominant and a cause for concerned, constant monitoring. This cardiac-specific anxiety followed by behavioral avoidance and physiological hyperreactivity may increase patients' already high risk of secondary cardiovascular disease and undermine their health-related quality of life (HRQoL). Unlike other cardiovascular diseases, no clinical practice guidelines exist for assessing or treating psychological sequelae of CA. Future research should identify modifiable psychological targets to reduce secondary cardiovascular disease risk and improve HRQoL.

Psychological Stress Management and Stress Reduction Strategies for Stroke Survivors: A Scoping Review

BACKGROUND

Stroke can be a life-changing event, with survivors frequently experiencing some level of disability, reduced independence, and an abrupt lifestyle change. Not surprisingly, many stroke survivors report elevated levels of stress during the recovery process, which has been associated with worse outcomes.

PURPOSE

Given the multiple roles of stress in the etiology of stroke recovery outcomes, we aimed to scope the existing literature on stress management interventions that have been trialed in stroke survivors.

METHODS

We performed a database search for intervention studies conducted in stroke survivors which reported the effects on stress, resilience, or coping outcome. Medline (OVID), Embase (OVID), CINAHL (EBSCO), Cochrane Library, and PsycInfo (OVID) were searched from database inception until March 11, 2019, and updated on September 1, 2020.

RESULTS

Twenty-four studies met the inclusion criteria. There was significant variation in the range of trialed interventions, as well as the outcome measures used to assess stress. Overall, just over half (13/24) of the included studies reported a benefit in terms of stress reduction. Acceptability and feasibility were considered in 71% (17/24) and costs were considered in 17% (4/24) of studies. The management of stress was rarely linked to the prevention of symptoms of stress-related disorders. The overall evidence base of included studies is weak. However, an increase in the number of studies over time suggests a growing interest in this subject.

CONCLUSIONS

Further research is required to identify optimum stress management interventions in stroke survivors, including whether the management of stress can ameliorate the negative impacts of stress on health.

Surviving cardiac arrest - what do we know about recovery & survivorship?

PURPOSE OF REVIEW

There has been increasing interest in examining how cardiac arrest survivors and their families experience life after sudden cardiac arrest (SCA). Understanding their experiences provides a basis to study tools and interventions to improve short- and long-term recovery and rehabilitation.

RECENT FINDINGS

Qualitative interview and survey-style studies explored the lived experience of SCA survivors and revealed common themes (e.g., need for recovery expectations and long-term follow-up resources). A heightened awareness for the unique needs of family and loved ones of survivors led to qualitative studies focusing on these members as well. Methodology papers published portend prospective assessment and follow-up cohort studies. However, no investigations evaluating discharge processes or specific interventions directed at domain impairments common after SCA were identified in the review period. International work continues to identify patient and family-centered priorities for outcome measurement and research.

SUMMARY

In line with increased recognition of the importance for recovery and rehabilitation after SCA, there has been a commensurate increase in investigations documenting the needs of survivors and families surviving SCA. Pediatric and underserved populations continue to be understudied with regards to recovery after SCA.

Systematic Review of the Evidence for Stroke Family Caregiver and Dyad Interventions

Stroke family caregiver and dyad literature has expanded over the past few years. The purpose of this review was to build upon 2 prior systematic reviews to critique, analyze, and synthesize the evidence pertaining to the impact of family caregiver and dyad interventions on stroke survivor and family caregiver outcomes. CINAHL, PsychINFO, PubMed, and reference lists were searched from December 1, 2016 through March 31, 2021. Using PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), articles were identified that tested outcomes from stroke family caregiver or dyad interventions that targeted the health or well-being of family caregivers. Data from the articles were abstracted into tables for analysis, then compared with recommendations from the 2 prior systematic reviews. A total of 18 articles met inclusion criteria (10 caregiver interventions; 8 dyad interventions) representing sample sizes ranging from 7 to 349 caregivers or dyads. Most were randomized controlled trials (n=13); 2 were cluster randomized trials; and 3 were single-group quasi-experimental designs. Of the 18 studies, 8 had <50 caregivers or dyads and 5 were small feasibility studies that reported data trends rather than testing for significance. Only 6 studies reported significant survivor outcomes. Eleven studies reported significant caregiver outcomes, the most common being burden. A number of survivor and caregiver outcomes were not significant, or only significant for certain subgroups. The limited number of studies, small sample sizes, and conflicting results, made it difficult to draw firm conclusions regarding the impact of these interventions on outcomes. Based on the available evidence from these 18 studies, recommendations from the 2 prior reviews were generally supported. Well-designed and well-powered randomized controlled clinical trials are still needed to confirm efficacy of stroke family caregiver and dyad interventions.

Emotional distress in neuro-ICU survivor-caregiver dyads: The recovering together randomized clinical trial

OBJECTIVE

Emotional distress is common in both survivors and their informal caregivers following admission to a neuroscience intensive care unit (Neuro-ICU) and can negatively affect their individual recovery and quality of life. Neuro-ICU survivor-caregiver dyads can influence each other's emotional distress over time, but whether such influence emerges during dyadic treatment remains unknown. The present study involved secondary data analysis of Neuro-ICU dyads enrolled in a randomized clinical trial of a dyadic resiliency intervention, Recovering Together (RT), versus a health education attention placebo control to test dyadic similarities in emotional distress before and after treatment.

METHOD

Data were collected from 58 dyads following Neuro-ICU admission. Emotional distress (depression, anxiety, and posttraumatic stress) was assessed at baseline, 6 weeks (postintervention), and 12 weeks later. Nonindependence within survivor-caregiver dyads was examined (i.e., correlations between cross-sectional symptoms and changes in symptoms over time); mutual influence of emotional functioning over time (i.e., "partner effects") was examined using cross-lagged path analyses.

RESULTS

There were strong, positive cross-sectional correlations between survivor and caregiver distress at postintervention and follow-up and between changes in survivor and caregiver distress from baseline to postintervention and postintervention to follow-up. There were no partner effects.

CONCLUSIONS

Neuro-ICU survivors and their informal caregivers show similar changes in emotional distress after treatment. These findings highlight the potential benefits of intervening on both survivor and caregiver distress following Neuro-ICU admission. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Understanding the interplay between lifestyle factors and emotional distress for hemorrhagic stroke survivors and their informal caregivers: Protocol for a mixed methods dyadic natural history study

Emotional distress (depression, anxiety, and PTS) and unhealthy lifestyle factors (e.g., smoking, alcohol consumption, poor diet, limited physical activity, medication adherence) are common in hemorrhagic stroke (HS) survivors and may increase risk for recurrence, morbidity, and mortality. Emotional distress and unhealthy lifestyle factors tend to be interdependent between survivors and their informal caregivers (e.g., family and friends who provide unpaid care; together called dyads), such that one partner's lifestyle and coping behaviors influence the other's behaviors, yet no research has closely examined this relationship in HS dyads over time. We will conduct a mixed methods study to quantitatively and qualitatively understand the longitudinal relationship between emotional distress and lifestyle factors across time in this population (HS dyads) to identify treatment targets to prevent emotional distress chronicity and stroke recurrence. In aim 1, we will assess emotional distress (i.e., depression, anxiety, and PTS) and lifestyle factors (smoking, alcohol consumption, poor diet, limited physical activity medication adherence/blood pressure control) in dyads of survivors of HS and their caregivers (N = 80), at three separate time points (hospitalization in the Neuro-ICU, 1, and 3 months later). We hypothesize that 1) lifestyle factors and emotional distress will be interrelated within and across time for both survivors and caregivers, and 2) lifestyle factors and emotional distress will be interdependent between survivors and caregivers. We also aim to explore the nuanced interplay between lifestyle factors and emotional distress and gain in depth information on barriers and facilitators for a dyadic intervention to optimize lifestyle behaviors and emotional functioning in HS dyads. Eligible patients will be adults who have a caregiver also willing to participate. Patients will be referred for study participation by the nursing team who will ensure that they are cognitively able to meaningfully participate. Multilevel dyadic modeling (i.e., actor-partner interdependence model; APIM) with distinguishable dyads will be used to determine influences of these factors onto each other over time. In Aim 2, we will conduct live video qualitative dyadic interviews (N = 20 or until theme saturation) at all time points from the same participants with and without emotional distress and at least one lifestyle risk factor, to understand the nuanced relationships between emotional distress and lifestyle behaviors, and barriers and facilitators to engagement in a skills-based psychosocial intervention. Interviews will be analyzed using inductive and deductive approaches. The present study is currently ongoing. So far, we enrolled 2 participants. Recruitment will end October 2022 with plans to analyze data by December 2022. The findings from this study will be used to further develop psychosocial interventions and inform novel treatments for survivors of HS and their informal caregivers.

Can a Dyadic Resiliency Program Improve Quality of Life in Cognitively Intact Dyads of Neuro-ICU Survivors and Informal Caregivers? Results from a Pilot RCT

BACKGROUND

Neuro-ICU hospitalization for an acute neurological illness is often traumatic and associated with heightened emotional distress and reduced quality of life (QoL) for both survivors and their informal caregivers (i.e., family and friends providing unpaid care). In a pilot study, we previously showed that a dyadic (survivor and caregiver together) resiliency intervention (Recovering Together [RT]) was feasible and associated with sustained improvement in emotional distress when compared with an attention placebo educational control. Here we report on changes in secondary outcomes assessing QoL.

METHODS

Survivors (n = 58) and informal caregivers (n = 58) completed assessments at bedside and were randomly assigned to participate together as a dyad in the RT or control intervention (both 6 weeks, two in-person sessions at bedside and four sessions via live video post discharge). We measured QoL domain scores (physical health, psychological, social relations, and environmental), general QoL, and QoL satisfaction using the World Health Organization Quality of Life Abbreviated Instrument at baseline, post treatment, and 3 months' follow-up. We conducted mixed model analyses of variance with linear contrasts to estimate (1) within-group changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up and (2) between-group differences in changes in QoL from baseline to post treatment and from post treatment to 3 months' follow-up.

RESULTS

We found significant within-group improvements from baseline to post treatment among RT survivors for physical health QoL (mean difference 1.73; 95% confidence interval [CI] 0.39-3.06; p = 0.012), environmental QoL (mean difference 1.29; 95% CI 0.21-2.36; p = 0.020), general QoL (mean difference 0.55; 95% CI 0.13-0.973; p = 0.011), and QoL satisfaction (mean difference 0.87; 95% CI 0.36-1.37; p = 0.001), and those improvements sustained through the 3-month follow-up. We found no significant between-group improvements for survivors or caregivers from baseline to post treatment or from post treatment to 3 months' follow-up for any QoL variables (i.e., domains, general QoL, and QoL satisfaction together).

CONCLUSIONS

In this pilot study, we found improved QoL among survivors, but not in caregivers, who received RT and improvements sustained over time. These RT-related improvements were not significantly greater than those observed in the control. Results support a fully powered randomized controlled trial to allow for a definitive evaluation of RT-related effects among dyads of survivors of acute brain injury and their caregivers.

A qualitative meta-synthesis of common and unique preferences for supportive services among persons with young onset dementia and their caregivers

BACKGROUND AND OBJECTIVES

Young onset dementias (young onset dementia) produce a myriad of stressors for persons with young onset dementia and their caregivers, yet there is a critical shortage of supportive services that address their needs. To develop such services, it is necessary to first comprehensively understand persons' with young onset dementia and their caregivers' service preferences. Therefore, we conducted a meta-synthesis to integrate and summarize qualitative data on persons' with young onset dementia and caregivers' preferences for supportive services for young onset dementia, defined as support provided by medical providers, psychosocial interventions, and any other resources/services provided to promote positive adjustment in persons with young onset dementia and their caregivers.

RESEARCH DESIGN AND METHODS

We searched five electronic databases for qualitative articles from inception to January 2020. We extracted and synthesized data from eligible articles using thematic analysis. After removal of duplicates, we screened 219 articles identified through database and hand searches.

FINDINGS

Forty-three studies met our inclusion criteria. We extracted findings from these 43 studies on preferences within three a priori defined domains: 1) general characteristics of supportive services, 2) format and modality of supportive services, and 3) content for supportive services. Persons with young onset dementia and caregivers predominantly expressed common preferences, with some unique preferences based on their specific roles within the partnership.

DISCUSSION AND IMPLICATIONS

Persons with young onset dementia and their caregivers endorsed largely overlapping preferences, including having direct contact with providers and the ability to participate together in programs that have content and skills relevant to their specific needs and challenges. Findings can directly inform the format, content, and procedures of supportive services for persons with young onset dementia and their caregivers.

Resilience in survivors of critical illness: A scoping review of the published literature in relation to definitions, prevalence, and relationship to clinical outcomes

Survivors of critical illness face substantial challenges in their recovery, including physical and cognitive dysfunction. Resilience is the ability to adapt and maintain one’s mental health after facing such challenges. Higher resilience levels have been found to be beneficial throughout the illness trajectory in cancer patients, but resilience has not been widely researched in critical care patients. We undertook a scoping review to identify published studies on resilience following critical illness and describe: how resilience has been measured; the prevalence of low resilience in critical care patients; and what associations (if any) exist between resilience and clinical outcomes. We searched: PubMed, Medline, PsychINFO, CINAHL, Web of Science, Cochrane Library, to identify relevant studies. We found 882 unique titles: 17 were selected for full text review, 10 were considered relevant. These included ICU inpatients and survivors, and trauma and sepsis survivors. A broad critical appraisal of each study was undertaken. The overall quality of published studies was low: there was wide variation in resilience-assessment tools across the studies, including the timing of measurement; only one used a validated tool. Estimates of low resilience ranged from 28%-67%, but with varying populations, high risk of inclusion bias, and small samples. Higher resilience levels were significantly associated with lower depression, anxiety, post-traumatic stress, pain, anger, executive dysfunction, and difficulty with self-care in critical care patients and survivors. Future studies should use validated resilience assessment, determine the optimum timing, and explore prevalence, associations with outcomes, and resilience-promoting interventions in non-selected or clearly defined populations.

Stroke Rehabilitation Use and Caregiver Psychosocial Health Profiles in Singapore: A Latent Profile Transition Analysis

OBJECTIVES

To identify and describe caregiver profiles based on their psychosocial health characteristics over a 12-month period and transitions among these profiles, to determine if stroke rehabilitation use at 12 months post-stroke differed by caregiver profile transition patterns, and to investigate if caregiver profiles at 3 months post-stroke moderate the association of stroke rehabilitation use at 3 months and 12 months post-stroke after accounting for covariates.

DESIGN

Latent profile transition analysis of caregiver psychosocial health with stroke rehabilitation use at 12 month post-stroke as outcome.

SETTING AND PARTICIPANTS

A total of 149 stroke patient-caregiver dyads from the Singapore Stroke Study.

METHODS

Cross-sectional latent profile analyses were conducted on caregiver psychosocial health indicators of burden, depression, health status, quality of relationship with patient, and social support. Changes in latent profile classification over 3 time points (baseline, 3 months, and 12 months post-stroke) were analyzed using latent transition analysis. A transition model with stroke rehabilitation use at 12 months post-stroke as the outcome was tested after accounting for covariates.

RESULTS

Two distinct caregiver psychosocial health latent profiles were found across time: nondistressed and distressed. Most caregivers were classified as nondistressed and remained nondistressed over time. Distressed caregivers at baseline were 76% likely to become nondistressed at 12 month post-stroke. Regardless of profile transition patterns, nondistressed caregivers at 12 months post-stroke tended to have cared for stroke rehabilitation nonusers at 12 months post-stroke. Patient depression explained profile classification at 3 months and 12 months post-stroke. After accounting for covariates, rehabilitation users at 3 months post-stroke tended to continue using rehabilitation at 12 months post-stroke only when they had nondistressed caregivers at 3 months post-stroke.

CONCLUSIONS AND IMPLICATIONS

Whether caregiver adaptation explains the associations between the latent profile transition patterns and rehabilitation use at 12 months post-stroke should be examined. Early psychosocial health assessment and sustained support should be made available to stroke caregivers to enhance their well-being and subsequent patient rehabilitation participation.

Thematic Analysis of Dyadic Coping in Couples With Young-Onset Dementia

Importance

A diagnosis of young-onset dementia (YOD) is a life-altering event for both persons with dementia and their spousal caregivers. Dyadic coping (DC) theoretical models acknowledge that dyads cope with stressors as a unit, but these models have yet to be used in YOD.

Objective

To explore the lived experiences of couples managing YOD using an integrated DC model.

Design, Setting, and Participants

This qualitative study recruited couples from a single major medical setting and through social media. Eligibility criteria included cohabitation, 1 partner diagnosed with YOD and able to participate, and both partners willing to participate. Live online video interviews were conducted from March to June 2020.

Exposures

One semistructured interview, which was recorded and subsequently transcribed. Recruitment was stopped once thematic saturation was reached.

Main Outcomes and Measures

Five themes were deductively derived based on the integrated DC framework, including stress communication, positive individual DC, positive conjoint DC, negative individual DC, and negative conjoint DC. Within each theme, subthemes were inductively identified to further characterize couples' dyadic coping experiences with YOD.

Results

A total of 23 couples were interviewed, comprising persons with dementia (11 women [48%]; mean [SD] age, 61.3 [4.65] years; mean [SD] time from diagnosis, 3.11 [3.85]) years; and spousal caregivers (13 women [57%]; mean [SD] age, 60.5 [5.40] years). Data supported the 5 a priori DC themes and novel subthemes describing couples' experiences with YOD. Specifically, couples enacted positive conjoint DC by approaching challenges using a teamwork approach to problem solving and relying on collaborative communication. In contrast, couples engaged in negative conjoint DC through mutual avoidance, leading to increased negative communication and conflict. Couples described initially engaging in avoidance and withdrawal to navigate YOD-related stressors. While these strategies provided short-term relief from challenging emotions, they prevented engagement in adaptive coping (eg, acceptance and collaborative problem-solving) to promote long-term adjustment.

Conclusions and Relevance

This study used an evidence-based integrated DC approach to identify the positive and negative coping behaviors of couples managing YOD. To our knowledge, this is the first study to use a DC framework to guide qualitative analysis, and it provides valuable insights into DC strategies used by couples navigating YOD-related stressors. Findings can inform the development of dyadic psychosocial services for couples managing YOD and have implications for other progressive illnesses.

Videoconferencing psychotherapy for couples and families: A systematic review

The delivery of videoconferencing psychotherapy (VCP) has been found to be an efficacious, acceptable and feasible treatment modality for individual therapy. However, less is known about the use of VCP for couple and family therapy (CFT). The focus of this systematic review was to examine the efficacy, feasibility and acceptability of using VCP as a treatment delivery modality for CFT. A systematic search was conducted, data relating to efficacy, feasibility and acceptability were extracted from included studies. The search returned 7,112 abstracts, with 37 papers (0.005%) included. The methods of the review were pre-registered (PROSPERO; CRD42018106137). VCP for CFT was demonstrated to be feasible and acceptable. A meta-analysis was not conducted; however, results from the included studies indicate that VCP is an efficacious delivery method for CFT. Recommendations for future research and implications regarding clinical practice are made, which may be of interest to practitioners given the COVID-19 pandemic.

Positive effects of resilience and self-efficacy on World Health Organization Quality of Life Instrument score among caregivers of stroke inpatients in China

AIM

Stroke is one of the major health challenges affecting life expectancy and quality of life around the world. However, there is limited reporting on the status of some caregivers, including Chinese caregivers of stroke inpatients. Limited information is available on evaluations using the World Health Organization Quality of Life Instrument (WHOQOL) and the effects of resilience and self-efficacy on WHOQOL score. Therefore, we conducted research to assess the role of resilience on the WHOQOL and to investigate the role of self-efficacy as a mediator between resilience and WHOQOL score among Chinese caregivers of stroke inpatients.

METHODS

This cross-sectional study to gather data from north-east and south-east China was conducted from June 2019 to October 2019. Over 380 caregivers of stroke inpatients at two general public hospitals were interviewed face-to-face. About 305 caregivers (80.26%) completed the questionnaire, which included the Ego Resilience Scale, the General Self-Efficacy Scale, and the brief version of the WHOQOL and asked about demographic characteristics. This study also examined factors associated with WHOQOL score and used linear regression analysis and structure equation modelling to construct direct and indirect models, respectively.

RESULTS

After adjustment for demographic characteristics, both resilience and self-efficacy were positively associated with all WHOQOL domains. Structure equation modelling revealed that self-efficacy mediated the relationship between resilience and WHOQOL score among caregivers of stroke inpatients.

CONCLUSION

Chinese caregivers of stroke inpatients exhibited good social health but poor physical, psychological, and environmental health. It is necessary for promoting resilience and improving WHOQOL score through the mediating effect of self-efficacy. These results suggest that interventions in health care focused on both enhancing resilience and providing self-efficacy training could effectively improve WHOQOL score.

Grief and Loss Associated With Stroke Recovery: A Qualitative Study of Stroke Survivors and Their Spousal Caregivers

Despite a focus on physical and cognitive outcomes, stroke survivors are also impacted by emotional and mental health challenges. Additionally, their caregivers may experience decreased well-being due to increased burden and role adjustment. A small body of literature characterizes this experience as a form of grief and loss. This study seeks to explore experiences of grief and loss reported by stroke survivors and caregivers, using Holbrook's 4-stage bereavement model. This cross-sectional, qualitative study was conducted among adult stroke survivors (n = 9) and their spousal caregivers (n = 5). Focus groups on experiences of recent hospitalizations and transitions home were transcribed, coded, and thematic analysis was conducted, identifying a major theme of loss. Data were reanalyzed guided by Holbrook's model. Common themes were losses and changes experienced by patients/caregivers, disbelief, and lack of understanding. Subthemes of denial and confusion were present. Less prevalent themes were loss of existing support systems and silver lining. Stroke survivors and caregivers experienced a range of negative emotions, impacting behaviors, self-perception, roles, and social support. Awareness of these issues can improve practice with those affected by stroke.

In It Together: A Qualitative Meta-Synthesis of Common and Unique Psychosocial Stressors and Adaptive Coping Strategies of Persons With Young-Onset Dementia and Their Caregivers

BACKGROUND AND OBJECTIVES

The common and unique psychosocial stressors and adaptive coping strategies of people with young-onset dementia (PWDs) and their caregivers (CGs) are poorly understood. This meta-synthesis used the stress and coping framework to integrate and organize qualitative data on the common and unique psychosocial stressors and adaptive coping strategies employed by PWDs and CGs after a diagnosis of young-onset dementia (YOD).

RESEARCH DESIGN AND METHODS

Five electronic databases were searched for qualitative articles from inception to January 2020. Qualitative data were extracted from included articles and synthesized across articles using taxonomic analysis.

RESULTS

A total of 486 articles were obtained through the database and hand searches, and 322 articles were screened after the removal of duplicates. Sixty studies met eligibility criteria and are included in this meta-synthesis. Four themes emerged through meta-synthesis: 1) common psychosocial stressors experienced by both PWDs and CGs, 2) unique psychosocial stressors experienced by either PWDs or CGs, 3) common adaptive coping strategies employed by both PWDs and CGs, and 4) unique adaptive coping strategies employed by either PWDs or CGs. Within each meta-synthesis theme, subthemes pertaining to PWDs, CGs, and dyads (i.e., PWD and CG as a unit) emerged.

DISCUSSION AND IMPLICATIONS

The majority of stressors and adaptive coping strategies of PWDs and CGs were common, supporting the use of dyadic frameworks to understand the YOD experience. Findings directly inform the development of resiliency skills interventions to promote adaptive coping in the face of a YOD diagnosis for both PWDs and CGs.

Feasibility and Efficacy of a Resiliency Intervention for the Prevention of Chronic Emotional Distress Among Survivor-Caregiver Dyads Admitted to the Neuroscience Intensive Care Unit: A Randomized Clinical Trial

IMPORTANCE

To our knowledge, there are no evidence-based interventions to prevent chronic emotional distress (ie, depression, anxiety, and posttraumatic stress [PTS]) in critical care survivors and their informal caregivers.

OBJECTIVE

To determine the feasibility and preliminary effect of the novel dyadic resiliency intervention Recovering Together (RT) on reducing symptoms of depression, anxiety, and PTS among hospitalized patients and their informal caregivers.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind, pilot randomized clinical trial of RT vs an educational control was conducted among 58 dyads in which either the survivor or caregiver endorsed clinically significant symptoms of depression, anxiety, or PTS. The study was conducted in the neuroscience intensive care unit at Massachusetts General Hospital. Data were collected from September 2019 to March 2020.

INTERVENTIONS

Both RT and control programs had 6 sessions (2 at bedside and 4 via live video after discharge), and both survivor and caregiver participated together.

MAIN OUTCOMES AND MEASURES

The primary outcomes were feasibility of recruitment and intervention delivery, credibility, and satisfaction. The secondary outcomes included depression and anxiety (measured by the Hospital Depression and Anxiety Scale), PTS (measured by the PTSD Checklist-Civilian Version), and intervention targets (ie, mindfulness, measured by the Cognitive and Affective Mindfulness Scale-Revised; coping, measured by the Measure of Current Status-Part A; and dyadic interpersonal interactions, measured by the Dyadic Relationship Scale). Main outcomes and targets were assessed at baseline, 6 weeks, and 12 weeks.

RESULTS

The 58 dyads were randomized to RT (29 dyads [50.0%]; survivors: mean [SD] age, 49.3 [16.7] years; 9 [31.0%] women; caregivers: mean [SD] age, 52.4 [14.3] years; 22 [75.9%] women) or control (29 dyads [50.0%]; survivors: mean [SD] age, 50.3 [16.4] years; 12 [41.3%] women; caregivers, mean [SD] age, 52.1 [14.9], 17 [58.6%] women). Feasibility (recruitment [76%], randomization [100%], and data collection [83%-100%]), adherence (86%), fidelity (100%; κ = 0.98), satisfaction (RT: 57 of 58 [98%] with scores >6; control: 58 of 58 [100%] with scores >6), credibility (RT: 47 of 58 [81%] with scores >6; control: 46 of 58 [80%] with scores >6), and expectancy (RT: 49 of 58 [85%] with scores >13.5; 51 of 58 [87%] with scores >13.5) exceeded benchmarks set a priori. Participation in RT was associated with statistically and clinically significant improvement between baseline and postintervention in symptoms of depression (among survivors: -4.0 vs -0.6; difference, -3.4; 95% CI, -5.6 to -1.3; P = .002; among caregivers: -3.8 vs 0.6; difference, -4.5; 95% CI, -6.7 to -2.3; P < .001), anxiety (among survivors: -6.0 vs 0.3; difference, -6.3; 95% CI, -8.8 to -3.8; P < .001; among caregivers: -5.0 vs -0.9; difference, -4.1; 95% CI, -6.7 to -1.5, P = .002), and PTS (among survivors: -11.3 vs 1.0; difference, -12.3; 95% CI, -18.1 to -6.5, P < .001; among caregivers, -11.4 vs 5.0; difference, -16.4, 95% CI, -21.8 to -10.9; P < .001). Improvements sustained through the 12-week follow-up visit. We also observed RT-dependent improvement in dyadic interpersonal interactions for survivors (0.2 vs -0.2; difference, 0.4; 95% CI, 0.0 to 0.8; P = .04).

CONCLUSIONS AND RELEVANCE

In this pilot randomized clinical trial, RT was feasible and potentially efficacious in preventing chronic emotional distress in dyads of survivors of the neuroscience intensive care unit and their informal caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03694678.