Caregiver Engagement in Stroke Care: Opportunities and Challenges in Australia and Denmark

Knowledge, Attitudes and Practice of Informal Caregivers of People Living With Stroke: A Scoping Review of Recent Literature

AIMS

The study aimed to explore the recent scientific literature regarding the knowledge, attitudes and practices of informal caregivers towards supporting a person with astroke.

DESIGN

This study was a scoping review that followed the Joanna Briggs Institute (JBI) methodology and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Scoping Review extension) guidelines.

DATA SOURCES

Searches were conducted across Medline, CINAHL, PsycINFO, EMBASE, Cochrane, SCOPUS and Web of Science from January 2009 to January 2024.

REVIEW METHODS

The search results from the various database sources were collated in EndNote 20 and duplicates were removed. Following the removal of duplicates, the studies were imported to Covidence and filtered based on the well-defined eligibility criteria. Three reviewers independently conducted screening and data extraction, and any conflicts were resolved through discussion.

RESULTS

The analysis included a total of 37 studies that focused on the knowledge, attitudes and practices related to stroke caregiving. Of these, 15 studies addressed knowledge, 24 studies examined attitudes and 33 studies looked at caregiver practices.

CONCLUSION

This scoping review finds that lack of knowledge impacts the attitudes and practices of informal stroke caregivers. With the increasing incidence of stroke and the growing number of caregivers, there is an urgent need for targeted, individualised interventions accompanied by comprehensive evaluation.

IMPACT

Caregivers of people with stroke are often unprepared to provide care. Further research is needed to support these individuals, ensuring improved quality of life and better health outcomes for both the caregiver and the person with stroke.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

The Effect of Interventions on Quality of Life, Depression, and the Burden of Care of Stroke Patients and Their Caregivers: A Systematic Review

ABSTRACT

BACKGROUND: The impact of stroke is a global concern for health policymakers. A large proportion of survivors require long-term support from family members who are typically unprepared for their caregiving duties. This study determined the effect of different interventions on quality of life (QoL), depression, and the burden of care of stroke patients and their caregivers. METHODS: A systematic review was conducted from 2000 up to May 2023. Study inclusion criteria were as follows: individuals serving as informal caregivers for stroke survivors 18 years and older, devoting a significant portion of their time to the care of such survivors; involvement in psychoeducational, informational, supportive, psychosocial, or combined interventions; exposure to standard or conventional care practices; evaluation of outcomes relating to the QoL for stroke caregivers, depression, caregiver burden, and levels of stroke survivors; and consideration of randomized controlled trials and quasi-experimental studies. RESULTS: Thirty-seven studies met the inclusion criteria and were synthesized in this systematic review. Details of intervention were divided into 3 groups: educational and psychoeducational programs, multidisciplinary approaches, and support and caregiver skill-building programs; 12 studies focused on different interventions affecting the QoL, 23 studies focused on the burden of stroke caregivers, and 20 studies focused on depression of stroke patients and their caregivers. CONCLUSION: The desired effectiveness of particular interventions was evident in the results, although conflicting findings have emerged. The study emphasizes the need for well-structured preliminary studies for each intervention type. More studies on interventions and outcomes might lead secondary researchers to conduct analyses to ensure the certainty of results.

Effects of personalized music listening on post-stroke cognitive impairment: A randomized controlled trial

BACKGROUND AND PURPOSE

Previous studies have suggested that music listening has the potential to positively affect cognitive functions and mood in individuals with post-stroke cognitive impairment (PSCI), with a preference for self-selected music likely to yield better outcomes. However, there is insufficient clinical evidence to suggest the use of music listening in routine rehabilitation care to treat PSCI. This randomized control trial (RCT) aims to investigate the effects of personalized music listening on mood improvement, activities of daily living (ADLs), and cognitive functions in individuals with PSCI.

MATERIALS AND METHODS

A total of 34 patients with PSCI were randomly assigned to either the music group or the control group. Patients in the music group underwent a three-month personalized music-listening intervention. The intervention involved listening to a personalized playlist tailored to each individual's cultural, ethnic, and social background, life experiences, and personal music preferences. In contrast, the control group patients listened to white noise as a placebo. Cognitive function, neurological function, mood, and ADLs were assessed.

RESULTS

After three months of treatment, the music group showed significantly higher Montreal Cognitive Assessment (MoCA) scores compared to the control group (p=0.027), particularly in the domains of delayed recall (p=0.019) and orientation (p=0.023). Moreover, the music group demonstrated significantly better scores in National Institutes of Health Stroke Scale (NIHSS) (p=0.008), Barthel Index (BI) (p=0.019), and Zarit Caregiver Burden Interview (ZBI) (p=0.008) compared to the control group. No effects were found on mood as measured by the Hamilton Anxiety Rating Scale (HAMA) and the Hamilton Depression Rating Scale (HAMD).

CONCLUSION

Personalized music listening promotes the recovery of cognitive and neurological functions, improves ADLs, and reduces caregiver burden in patients with PSCI.

Impact of telehealth on stroke survivor-caregiver dyad in at-home rehabilitation: A systematic review

AIM

To examine studies involving the impact of telerehabilitation (TLR), tele-training and tele-support on the dyad stroke survivor and caregiver in relation to psychological, physical, social and health dimensions.

DESIGN

A systematic review was conducted.

DATA SOURCES

The following electronic databases were consulted until September 2023: PsycInfo, CINAHL, Eric, Ovid, PubMed, Scopus, Cochrane Central and Web of Science.

REVIEW METHODS

It was conducted and reported following the checklists for Reviews of PRISMA 2020 Checklist. Critical evaluation of the quality of the studies included in the review was performed with the Joanna Briggs Institute Checklists.

DATA SYNTHESIS

A total of 2290 records were identified after removing duplicates, 501 articles were selected by title and abstract and only 21 met the inclusion criteria. It included 4 quasi-experimental studies, 7 RCTs, 1 cohort study and 9 qualitative studies. The total number of participants between caregivers and stroke survivors was 1697, including 858 stroke survivors and 839 caregivers recruited from 2002 to 2022. For a total of 884 participants who carried out TLR activities in the experimental groups,11 impact domains were identified: cognitive/functional, psychological, caregiver burden, social, general health and self-efficacy, family function, quality of life, healthcare utilization, preparedness, quality of care and relationship with technology.

CONCLUSIONS

The results support the application of telehealth in the discharge phase of hospitals and rehabilitation centres for stroke survivors and caregivers. TLR could be considered a substitute for traditional rehabilitation only if it is supported by a tele-learning programme for the caregiver and ongoing technical, computer and health support to satisfy the dyad's needs.

IMPACT

Designing a comprehensive telemedicine programme upon the return home of the dyad involved in the stroke improves the quality of life, functional, psychological, social, family status, self-efficacy, use of health systems and the dyad's preparation for managing the stroke.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

A sense of injustice in care networks: An intersectional exploration of the collaboration between professionals and carers with a migration background

This study tries to understand the power of knowledge within collaborative care networks to provide insights for designing successful collaboration within care networks by combining intersectionality and epistemic (in)justice. Becoming an informal carer for someone with an acquired brain injury (ABI) causes a dramatic disruption of daily life. Collaboration between professionals and carers with a migration background may result in unjust and unfair situations within care networks. Carer experiences are shaped by aspects of diversity which are subject to power structures and processes of social (in)justice in care networks. In this study, intersectionality was used to both generate complex in-depth insights into the different active layers of carer experiences and focus on within-group differences. Intersectionality was combined with the theoretical concept of epistemic (in)justice to unravel underlying dynamics in collaborative care networks contributing to the understanding that carers with a migration background are often not seen as 'knowers of reality.' This qualitative study conducted in the Netherlands between 2019 and 2022 incorporated three informal group conversations (N = 32), semi-structured interviews (N = 21), and three dialogue sessions (N = 7) with carers caring for someone with an ABI. A critical friend and a community of practice, with carers, professionals, and care recipients (N = 8), contributed to the analysis. Three interrelated themes were identified as constituting different layers of the carer experience: (a) I need to keep going, focusing on carers' personal experiences and how experiences were related to carers social positioning; (b) the struggle of caring together, showing how expectations of family members towards carers added to carer burden; and (c) trust is a balancing act, centering on how support from professionals shaped carers' experiences, in which trusting professionals' support proved challenging for carers, and how this trust was influenced by contextual factors at organizational and policy levels. Overall, the need for diversity-responsive policies within care organizations is apparent. Carers with a migration background need to feel heard so they can meaningfully tailor care to meet recipients' needs.

Carer-supported home-based exercises designed to target physical activity levels and functional mobility after stroke: a scoping review

PURPOSE

To explore the literature on carer-supported home-based exercise programs for people after stroke, as a form of physical activity. The review focus was to examine the training carers receive, the content of programs, and investigate the physical activity levels and functional mobility of people after stroke.

MATERIALS AND METHODS

A scoping review was undertaken, guided by Joanna Briggs Institute methodology. The concept of home-based carer-supported exercise, in people after stroke, was searched across five databases. Outcomes of interest were physical activity levels and functional mobility.

RESULTS

We screened 2285 references and included 10 studies: one systematic review, five randomised controlled trials, one trial with non-equivalent control, and four uncontrolled studies. Carer training ranged from one to twelve sessions. Exercise interventions commonly including walking, other whole body functional exercises and balance activities. In eight studies interventions were in addition to standard care. Five studies reported significant between-group differences for functional mobility, favouring the intervention. One study reported physical activity levels.

CONCLUSION

There was large variation in the volume and content of training provided to carers. Physical activity levels were infrequently objectively reported. Future studies should include greater details on their protocols to allow for replication and implementation into clinical practice.

Sex Differences in the Role of Multimorbidity on Poststroke Disability: The Taiwan Stroke Registry

BACKGROUND AND OBJECTIVES

Multimorbidity is common in patients who experience stroke. Less is known about the effect of specific multimorbidity patterns on long-term disability in patients with stroke. Furthermore, given the increased poststroke disability frequently seen in female vs male patients, it is unknown whether multimorbidity has a similar association with disability in both sexes. We assessed whether specific multimorbidity clusters were associated with greater long-term poststroke disability burden overall and by sex.

METHODS

In the Taiwan Stroke Registry, an ongoing nationwide prospective registry, patients with first-ever ischemic stroke were enrolled; this analysis is restricted to those individuals surviving to at least 6 months poststroke. Using a hierarchical clustering approach, clusters of prestroke multimorbidity were generated based on 16 risk factors; the algorithm identified 5 distinct clusters. The association between clusters and 12-month poststroke disability, defined using the modified Rankin Scale (mRS), was determined using logistic regression models, with additional models stratified by sex. The longitudinal association between multimorbidity and functional status change was assessed using mixed-effects models.

RESULTS

Nine-thousand eight hundred eighteen patients with first-ever ischemic stroke were included. The cluster with no risk factors was the reference, "healthier" risk group (N = 1,373). Patients with a cluster profile of diabetes, peripheral artery disease (PAD), and chronic kidney disease (CKD) (N = 1882) had significantly greater disability (mRS ≥ 3) at 1 month (OR [95% CI] = 1.36 [1.13-1.63]), 3 months (OR [95% CI] = 1.27 [1.04-1.55]), and 6 months (OR [95% CI] = 1.30 [1.06-1.59]) but not at 12 months (OR [95% CI] = 1.16 [0.95-1.42]) than patients with a healthier risk factor profile. In the sex-stratified analysis, the associations with this risk cluster remained consistent in male patients (OR [95% CI] = 1.42 [1.06-1.89]) at 12 months, who also had a higher comorbidity burden, but not in female patients (OR [95% CI] = 0.95 [0.71-1.26]), who had higher proportions of severe strokes and severe disability (p-interaction = 0.04).

DISCUSSION

Taiwanese patients with multimorbidity, specifically the concurrent presence of diabetes, PAD, and CKD, had higher odds of a worse functional outcome in the first 6 months poststroke. Clusters of multimorbidity may be less informative for long-term disability in female patients. Further studies should evaluate other mechanisms for worse disability in female patients poststroke.

Effect of "Internet + tertiary hospital-primary hospital-family linkage home care" model on self-care ability and quality of life of discharged stroke patients

OBJECTIVE

To investigate the intervention effect of an "Internet + tertiary hospital-primary hospital-family linkage home care" model on the quality of life and self-care abilities of discharged stroke patients.

METHODS

The clinical data of 90 patients with stroke who were hospitalized and discharged from the Department of Neurology of the Affiliated Hospital of Youjiang Medical College for Nationalities from October 2020 to September 2021 were retrospectively analyzed. They were split into a control group (41 cases) and an intervention group (40 cases) based on different care modes. The intervention group was given the "Internet + tertiary hospital-primary hospital-family connection home care" paradigm, while the control group received normal nursing interventions. The degree of nerve defect, quality of life, anxiety and depression, self-care ability and exercise ability of the patients were evaluated by National Institutes of Health Stroke Scale (NIHSS), Stroke Specific Quality of Life Scale (SS-QOL), General Hospital Anxiety and Depression Scale (HADS), Self-care Ability Scale (ESCA), and Fugl-Meyer Motor Function Assessment (FMA) before discharge and at 3rd, 6th and 12th month after discharge, respectively. The re-hospitalization rate, treatment compliance and exercise ability of the two groups were compared within a year after discharge.

RESULTS

The scores of SS-QOL, ESCA and FMA in the intervention group increased with time, and the scores of SS-QOL, ESCA and FMA at 3rd, 6th and 12th month after discharge were higher than those in the control group (all P<0.05). The NIHSS and HADS scores decreased over time, and the NIHSS and HADS scores were lower than the control group at 12th month after discharge (P<0.05). Within a year of discharge, the intervention group had a lower rehospitalization rate than the control group (P<0.05), and the treatment compliance score was higher in the intervention group than that in the control group (P<0.05).

CONCLUSION

The "Internet + tertiary hospital-primary hospital-family nursing" model can improve self-care ability and treatment compliance of patients, improve their nerve defects and psychological status as well as quality of life, and reduce rehospitalization rate.

Factors Associated With Transition From Community to Permanent Residential Aged Care Following Stroke: A Linked Registry Data Study

BACKGROUND

Understanding factors that influence the transition to permanent residential aged care following a stroke or transient ischemic attack may inform strategies to support people to live at home longer. We aimed to identify the demographic, clinical, and system factors that may influence the transition from living in the community to permanent residential care in the 6 to 18 months following stroke/transient ischemic attack.

METHODS

Linked data cohort analysis of adults from Queensland and Victoria aged ≥65 years and registered in the Australian Stroke Clinical Registry (2012-2016) with a clinical diagnosis of stroke/transient ischemic attack and living in the community in the first 6 months post-hospital discharge. Participant data were linked with primary care, pharmaceutical, aged care, death, and hospital data. Multivariable survival analysis was performed to determine demographic, clinical, and system factors associated with the transition to permanent residential care in the 6 to 18 months following stroke, with death modeled as a competing risk.

RESULTS

Of 11 176 included registrants (median age, 77.2 years; 44% female), 520 (5%) transitioned to permanent residential care between 6 and 18 months. Factors most associated with transition included the history of urinary tract infections (subhazard ratio [SHR], 1.41 [95% CI, 1.16-1.71]), dementia (SHR, 1.66 [95% CI, 1.14-2.42]), increasing age (65-74 versus 85+ years; SHR, 1.75 [95% CI, 1.31-2.34]), living in regional Australia (SHR, 31 [95% CI, 1.08-1.60]), and aged care service approvals: respite (SHR, 4.54 [95% CI, 3.51-5.85]) and high-level home support (SHR, 1.80 [95% CI, 1.30-2.48]). Protective factors included being dispensed antihypertensive medications (SHR, 0.68 [95% CI, 0.53-0.87]), seeing a cardiologist (SHR, 0.72 [95% CI, 0.57-0.91]) following stroke, and less severe stroke (SHR, 0.71 [95% CI, 0.58-0.88]).

CONCLUSIONS

Our findings provide an improved understanding of factors that influence the transition from community to permanent residential care following stroke and can inform future strategies designed to delay this transition.

Validating the caregiver self-efficacy in contribution to self-care scale Thai version for stroke: A psychometric evaluation

AIM

To test the validity and reliability of the Caregiver Self-Efficacy in Contribution to Self-Care Scale Thai Version (CC-Self Efficacy Scale (Thai)) for Stroke.

DESIGN

A cross-sectional study was undertaken from September to December 2022.

METHODS

Four hundred thirty-four caregivers of people with stroke were selected from the registry of stroke patients in primary care units or hospitals following inclusion criteria. The research assistants collected information when the caregiver took a patient for a doctor's appointment or visited the patient's and caregiver's home.

RESULTS

The 434 caregivers had a mean age of 48 years, female 77.67%, 51.97% child or grandchild of patients, and 72.85% living with the patient. Ten items of the CC-Self Efficacy Scale (Thai) were normally distributed and appropriate for exploratory factor analysis (EFA). EFA suggested three-factor model. The confirmatory factor analysis (CFA) of the three-factor model was an unfit model, with the root mean square error of approximation (RMSEA) = 0.09. We regrouped items based on content to create six-factor model. CFA supported the six-factor model of CC-Self Efficacy Scale (Thai) questionnaire with the reliability judged by McDonald's omega being 0.87. The 434 sample size was enough for EFA and CFA. The CC-Self Efficacy Scale (Thai) with the six-factor model is appropriate for evaluating the caregiver confidence of people with stroke.

Stress in Caregivers of Stroke Patients During Rehabilitation: An Observational Study

INTRODUCTION

Stroke causes a high burden of death and disability all over the world. The majority of stroke survivors continue to have difficulties, and their families must shoulder a considerable portion of the expenditures of ongoing rehabilitation and long-term care. In India, stroke rehabilitation is still underachieved due to various reasons leading to delay or incomplete recovery of the patients thus adding up more burden on the caregivers. Thus, studying the caregiver burden of stroke rehabilitation will help policymakers tackle this issue faced by our lower economically challenged citizens.

OBJECTIVES

The objective is to measure the perceived burden on caregivers during stroke rehabilitation.

METHODS AND MATERIALS

The observational study was conducted by interviewing the stroke survivors' caregivers and visiting the physiotherapy OPD using the caregiver burden scale/questionnaire.

RESULTS

The study had 76 caregivers, 51.32% were women and 48.68% were men. The average age for caregivers was 42 years and 55 years for patients. The average duration of giving care was six months. The perceived caregiver burden score was low (mean-19.61) suggesting that not all assistance is associated with stress. The correlation of each burden measure with Modified Rankin Scale for disability is significantly correlated (r=0.7, P<0.0001). Further investigation revealed that caregivers had considerably higher levels of stress when the patient needed to exercise, walk or use the restroom. A low yearly income, a higher secondary education, and a small number of family members were shown to be connected with individuals who scored the highest on stress.

CONCLUSION

Based on this study, we conclude that people with low income residing in nuclear families require more support for caregiving during rehabilitation. We recommend that health and welfare policy measures be developed to lessen caregiver burden in order to improve caregivers' post-stroke experiences.

Experiences and needs of the caregivers of stroke survivors in Malaysia-A phenomenological exploration

INTRODUCTION

Informal caregivers play a crucial role in supporting the activities of daily living, rehabilitation, and the road to recovery for stroke survivors. However, these informal caregivers are often reported as experiencing neglect and lack of recognition despite their primary contribution to stroke recovery. This study investigated the experiences of the caregivers of stroke survivors and access to stroke care in Malaysia.

METHOD

This qualitative study with a phenomenological approach utilized in-depth interviews, including ten primary caregivers, one formal caregiver, and stroke healthcare providers as the participants. The interviews were done until the data saturation was achieved, and the data was analyzed using thematic analysis.

RESULT

Three primary themes and 14 subthemes were identified from the interviews. The role of primary caregivers of stroke survivors had tremendous physical, mental and social impact on the caregivers. Caregivers had two primary needs. The need for information about comprehensive stroke care at home and the need for psychological support to themselves. The key internal driver for providing care was identified to be the motivation level of the stroke survivor and the external driver was identified to be the societal support with access to comprehensive stroke care.

CONCLUSION

The role of informal caregivers becomes critical for continuum of stroke care. As caregivers take up the roles and responsibilities of those who contribute to stroke rehabilitation single-handedly soon after hospital discharge. Results of this study highlights the needs for providing systematic support to caregivers for engaging them in effective stroke care, particularly in the community. Stroke service providers, policy makers and program planners must be sensitized to empower caregivers of stroke survivors in effectively supporting stroke survivor in their family on the road of recovery.

Using Large-Scale Sensor Data to Test Factors Predictive of Perseverance in Home Movement Rehabilitation: Optimal Challenge and Steady Engagement

Persevering with home rehabilitation exercise is a struggle for millions of people in the US each year. A key factor that may influence motivation to engage with rehabilitation exercise is the challenge level of the assigned exercises, but this hypothesis is currently supported only by subjective, self-report. Here, we studied the relationship between challenge level and perseverance using long-term, self-determined exercise patterns of a large number of individuals (N = 2,581) engaging in home rehabilitation with a sensor-based exercise system without formal supervision. FitMi is comprised of two puck-like sensors and a library of 40 gamified exercises for the hands, arms, trunk, and legs that are designed for people recovering from a stroke. We found that individuals showed the greatest perseverance with the system over a 2-month period if they had (1) a moderate level of motor impairment and (2) high but not perfect success during the 1st week at completing the exercise game. Further, a steady usage pattern (vs. accelerating or decelerating use) was associated with more overall exercise, and declines in exercise amount over time were associated with exponentially declining session initiation probability rather than decreasing amounts of exercise once a session was initiated. These findings confirm that an optimized challenge level and regular initiation of exercise sessions predict achievement of a greater amount of overall rehabilitation exercise in a group of users of commercial home rehabilitation technology and suggest how home rehabilitation programs and exercise technologies can be optimized to promote perseverance.

Exploring the shared experiences of people with stroke and caregivers in preparedness to manage post-discharge care: A hermeneutic study

AIMS AND OBJECTIVES

To explore the shared experiences of people with stroke and caregivers in preparedness to manage post-discharge care.

BACKGROUND

People with stroke and caregivers show dyadic effects in dealing with post-discharge care challenges. However, few studies have explored their shared experiences and unique challenges for each dyadic member in preparedness to manage post-discharge care. This study addresses this research gap.

DESIGN

An interpretive approach underpinned by Gadamer's philosophical hermeneutics.

METHODS

Semi-structured interviews were conducted with people with stroke and caregivers in 5 days before hospital discharge (n = 26) or 2 weeks after discharge (n = 4) between July and December 2019. The study followed a five-step data analysis method aligning with Gadamerian hermeneutics. The study reporting followed the COREQ checklist.

RESULTS

Three themes and six subthemes were identified. First, both people with stroke and caregivers experienced psychological stress, although the sources differed. Second, stroke dyads demonstrated resilience built on positive thoughts, confidence, and support from family and health professionals. Third, stroke dyads exhibited different levels of certainty about post-discharge care. They desired to be equal partners in co-developing and co-implementing discharge plans.

CONCLUSIONS

Similarities and differences in perceived preparedness to manage post-discharge care existed between stroke dyadic members. A co-design approach to developing and implementing discharge plans would enhance planned post-discharge care.

IMPACT

Hospital-to-home transition is a challenging time for people with stroke and their caregivers. Understanding the shared experiences of stroke dyads in preparedness for post-discharge care enables nurses to take proactive actions to enhance managing post-discharge care. Early identification of those at risk of developing psychological stress will enable nurses to co-develop stress-coping strategies. These will have a positive influence on the dyad when facing setbacks due to stroke-related complications.