Supporting the Health and Well-Being of Caregivers of Persons with Pain Strategies to address stress and improve self-care

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Tonkikh, O., et al. Supporting the Health and Well-Being of Caregivers of Persons with Pain. Am J Nurs 2023; 123 (6): 55-61.

Supporting the Health and Well-Being of Caregivers of Persons with Pain

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Resilience-enhancing interventions for family caregivers: A systematic review

OBJECTIVES

To synthesize interventions designed to enhance resilience in family caregivers (FCs).

METHODS

Electronic databases including PubMed, CINAHL, PsycINFO, and Scopus, were searched using index and keyword methods for articles published before January 2020. The review process followed the PRISMA review guidelines. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Six studies (seven articles) were included in this review. Quantitative evidence supports the benefits of psychoeducation, mindfulness-based intervention, and cognitive behavioral therapy (CBT)-based intervention but not expressive writing in improving in FCs' resilience. Four of the six included studies were randomized controlled trials. All included studies only met 40% to 60% of the MMAT criteria, indicating low to moderate levels of study quality.

CONCLUSION

This review showed emerging evidence that psychoeducation, mindfulness-based intervention, and CBT-based intervention may improve caregiver resilience. However, it remains unclear which intervention and what dosage is the most effective in promoting FCs' resilience. Due to the small number of relevant studies and a low-to-moderate level of overall study quality, more rigorous clinical trials are needed to strengthen the current limited evidence base for FC resilience interventions.

Using artificial intelligence to improve pain assessment and pain management: a scoping review

CONTEXT

Over 20% of US adults report they experience pain on most days or every day. Uncontrolled pain has led to increased healthcare utilization, hospitalization, emergency visits, and financial burden. Recognizing, assessing, understanding, and treating pain using artificial intelligence (AI) approaches may improve patient outcomes and healthcare resource utilization. A comprehensive synthesis of the current use and outcomes of AI-based interventions focused on pain assessment and management will guide the development of future research.

OBJECTIVES

This review aims to investigate the state of the research on AI-based interventions designed to improve pain assessment and management for adult patients. We also ascertain the actual outcomes of Al-based interventions for adult patients.

METHODS

The electronic databases searched include Web of Science, CINAHL, PsycINFO, Cochrane CENTRAL, Scopus, IEEE Xplore, and ACM Digital Library. The search initially identified 6946 studies. After screening, 30 studies met the inclusion criteria. The Critical Appraisals Skills Programme was used to assess study quality.

RESULTS

This review provides evidence that machine learning, data mining, and natural language processing were used to improve efficient pain recognition and pain assessment, analyze self-reported pain data, predict pain, and help clinicians and patients to manage chronic pain more effectively.

CONCLUSIONS

Findings from this review suggest that using AI-based interventions has a positive effect on pain recognition, pain prediction, and pain self-management; however, most reports are only pilot studies. More pilot studies with physiological pain measures are required before these approaches are ready for large clinical trial.

Family Caregivers' Challenges in Cancer Pain Management for Patients Receiving Palliative Care

CONTEXT

Family caregivers (FCs) of cancer patients play a crucial role in managing their care partner's pain, but little research has examined FCs' specific challenges regarding the provision of pain management (PM) to cancer patients receiving palliative care.

OBJECTIVES

To determine the demographic and clinical characteristics of FCs who encounter challenges in PM and to elucidate the specific challenges that FCs face when managing pain for their care partner with cancer.

METHODS

We conducted a secondary analysis of 40 interview transcripts of FCs who were caring for persons with cancer. Interviews were audio-recorded, transcribed verbatim, and analyzed using deductive thematic analysis.

RESULTS

The three major identified challenges to PM for FCs of persons with cancer were: (1) communication and teamwork issues, (2) caregiver-related issues, and (3) patient-related issues. Communication and teamwork issues encompassed caregivers' receipt of inadequate information regarding PM, and inappropriate and ineffective communication from the healthcare team. Caregiver issues pertained to caregivers' fear and beliefs, concurrent responsibilities, and lack of pain-related knowledge and skills. Patient issues related to their own fear and beliefs, psychological and physiological well-being, adherence to medications, and reluctance to report pain.

CONCLUSION

Findings of this study have implications for future research and practice related to cancer PM in palliative care. Results suggest the need for FC training in PM as well as clear clinical practice guidelines and resources to help providers prepare, educate, and communicate with FCs regarding PM.

Digital health interventions to support family caregivers: An updated systematic review

Objective

Chronic diseases are the leading causes of death and disability in the U.S., and disease management largely falls onto patients' family caregivers. The long-term burden and stress of caregiving negatively impact caregivers' well-being and ability to provide care. Digital health interventions have the potential to support caregivers. This article aims to provide an updated review of interventions using digital health tools to support family caregivers and the scope of the Human-Centered Design (HCD) approaches.

Methods

We conducted a systematic search on July 2019 and January 2021 in PubMed, CINAHL, Embase, Cochrane Library, PsycINFO, ERIC, and ACM Digital Library, limiting to 2014-2021 to identify family caregiver interventions assisted by modern technologies. The Mixed Methods Appraisal Tool and the Grading of Recommendations Assessment, Development and Evaluation were used to evaluate the articles. Data were abstracted and evaluated using Rayyan and Research Electronic Data Capture.

Results

We identified and reviewed 40 studies from 34 journals, 10 fields, and 19 countries. Findings included patients' conditions and relationships with family caregivers, how the technology is used to deliver the intervention, HCD methods, theoretical frameworks, components of the interventions, and family caregiver health outcomes.

Conclusion

This updated and expanded review revealed that digitally enhanced health interventions were robust at providing high-quality assistance and support to caregivers by improving caregiver psychological health, self-efficacy, caregiving skills, quality of life, social support, and problem-coping abilities. Health professionals need to include informal caregivers as an essential component when providing care to patients. Future research should include more marginalized caregivers from diverse backgrounds, improve the accessibility and usability of the technology tools, and tailor the intervention to be more culturally and linguistically sensitive.

Family Caregiver Challenges in Pain Management for Patients with Advanced Illnesses: A Systematic Review

Although pain management is integral to the caregiving role, there is a paucity of evidence synthesizing specific challenges family caregivers (FCs) face when managing pain for their care partners. This review comprehensively identified and summarized such challenges in the setting of advanced illnesses. Electronic databases (PubMed, CINAHL, PsycINFO, Scopus, and Health and Psychosocial Instruments) were searched using index and keyword methods for all articles published before April 2021. Fifty-five studies were included in this review. Most articles were published within the last 10 years (54%) in community settings, with home hospice care comprising the majority (50%). Most studies included patients with an advanced cancer diagnosis (84%), and 16% of the studies included patients with a noncancer diagnosis. Four major categories of challenges were identified: (1) caregiver-related issues (e.g., fears, beliefs, function), (2) caregivers' limited knowledge and skills in pain management (e.g., verbal and nonverbal pain assessment skills, pharmacological knowledge, documentation, safe management of medication), (3) communication challenges with health care providers, and (4) patient-related issues (e.g., inability to report pain). Many of these challenges have not been fully addressed in prior literature. Thus, this review provides a framework for needed future research to develop interventions that target FCs' specific challenges in providing pain management. The results also highlight a significant lack of research surrounding challenges faced by caregivers of care partners having a noncancer, dementia, or multimorbidity diagnosis.

Using Artificial Intelligence to Improve Pain Assessment and Pain Management: A Scoping Review

Approximate 50 million U.S. adults experience chronic pain. It is a widely held view that pain has been linked to sleep disturbance, mental problems, and reduced quality of life. Uncontrolled pain has led to increased healthcare utilization, hospitalization, emergency visits, and financial burden. Recognizing, assessing, understanding, and treating pain can improve outcomes of patients and healthcare use. A comprehensive synthesis of the current use of AI-based interventions in pain management and pain assessment and their outcomes will guide the development of future clinical trials. This review aims to investigate the state of the science of AI-based interventions designed to improve pain management and pain assessment for adult patients. The electronic databases Web of Science, CINAHL, PsycINFO, Cochrane CENTRAL, Scopus, IEEE Xplore, and ACM Digital Library were searched. The search identified 2131 studies, and 18 studies met the inclusion criteria. The Critical Appraisals Skills Programme was used to assess the quality. This review provides evidence that machine learning, deep learning, data mining, and natural language processing were used to improve efficient pain recognition and pain assessment (44%), analyze self-reporting pain data (6%), predict pain (6%), and help physicians and patients to more effectively manage with chronic pain (44%). Findings from this review suggest that using AI-based interventions to improve pain recognition, pain prediction, and pain self-management is effective; however, most studies are pilot study which raises concerns about the generalizability of findings. Future research should focus on examining AI-based approaches on a larger cohort and over a longer period of time.

Web and mobile-based symptom management interventions for physical symptoms of people with advanced cancer: A systematic review and meta-analysis

BACKGROUND

Symptom management is a critical aspect of comprehensive palliative care for people with advanced cancer. Web and mobile-based applications are promising e-Health modalities that can facilitate timely access to symptom management interventions for this population.

AIM

To evaluate the efficacy of web and mobile-based symptom management interventions in alleviating physical symptom burden in people with advanced cancer.

DESIGN

A systematic review and meta-analysis was conducted. PROSPERO ID = CRD42020155295.

DATA SOURCES

We searched databases including PubMed, PsycINFO, and CINAHL from 1991 until 2019. Inclusion criteria were: adults with advanced cancer, web or mobile-based interventions targeting symptom management, and report of physical symptom data. Risk of bias was assessed using the ROBINS-I and RoB2. Using RevMan, standardized mean difference (SMD) and 95% confidence intervals were calculated. Heterogeneity was assessed using the I² statistic. An assessment of interventions was conducted by evaluating the delivery mode, duration, and evaluation of application feature and theoretical elements.

RESULTS

A total of 19 studies are included in the systematic review and 18 in the meta-analysis. Majority of the studies were deemed to have high risk of bias. Most of the interventions used a web-application for delivering their education (n = 17). While the interventions varied regarding duration and content, they were mainly guided by a symptom management theory. Web and mobile-based interventions significantly improved the overall physical symptom burden (SMD = -0.18; 95% CI = -0.28 to -0.09; I² = 0%; p = 0.0002).

CONCLUSIONS

Web and mobile-based intervention are efficacious in decreasing the overall physical symptom burden in people with advanced cancer.

Tailored Strategies and Shared Decision-Making for Caregivers Managing Patients’ Pain: A Web App

Family caregivers (FCs) are essential in helping manage pain for patients who receive hospice care at home, but an accessible resource to prepare FCs in pain management is lacking. This study aims to develop an accessible resource that aids FCs in pain management. First, we conducted two literature reviews and two secondary data analyses to investigate the challenges that FCs face when managing pain for patients. Based on the results, we identified 20 common challenges that prevent FCs from providing effective pain management. Second, we developed evidence-based content to address each identified challenge, and a library to provide FCs with pain education. Third, experts and clinicians (n=10) in hospice care validated the content, and FCs (n=10) gave feedback on how to improve the understandability of the content. Currently, we are converting the content to a web app prototype. The web app will consist of: (1) an assessment tool with questions to assess the FCs’ challenges when managing patients’ pain, (2) computer-generated strategies tailored to address the identified challenges, (3) discussion questions for FCs to use with their care team to prioritize goals of pain management, and (4) a library to enhance access to educational materials. This study presented the process of developing an evidence-based and user-centered web app. This study will advance the field of pain management in hospice care by providing accessible and evidence-based tools to support and engage FCs in pain management. Also, this web app will allow best practices to be quickly translated from research into practice.

Interventions to Support Family Caregivers in Pain Management: A Systematic Review

CONTEXT

Family caregivers encounter many challenges when managing pain for their loved ones. There is a lack of clear recommendations on how to prepare caregivers in pain management.

OBJECTIVES

To evaluate existing interventions that support family caregivers in providing pain management to patients with all disease types.

METHODS

Four electronic databases were systematically searched (PubMed, Cumulative Index for Nursing Allied Health Literature, PsycINFO, and Scopus) using index and keyword methods for articles published before December 2019. The Mixed Methods Appraisal Tool was used to assess the quality.

RESULTS

The search identified 6851 studies, and 25 studies met the inclusion criteria. Only two studies exclusively focused on noncancer populations (8%). Three types of interventions were identified in this review: educational interventions, cognitive-behavioral interventions, and technology-based interventions. Both educational and cognitive-behavioral interventions improved family caregiver and patient outcomes, but the content and intensity of these interventions in these studies varied widely, and there was a limited number of randomized clinical trials (68%). Hence, it is unclear what strategies are most effective to prepare family caregivers in pain management. Technology-based interventions were feasible to support family caregivers in providing pain management.

CONCLUSION

Providing adequate pain management training can improve patient and family caregiver outcomes. However, the most effective interventions for family caregivers are still unclear. More rigorous and replicable clinical trials are needed to examine the effects of educational interventions, cognitive-behavioral interventions, and technology-based interventions. Also, more studies are needed in patients with a noncancer diagnosis or multimorbidity.

A Systematic Review of Health Dialog Systems

BACKGROUND

 Health dialog systems have seen increased adoption by patients, hospitals, and universities due to the confluence of advancements in machine learning and the ubiquity of high-performance hardware that supports real-time speech recognition, high-fidelity text-to-speech, and semantic understanding of natural language.

OBJECTIVES

 This review seeks to enumerate opportunities to apply dialog systems toward the improvement of health outcomes while identifying both gaps in the current literature that may impede their implementation and recommendations that may improve their success in medical practice.

METHODS

 A search over PubMed and the ACM Digital Library was conducted on September 12, 2017 to collect all articles related to dialog systems within the domain of health care. These results were screened for eligibility with the main criteria being a peer-reviewed study of a system that includes both a natural language interface and either end-user testing or practical implementation.

RESULTS

 Forty-six studies met the inclusion criteria including 24 quasi-experimental studies, 16 randomized control trials, 2 case-control studies, 2 prospective cohort studies, 1 system description, and 1 human-computer conversation analysis. These studies evaluated dialog systems in five application domains: medical education (n = 20), clinical processes (n = 14), mental health (n = 5), personal health agents (n = 5), and patient education (n = 2).

CONCLUSION

 We found that dialog systems have been widely applied to health care; however, most studies are not reproducible making direct comparison between systems and independent confirmation of findings difficult. Widespread adoption will also require the adoption of standard evaluation and reporting methods for health dialog systems to demonstrate clinical significance.

A CRITICAL REVIEW OF PAIN MANAGEMENT TRAINING PROGRAMS FOR FAMILY CAREGIVERS

Many American family caregivers (FCs) manage hospice and palliative patients’ pain at home. However, FCs encounter many barriers to pain management due to inadequate training. Although some studies have designed pain management training programs for caregivers, the content and durations vary greatly. Thus, there is a lack of consistent recommendation on how to educate caregivers on pain management. The purpose of this study is to critically evaluate existing training programs to inform clinical practice and future program design. A literature review was conducted to search available articles published before June 2018 in databases including PubMed, CINAHL, PsycINFO, and Scopus. Search strategies used index and keyword methods. The inclusion criteria were peer-reviewed, research studies published in English that evaluated a pain management education or training for family caregivers. Twenty-seven studied were included. All studies improved either patients’ outcomes (e.g. pain intensity, hospital visits) or caregivers’ outcomes (e.g. knowledge, quality of life). Most studies (85%) had research teams provide caregivers with pain management education via multiple face-to-face training sessions and written booklet, while some studies (15%) had practicing nurses used videophones, web-based platforms, and telehealth to enhance the collaboration of care and pain management with caregivers. Providing adequate pain management training can improve patients’ and caregivers’ outcomes. However, in-person training programs are not practical for busy and overwhelmed caregivers. Researcher-delivered training sessions are not clinically adoptable. Future studies should develop pain management interventions that allow nurses to coach caregivers during routine visits and enhance their communication and collaboration with caregivers.

IDENTIFY THE BARRIERS THAT FAMILY CAREGIVERS FACE IN MANAGING PATIENTS’ PAIN: A LITERATURE REVIEW

Most Americans enrolled in palliative and hospice care receive care at home and thus rely on their family caregivers (FCs) to manage their pain. However, FCs encounter many barriers to pain management. Previous studies focused on barriers faced by FCs of cancer patients. However, as palliative and hospice care evolves, the populations and diagnoses become diverse, and more barriers have been identified. Hence, the purpose of this study is to comprehensively investigate FCs’ barriers to pain management. A literature review was conducted to search available articles published before June 2018 in databases including PubMed, CINAHL, PsycINFO, and Scopus. Search strategies used index and keyword methods. The inclusion criteria were peer-reviewed, research studies published in English that explored barriers that FCs faced in managing pain. Eighty-six studied were identified: 76% of the studies focused on cancer pain and 6% focused on dementia pain. The identified barriers included: (1) caregivers’ limited knowledge in drug/non-drug pain management and verbal/non-verbal pain assessment; (2) caregivers’ issues (e.g. function, fear of analgesic, misbeliefs in pain management); (c) caregivers’ organizational skills (treatment recording and tracking); (d) patients’ issues (e.g. inability to verbalize pain); (e) communication issues with care teams. This is one of the few literature reviews that comprehensively investigate the barriers that family caregivers experience beyond cancer pain management. The results can be used to develop a screening questionnaire for palliative and hospice providers to assess and resolve FCs’ barriers to pain management, thereby improving the quality of pain management and patients’ and FCs’ outcomes.

Adapting the Resilience Framework for Family Caregivers of Hospice Patients With Dementia

Family caregivers face ongoing, formidable stress and burden. Caregivers need sustainable support to maintain resilience. We aim to identify challenges, possible solutions that are resources for resilience, and expected consequences from the perspective of 39 family caregivers of hospice patients with dementia. The resilience framework was used to guide the coding and synthesis of the qualitative data. Identified challenges included difficulties in communication, providing care and decision-making, lack of knowledge, emotional challenges, concern about care facility selection, death with dignity, and lack of public awareness. Resilience resources for caregiving challenges were identified at the individual, community, and societal levels. Anticipated benefits of using these resources included the ability to provide better care and have a better quality of life for both patients and caregivers. The findings of this study can guide the design and implementation of supportive interventions designed for family caregivers of hospice patients with dementia to bolster available resilience resources.

Examining age-related differences in functional domain impairment following traumatic brain injury

OBJECTIVE

To examine differences in the functional recovery trajectories between younger and older adults with mild-moderate traumatic brain injury (TBI) in the first year postinjury as well as health-related quality of life.

DESIGN

Observational cohort.

SETTING

Level one trauma centre in the State of Washington.

PARTICIPANTS

Adults with mild-moderate TBI (N = 34; younger adults, n = 19, and older adults, n = 15).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Functional Status Examination (FSE) and health-related quality of life (HRQOL; SF-12v2).

RESULTS

Older adults consistently showed significantly worse functional performance than younger adults following TBI in the following FSE domains: mobility, ability to travel, home maintenance and overall functional status. For both groups, preinjury physical health was significantly correlated with ability to travel and social integration at 12-month postinjury. Older participants' preinjury physical and mental health had significant and negative correlation with their functional status.

CONCLUSIONS

Our study provides insights and implications into adults' specific functional impairments following TBI, and which domains have persistent deficits.

IMPLICATIONS FOR PRACTICE

Early intervention and rehabilitation should focus on improving older adults' physical functioning and mobility. Our study may also inform future research and design of post-TBI interventions for older adults.

Development and Preliminary Evaluation of a Pain Management Manual for Hospice Providers to Support and Educate Family Caregivers

BACKGROUND

Family caregivers encounter many barriers to managing patients' pain in the home hospice setting. However, there are limited clinically applicable resources for hospice providers to help family caregivers identify and address these barriers.

AIM

To develop a pain management manual for hospice providers to support family caregivers and conduct a preliminary providers' evaluation of the manual.

DESIGN AND PARTICIPANTS

A pain management manual was developed and structured into 3 parts: (1) 5 common pain management case scenarios based on a secondary data analysis of a hospice clinical trial; (2) a list of suggested assessment questions and strategies for each case scenario was developed based on a caregiver framework; and (3) pain educational material was included from established clinical guidelines. The manual was vetted by 5 experts and then was evaluated by interviewing 25 hospice providers. Interview data were analyzed using thematic analysis.

RESULTS

The hospice providers found that the manual could potentially serve as a reference in their practice and be a source for their continuing education. They suggested enhancing the clarity of the case scenarios and adding additional strategies to the manual. Moreover, they suggested expanding the paper-based version and developing a web-based platform to deliver the content would maximize its utility.

CONCLUSIONS

The manual has the potential to be integrated into routine hospice care to improve the quality of pain management.

Communicating Caregivers' Challenges With Cancer Pain Management: An Analysis of Home Hospice Visits

CONTEXT

Family caregivers (FCGs) of hospice cancer patients face significant challenges related to pain management. Addressing many of these challenges requires effective communication between FCGs and hospice nurses, yet little empirical evidence exists on the nature of communication about pain management between hospice nurses and FCGs.

OBJECTIVES

We identified ways in which FCGs of hospice cancer patients communicated their pain management challenges to nurses during home visits and explored nurses' responses when pain management concerns were raised.

METHODS

Using secondary data from audio recordings of hospice nurses' home visits, a deductive content analysis was conducted. We coded caregivers' pain management challenges and immediate nurses' responses to these challenges.

RESULTS

From 63 hospice nurse visits, 101 statements describing caregivers' pain management challenges were identified. Thirty percent of these statements pertained to communication and teamwork issues. Twenty-seven percent concerned caregivers' medication skills and knowledge. In 52% of the cases, nurses responded to caregivers' pain management challenges with a validating statement. They provided information in 42% of the cases. Nurses did not address 14% of the statements made by caregivers reflecting pain management challenges.

CONCLUSION

To optimize hospice patients' comfort and reduce caregivers' anxiety and burden related to pain management, hospice nurses need to assess and address caregivers' pain management challenges during home visits. Communication and educational tools designed to reduce caregivers' barriers to pain management would likely improve clinical practice and both patient- and caregiver-related outcomes.

Exploring the Challenges that Family Caregivers Faced When Caring for Hospice Patients with Heart Failure

Although patients with heart disease comprise the second largest diagnostic group in hospice care, the challenges faced by family caregivers of hospice patients with heart failure are poorly understood and often go unaddressed. This study explored the challenges and needs of family caregivers of adults with advanced heart failure receiving hospice care in the home. The baseline quantitative and qualitative data from 28 family caregivers' participation in a large-scale hospice clinical trial of a problem-solving therapy intervention were analyzed. The quantitative data showed that family caregivers were mildly anxious and had worse financial and physical quality of life than their social and emotional quality of life. The qualitative data showed that caregiver challenges were related to patient care and symptom management, inadequate social support, communication issues, and financial concerns. The results provide insight to hospice social workers and researchers to develop practical tools that can be used in routine care to evaluate family caregivers' needs comprehensively.

Pain Management Concerns From the Hospice Family Caregivers' Perspective

BACKGROUND

Pain management is a challenging task for family caregivers in home hospice care. However, there are limited studies that examine the challenges regarding pain management in hospice care from family caregivers' perspectives.

OBJECTIVES

To identify the challenges related to pain management faced by family caregivers in hospice care and to examine the validity of an existing framework that outlines pain management challenges for hospice family caregivers.

DESIGN

We conducted a theory-driven, deductive content analysis of secondary data obtained from hospice family caregivers' interviews from a randomized clinical trial.

SETTING/PARTICIPANTS

We included baseline interviews of 15 hospice caregivers of patients from hospice agencies in the States of Washington. The majority of the participants were white and female caregivers. They were spouse/partner or adult child living with the patient.

RESULTS

The study identified 5 out of the 6 major themes in the original framework and confirmed that hospice family caregivers face a variety of challenges: caregiver-centric issues, caregiver's medication skills and knowledge, communication and teamwork, organizational skill, and patient-centric issues. A couple of the subthemes in the original framework were not present in our findings. We also expanded the original framework by adding 1 subtheme and revised 2 definitions in the original framework.

CONCLUSION

The study provided an investigation on hospice family caregivers' difficulties in pain management. The results can inform health-care providers and researchers of family caregivers' challenges and provide insights for future designs of educational tools targeting pain management strategies, so that family caregivers can perform pain management effectively at home.

Pilot testing a digital pet avatar for older adults

Social isolation in older adults is a major public health concern. An embodied conversational agent (ECA) has the potential to enhance older adults' social interaction. However, little is known about older adults' experience with an ECA. In this paper, we conducted a pilot study to examine the perceived acceptance and utility of a tablet-based conversational agent in the form of an avatar (termed "digital pet") for older adults. We performed secondary analysis of data collected from a study that employed the use of a digital pet in ten older adults' homes for three months. Most of the participants enjoyed the companionship, entertainment, reminders, and instant assistance from the digital pet. However, participants identified limited conversational ability and technical issues as system challenges. Privacy, dependence, and cost were major concerns. Future applications should maximize the agent's conversational ability and the system's overall usability. Our results can inform future designs of conversational agents for older adults, which need to include older adults as system co-designers to maximize usability and acceptance.

Visualization approaches to support healthy aging: A systematic review

Background

Informatics tools have the potential to support the growing number of older adults who are aging in place. Many tools include visualizations (data visualizations and visualizations of physical representations). However, the role of visualizations in supporting aging in place remains largely unexplored.

Objective

To synthesize and identify gaps in the literature evaluating visualizations (data visualizations and visualizations of physical representations) for informatics tools to support healthy aging.

Methods

We conducted a search in CINAHL, Embase, Engineering Village, PsycINFO, PubMed, and Web of Science using a priori defined terms for publications in English describing community-based studies evaluating visualizations used by adults aged ≥ 65 years.

Results

Six out of the identified 251 publications were eligible. Most studies described in the publications were user studies and all varied methodological quality. Three publications described visualizations of virtual representations supported performing at-home exercises. Participants found visual representations either (1) helpful, motivational, and supported their understanding of their health behaviours or (2) not an improvement over alternatives. Three publications described data visualizations that aimed to support understanding of one’s health. Participants were able to interpret data visualizations that used precise data and encodings that were more concrete better than those that did not provide precision or were abstract. Participants found data visualizations helpful in understanding their overall health and granular data.

Conclusions

Few studies were identified that used and evaluated visualizations for older adults to promote engagement in exercises or understanding of their health. While visualizations demonstrated some promise to support older adult users in these activities, the studies had various methodological limitations. More research is needed, including research that overcomes methodological limitations of studies we identified, to develop visualizations that older adults could use with ease and accuracy to support their health behaviours and decision making.

Understanding Older Adult Use of Data Visualizations as a Resource for Maintaining Health and Wellness

To better understand how older adults use health visualizations and the potential barriers that impact utility, we conducted semistructured interviews with 21 older adults. Within these sessions, we presented participants with two interactive visualizations for exploration. Through an affinity mapping exercise, we extracted five key themes associated with how older adults utilize health visualizations and provide corresponding recommendations as points of consideration for designers developing older adult focused health visualizations. By examining how older adults perceive the utility of health visualizations, we lay the groundwork for design choices that impact eventual use and adoption of systems that generate data for such visualizations.

Behavioral and Educational Interventions to Support Family Caregivers in End-of-Life Care

The demand for family caregivers steadily increases as the number of people receiving hospice and palliative care rises. Family caregivers play a significant role in supporting their loved ones in end-of-life care. However, there is limited evidence about the effectiveness of the interventions for supporting family caregivers. This article synthesizes behavioral and educational interventions that support family caregivers in end-of-life care. A systematic review was conducted and searched interventional studies published between 2004 and 2014 in PubMed, CINAHL, Embase, and The Cochrane Library electronic databases. Fourteen studies were identified and analyzed: 4 educational studies, 6 cognitive behavioral therapy studies, and 4 psychoeducational studies. All educational and behavioral interventions had developed structures and treatment manuals and improved family caregivers’ outcomes. The cognitive behavioral therapy resulted in more positive outcomes than the other 2 interventions. More rigorous randomized controlled trials are needed to replicate current effective interventions with larger and diverse sample. Future studies need to develop tools for assessing family caregivers’ needs, create consistent and specific tools to effectively measure family caregivers’ outcomes, incorporate a cost-effectiveness analysis, and find the most efficient intervention format and method.

Family Caregivers' Pain Management in End-of-Life Care: A Systematic Review

CONTEXT

Pain management was the most identified burden faced by family caregivers in end-of-life caregiving.

OBJECTIVES

To synthesize current scientific evidence on family caregivers' experience of pain management in end-of-life care.

METHODS

A systematic review was conducted using CINAHL, Embase, PubMed, and Cochrane Library electronic databases. Data were extracted from each included paper and organized into tables to synthesize the findings.

RESULTS

Fourteen research papers focusing on family caregivers' experience of pain management and strategies in end-of-life care were included. Nine were observational studies, 3 were case studies, and 2 were experimental studies. These studies mainly focused on exploring family caregivers' engagement in pain management and communication with the hospice care team about pain control; family caregivers' knowledge, skills, and self-efficacy in pain management; and family caregivers' concerns and experience of pain management.

CONCLUSION

This review identified themes similar to previous reviews on family caregivers of patients with cancer or in palliative care: inadequate knowledge and assessment skills in pain management, misunderstanding of pain medications, and poor communication with the care team. Future research should design educational programs and material for family caregivers to improve their pain management knowledge and skills, communication, and engagement in care. The scientific knowledge on this topic is scarce, and level of evidence is low; it is therefore imperative to have more exploratory studies to expand the quality and quantity of evidence and increase our understanding of family caregivers' needs and barriers to pain management based on larger and more diverse patient and caregiver samples.

A systematic review of telehealth tools and interventions to support family caregivers

We conducted a systematic review of studies employing telehealth interventions which focused on family caregivers' outcomes. The Embase, CINHAL, Cochrane and PubMed databases were searched using combinations of keywords including "telehealth," "telemedicine," "telecare," "telemonitoring," "caregiver" and "family." The initial search produced 4205 articles, of which 65 articles met the inclusion criteria. The articles included 52 experimental studies, 11 evaluation studies, one case study and one secondary analysis. Thirty-three articles focused on family caregivers of adult and older patients, while 32 articles focused on parental caregivers of paediatric patients. The technologies included video, web-based, telephone-based and telemetry/remote monitoring. Six main categories of interventions were delivered via technology: education, consultation (including decision support), psychosocial/cognitive behavioural therapy (including problem solving training), social support, data collection and monitoring, and clinical care delivery. More than 95% of the studies reported significant improvements in the caregivers' outcomes and that caregivers were satisfied and comfortable with telehealth. The review showed that telehealth can positively affect chronic disease care, home and hospice care.

Functional domains in nuclear import factor p97 for binding the nuclear localization sequence receptor and the nuclear pore

The interaction of the nuclear protein import factor p97 with the nuclear localization sequence (NLS) receptor, the nuclear pore complex, and Ran/TC4 is important for coordinating the events of protein import to the nucleus. We have mapped the binding domains on p97 for the NLS receptor and the nuclear pore. The NLS receptor-binding domain of p97 maps to the C-terminal 60% of the protein between residues 356 and 876. The pore complex-binding domain of p97 maps to residues 152-352. The pore complex-binding domain overlaps the Ran-GTP- and Ran-GDP-binding domains on p97, but only Ran-GTP competes for docking in permeabilized cells. The N-ethylmaleimide sensitivity of the p97 for docking was investigated and found to be due to inhibition of p97 binding to the pore complex and to the NLS receptor. Site-directed mutagenesis of conserved cysteine residues in the pore- and receptor-binding domains identified two cysteines, C223 and C228, that were required for p97 to bind the nuclear pore. Inhibition studies on docking and accumulation of a NLS protein provided additional evidence that the domains identified biochemically are the functional domains involved in protein import. Together, these results suggest that Ran-GTP dissociates the receptor complex and prevents p97 binding to the pore by inducing a conformational change in the structure of p97 rather than simple competition for binding sites.

Different binding domains for Ran-GTP and Ran-GDP/RanBP1 on nuclear import factor p97

Several proteins are required for the transport of nuclear proteins from the cytoplasm to the nucleus, including the nuclear location sequence receptor (NLS receptor), p97, the small nuclear GTPase Ran/TC4, and several nucleoporins. The interaction of Ran with p97 is thought to regulate the interaction of these transport components. Ran-GTP alone binds p97, but Ran-GDP binds p97 only in conjunction with RanBP1. Using site-directed mutagenesis and deletion analysis, we have identified two distinct but overlapping binding domains for Ran-GTP and Ran-GDP/RanBP1 on p97. A short acidic sequence in p97 is part of the Ran-GDP/RanBP1 binding domain, possibly functioning in a similar manner as the C-terminal acidic sequence in Ran. A conserved cysteine residue in p97, Cys-158, is required for binding Ran-GDP/RanBP1, but not for binding of Ran-GTP to p97. In a permeabilized cell protein import assay, a mutant p97 with alanine substituted for Cys-158 is unable to support import in the presence of NLS receptor and Ran. These results support a direct active role for Ran-GDP in the receptor complex and provide evidence that the activity of downstream effectors of small GTPases may be regulated by both GTP- and GDP-bound forms of the protein.

RanBP1 stabilizes the interaction of Ran with p97 nuclear protein import

Three factors have been identified that reconstitute nuclear protein import in a permeabilized cell assay: the NLS receptor, p97, and Ran/TC4. Ran/TC4, in turn, interacts with a number of proteins that are involved in the regulation of GTP hydrolysis or are components of the nuclear pore. Two Ran-binding proteins, RanBP1 and RanBP2, form discrete complexes with p97 as demonstrated by immunoadsorption from HeLa cell extracts fractionated by gel filtration chromatography. A > 400-kD complex contains p97, Ran, and RanBP2. Another complex of 150-300 kD was comprised of p97, Ran, and RanBP1. This second trimeric complex could be reconstituted from recombinant proteins. In solution binding assays, Ran-GTP bound p97 with high affinity, but the binding of Ran-GDP to p97 was undetectable. The addition of RanBP1 with Ran-GDP or Ran-GTP increased the affinity of both forms of Ran for p97 to the same level. Binding of Ran-GTP to p97 dissociated p97 from immobilized NLS receptor while the Ran-GDP/RanBP1/p97 complex did not dissociate from the receptor. In a digitonin-permeabilized cell docking assay, RanBP1 stabilizes the receptor complex against temperature-dependent release from the pore. When added to an import assay with recombinant NLS receptor, p97 and Ran-GDP, RanBP1 significantly stimulates transport. These results suggest that RanBP1 promotes both the docking and translocation steps in nuclear protein import by stabilizing the interaction of Ran-GDP with p97.

Sequence and characterization of cytoplasmic nuclear protein import factor p97

Nuclear location sequence-mediated binding of karyophilic proteins to the nuclear pore complexes is one of the earliest steps in nuclear protein import. We previously identified two cytosolic proteins that reconstitute this step in a permeabilized cell assay: the 54/56-kD NLS receptor and p97. A monoclonal antibody to p97 localizes the protein to the cytoplasm and the nuclear envelope. p97 is extracted from nuclear envelopes under the same conditions as the O-glycosylated nucleoporins indicating a tight association with the pore complex. The antibody inhibits import in a permeabilized cell assay but does not affect binding of karyophiles to the nuclear pore complex. Immunodepletion of p97 renders the cytosol inactive for import and identifies at least three other cytosolic proteins that interact with p97. cDNA cloning of p97 shows that it is a unique protein containing 23 cysteine residues. Recombinant p97 binds zinc and a bound metal ion is required for the nuclear envelope binding activity of the protein.