Deborah Ejem

The effects of caregiver emotional stress on the depressive symptomatology of the care recipient

Objectives: Depression is a leading mental health issue affecting elderly individuals worldwide. Previous research widely neglects caregiver emotional stress as a probable contributing factor of depression in the elderly. This study investigated caregiver emotional stress as a chronic life stressor of an elderly care recipient using the life stress paradigm as the theoretical foundation. Methods: The relationships between caregiver emotional stress and care receiver depressive symptoms, as well as other social and psychological mediation factors, were investigated using the 2004 wave of the National Long-Term Care Study (NLTCS). The NLTCS is a nationally representative longitudinal study used to identify frail and disabled elderly Medicare recipients living in the United States. The analytic sample of this study included 1340 caregiver–care receiver dyads who were asked a series of questions concerning their mental health (i.e. emotional stress and depressive symptoms), as well as the availability of social and psychological resources. Results: Overall, the results showed that high levels of emotional stress reported by the caregiver were associated with a higher likelihood of the disabled care receiver reporting depressive symptoms. Conclusion: The findings of this investigation point to the importance of studying caregivers and care receivers as dyads as the stress associated with the caregiving role affects each member.

Family caregiving for persons with heart failure at the intersection of heart failure and palliative care: a state-of-the-science review

Many of the 23 million individuals with heart failure (HF) worldwide receive daily, unpaid support from a family member or friend. Although HF and palliative care practice guidelines stipulate that support be provided to family caregivers, the evidence base to guide care for this population has not been comprehensively assessed. In order to appraise the state-of-the-science of HF family caregiving and recommend areas for future research, the aims of this review were to summarize (1) how caregivers influence patients, (2) the consequences of HF for caregivers, and (3) interventions directed at HF caregivers. We reviewed all literature to December 2015 in PubMed and CINAHL using the search terms “heart failure” AND “caregiver.” Inclusion criteria dictated that studies report original research of HF family caregiving. Articles focused on children or instrument development or aggregated HF with other illnesses were excluded. We identified 120 studies, representing 5700 caregivers. Research on this population indicates that (1) caregiving situations vary widely with equally wide-ranging tasks for patients to help facilitate their health behaviors, psychological health and relationships, and quality of life (QoL); (2) caregivers have numerous unmet needs that fluctuate with patients’ unpredictable medical status, are felt to be ignored by the formal healthcare system, and can lead to distress, burden, and reduced QoL; and (3) relatively few interventions have been developed and tested that effectively support HF family caregivers. We provide recommendations to progress the science forward in each of these areas that moves beyond descriptive work to intervention development and clinical trials testing.

Engaging patients and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial

BackgroundEarly palliative care (EPC) is recommended but rarely integrated with advanced heart failure (HF) care. We engaged patients and family caregivers to study the feasibility and site differences in a two-site EPC trial, ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers).MethodsWe conducted an EPC feasibility study (4/1/14–8/31/15) for patients with NYHA Class III/IV HF and their caregivers in academic medical centers in the northeast and southeast U.S. The EPC intervention comprised: 1) an in-person outpatient palliative care consultation; and 2) telephonic nurse coach sessions and monthly calls. We collected patient- and caregiver-reported outcomes of quality of life (QOL), symptom, health, anxiety, and depression at baseline, 12- and 24-weeks. We used linear mixed-models to assess baseline to week 24 longitudinal changes.ResultsWe enrolled 61 patients and 48 caregivers; between-site demographic differences included age, race, religion, marital, and work status. Most patients (69%) and caregivers (79%) completed all intervention sessions; however, we noted large between-site differences in measurement completion (38% southeast vs. 72% northeast). Patients experienced moderate effect size improvements in QOL, symptoms, physical, and mental health; caregivers experienced moderate effect size improvements in QOL, depression, mental health, and burden. Small-to-moderate effect size improvements were noted in patients’ hospital and ICU days and emergency visits.ConclusionsBetween-site demographic, attrition, and participant-reported outcomes highlight the importance of intervention pilot-testing in culturally diverse populations. Observations from this pilot feasibility trial allowed us to refine the methodology of an in-progress, full-scale randomized clinical efficacy trial.Trial registrationClinicaltrials.gov NCT03177447 (retrospectively registered, June 2017).

Incongruence between women's survey- and interview-determined decision control preferences: A mixed methods study of decision-making in metastatic breast cancer

Women with metastatic breast cancer face numerous, complex treatment and advance care planning (ACP) decisions. Our aim was to develop a better understanding of women with metastatic breast cancers decision‐making preferences overtime and relative to specific types of decisions.

Caregiver Burden, Care Recipient Depressive Symptomology, and Social Exchange: Does Race Matter?

Informal caregivers play a vital role in supporting seriously ill patients. However, informal caregiving is burdensome and can lead to negative health outcomes for the caregiver and the care recipient. The study’s aim was to evaluate relationships among caregiver burden, care recipient depressive symptomology, and race. Guided by the social exchange perspective, we examined cross-sectional dyadic data from the National Long-Term Care Survey (N = 1279). Using ordinal logistic regression, we found that higher caregiver-reported objective burden was associated with higher care recipient depressive symptoms (P < .05), an association that was stronger for blacks. Interestingly, despite significant levels of objective burden, there was an association between lower depressive symptoms in black care recipients when there was an exchange of the social good “helpful company” with a caregiver. These findings illustrate the importance of supporting reciprocal exchange as a promising component of maintaining balanced caregiver–care recipient relationships among black older adults and their informal caregivers.

Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study

BACKGROUND Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF). OBJECTIVES To describe evaluation practices and treatment recommendations made during protocol-driven OPCCs for advanced HF. METHODS We performed content analysis of OPCCs completed as part of ENABLE CHF-PC, an early palliative care HF intervention, conducted at sites in the Northeast and Southeast. T-tests, Fishers exact, and Chi-square tests were used to evaluate sociodemographic, outcome measures, and site content differences. RESULTS Of 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast, n=27; Southeast, n=12). Social and medical history assessed most were close relationships (n=35, 90%), family support (n=33, 85%), advance directive status (n=33, 85%), functional status (n=30, 77%); and symptoms were mood (n= 35, 90%), breathlessness (n=28, 72%), and chest pain (n=24, 62%). Treatment recommendations focused on care coordination (n=13, 33%) and specialty referrals (n=12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%). CONCLUSION OPCCs for HF focused on evaluating medical and social history, along with goals of care and code status discussions. Symptom evaluation commonly included mood disorders, pain, dyspnea, and fatigue. Notable regional differences were found in topics evaluated and OPCC completion rates.

Factors That Influence Blood Pressure in 3- to 5-Year-Old Children: A Pilot Study:

While incident elevations in blood pressure (BP) are apparent in preschool years, factors influencing BP in this population have received little attention. The purposes of this pilot study were to determine the feasibility of collecting data from preschoolers and their mothers and to determine effect sizes of relationships between BP and sex, race, birth status, body mass index (BMI), waist circumference (WC), geographic location, serum C-reactive protein (CRP), and salivary cortisol (morning, afternoon). A hypothesis-generating correlational design was used; 56 children, aged 3–5 years, were enrolled from six rural and urban Head Start programs in a southeastern state. On Day 1 of data collection, mothers completed demographic questionnaires and children had blood drawn by finger stick. On Day 2, children gave saliva samples for cortisol, were measured for height by stadiometer, weight by digital scales, and WC by tape measure and had their BP measured by Dinamap. Incident elevations in BP were found in 30% of children (17/56), the majority of which were of systolic BP; 65% of those with elevations were of normal weight. Data collection was feasible with few problems. Small-to-medium effect sizes were noted for BP status (normal, prehypertensive, and hypertensive) and cortisol p.m. and birth status (parent-reported prematurity or term); small effect sizes were seen for BP status and BMI, race, sex, and geographic location. CRP and cortisol had medium- and small-to-medium effect sizes, respectively, with diastolic blood pressure. Studies with larger, more diverse samples need to be conducted to test hypotheses posited from these estimated effect sizes.

OS 24-04 A PILOT STUDY ASSESSING THE FEASIBILITY OF VASCULAR FUNCTION IN LOW SOCIOECONOMIC STATUS PRESCHOOL CHILDREN.

Objective: To assess the feasibility of measuring non-invasively central aortic blood pressure (BP) and indices of arterial stiffness (aortic augmentation index (AIx) and pulse wave velocity (PWV)) in 3–5 year old children and assess if vascular function is affected by vascular inflammation (Serum C-reactive protein (CRP)) and /or cortisol. Design and Method: Central BP, AIx, and PWV were measured using applanation tonometry (SphygmoCor) in 16 children recruited from Head Start centers in AL. Results: We recruited 16 preschool African American children (age 53.1 ± 9.1 months, 69% males, weight 39.8 ± 8 lbs, height 36.2 ± 3.2 in). Of these 38% (n = 6) had an elevated blood pressure reading (> 90% for height, gender and age). BMI were comparable between the groups. Brachial (111 ± 9/69 ± 4 vs. 93 ± 11/55 ± 6 mmHg, p < 0.05) and central (93 ± 12/72 ± 6 vs. 85 ± 7/57 ± 6 mmHg, p < 0.05) BP, CRP (3.1[2.3–6.3] vs. 0.2[0.1–0.3] mg/L, p < 0.05) and cortisol (0.21 ± 0.09 vs. 0.15 ± 0.06, p = 0.09) were higher in children with hypertensive BP readings. There was no significant difference in PWV between the groups but AIx was higher in children with hypertensive BP readings (31 ± 8 vs.18 ± 16%, p = 0.07). Serum CRP correlated with systolic (Spearman r = 0.70) and diastolic (0.68) BP percentiles and with central systolic (0.58) and diastolic (0.71) BP readings (all p < 0.05) but not with AIx (0.25, p = 0.4) or PWV (−0.2, p > 0.9). Serum cortisol showed moderate correlations with AIx (0.43, p = 0.1) and PWV (-0.48, p = 0.1) but not with BP readings. Conclusions: Non-invasive assessment of central aortic BP and measures of arterial stiffness are feasible in preschool children. Children with hypertensive BP readings may have evidence of arterial stiffness as early as 3–5 years of age. Vascular function is associated with inflammatory and stress markers. Further studies are needed to determine vascular function changes in preschool children to elucidate mechanisms of early onset hypertension.