Low resilience is associated with worse health-related quality of life in caregivers of service members and veterans with traumatic brain injury: a longitudinal study.

PURPOSE: To examine [a] the association of caregiver health-related quality of life (HRQOL) and service member/veteran (SMV) neurobehavioral outcomes with caregiver resilience; [b] longitudinal change in resilience at the group and individual level; and [c] the magnitude of change at the individual level. METHODS: Caregivers (N = 232) of SMVs with traumatic brain injury completed a resilience measure, and 18 caregiver HRQOL and SMV neurobehavioral outcome measures at a baseline evaluation and follow-up evaluation three years later. Caregivers were divided into two resilience groups at baseline and follow-up: [1] Low Resilience (≤ 45 T, baseline n = 99, follow-up n = 93) and [2] High Resilience (> 45 T, baseline n = 133, follow-up n = 139). RESULTS: At baseline and follow-up, significant effects were found between Low and High Resilience groups for the majority of outcome measures. There were no significant differences in resilience from baseline to follow-up at the group-mean level. At the individual level, caregivers were classified into four longitudinal resilience groups: [1] Persistently Low Resilience (Baseline + Follow-up = Low Resilience, n = 60), [2] Reduced Resilience (Baseline = High Resilience + Follow-up = Low Resilience, n = 33), [3] Improved Resilience (Baseline = Low Resilience + Follow-up = High Resilience, n = 39), and [4] Persistently High Resilience (Baseline + Follow-up = High Resilience, n = 100). From baseline to follow-up, approximately a third of the Reduced and Improved Resilience groups reported a meaningful change in resilience (≥ 10 T). Nearly all of the Persistently High and Persistently Low Resilience groups did not report meaningful change in resilience (< 10 T). CONCLUSION: Resilience was not a fixed state for all caregivers. Early intervention may stall the negative caregiving stress-health trajectory and improve caregiver resilience.

Health outcomes before and during the COVID-19 pandemic in caregivers of service members and veterans with traumatic brain injury.

PURPOSE: To examine change in health-related quality of life (HRQOL) during the COVID-19 pandemic in caregivers of service members/veterans (SMVs) with traumatic brain injury (TBI), by comparing HRQOL during the first year of the pandemic to HRQOL 12 months pre-pandemic. METHODS: Caregivers (N = 246) were classified into three COVID-19 Pandemic Impact groups based on impact ratings of the pandemic on HRQOL: No Impact (n = 50), Mild Impact (n = 117), and Moderate-Severe Impact (n = 79). Caregivers completed 19 measures across physical, social, caregiving, and economic HRQOL domains, and a measure of SMV Adjustment. T-scores were used to determine individual symptom trajectories for each measure as follows: Asymptomatic (pre + during < 60 T); Developed (pre < 60 + during ≥ 60 T); Improved (pre ≥ 60 T + during < 60 T); and Persistent (pre + during ≥ 60 T). RESULTS: Using ANOVA, during the pandemic, the Moderate-Severe Impact group reported worse scores on 19 measures (d = 0.41-0.89) compared to the No Impact group and 18 measures (d = 0.31-0.62) compared to the Mild Impact group (d = 0.31-0.38). The Mild Impact group reported worse scores on two measures compared to the No Impact group (d = 0.42-0.43). Using the entire sample, the majority of HRQOL measures were classified as Asymptomatic (47.2-94.7%), followed by Persistent (2.4-27.2%). Few were classified as Developed (0.4-12.6%) or Improved (2.4-13.8%). Using repeated measures ANOVA, no meaningful effects sizes were found for mean scores on all measures completed pre-pandemic compared to during the pandemic (d ≤ 0.17). CONCLUSION: The vast majority of caregivers reported stability in HRQOL pre-pandemic compared to during the pandemic. The COVID-19 pandemic was not associated with a high prevalence of decline in caregiver HRQOL.

Resilience is associated with health-related quality of life in caregivers of service members and veterans following traumatic brain injury.

PURPOSE: To examine factors related to resilience in military caregivers across caregiver health-related quality of life (HRQOL), caregiver sociodemographic variables, and service member/veteran (SMV) injury and health status. METHODS: Caregivers (N = 346, Female = 96.2%; Spouse = 91.0%; Age: M = 40.6 years, SD = 9.3) of SMVs following a mild, moderate, severe, or penetrating TBI were recruited from U.S. military treatment facilities and via community outreach. Caregivers completed select TBI-CareQOL and NIH Toolbox scales, the Caregiver Appraisal Scale, Caregiver Questionnaire, and Mayo-Portland Adaptability Inventory-4. Caregivers were divided into three groups using the TBI-QOL Resilience scale: (1) Low-Moderate Resilience (n = 125), (2) Moderate Resilience (n = 122), and (3) Moderate-High Resilience (n = 99). RESULTS: Factors related to low caregiver resilience were strain on employment, financial burden from out-of-pocket expenses, caring for children, less personal time, caring for both verbal and physical irritability, anger, and aggression, and lower SMV functional ability (all p's < .05). The Low-Moderate Resilience group had consistently worse HRQOL scores compared to the Moderate and Moderate-High Resilience groups (ps < .001; d = .50-1.60), with the exception of Caregiving Ideology. CONCLUSION: Lower resilience among caregivers of SMVs following TBI is associated with poorer caregiver HRQOL. Programs aimed at promoting and maintaining resilience in military caregivers long-term is important for their own health, the health of the SMV, and the health of their children.

Long-term neurobehavioural symptom reporting following mild, moderate, severe, and penetrating traumatic brain injury in U.S. military service members.

The purpose of this study was to examine long-term neurobehavioural symptom reporting following mild, moderate, severe, or penetrating TBI in U.S. military service members and veterans (SMV). Participants were 445 SMVs divided into four groups: 158 uncomplicated mild TBI ("unMTBI" group), 105 penetrating, severe, moderate, or complicated mild TBI ("smcTBI" group), 101 injured controls (IC), and 81 non-injured controls (NIC). Two independent cohorts were examined that included participants 5-years or 10-year post-injury. Participants completed the TBI-Quality of Life, Neurobehavioural Symptom Inventory, and Post-traumatic Stress Disorder Checklist. At 5-years and 10-years post-injury, there were significant main effects for the majority of measures (all p's < .005). At 10-years post-injury, the NIC group had consistently better scores compared to the IC, unMTBI, and smcTBI groups. At 5-years post-injury, either (a) the IC and NIC group had better scores compared to both TBI groups, or (b) the NIC group had better scores compared to the IC, unMTBI, and smcTBI groups. A high proportion of SMVs reported poor long-term neurobehavioural symptoms following TBI or bodily injury without TBI. Injured SMVs (regardless of injury type) can have long-term symptoms that impact mental health and overall quality of life requiring long-term follow-up and care.

Family caregivers of service members in United States Department of Defense health care report impairment in longitudinal health outcomes.

OBJECTIVE: To examine elevated symptoms on health-related quality of life (HRQOL) measures over 2 years in caregivers of service members with traumatic brain injury (TBI). To compare outcomes to caregivers of veterans. METHOD: Caregivers (N = 315) were classified into two groups: (a) service member caregiver group (n = 55) and (b) veteran caregiver group (n = 260). Caregivers completed 17 HRQOL measures at a baseline evaluation and follow-up evaluation 24 months later. RESULTS: In the service member caregiver group, the highest frequency of clinically elevated T-scores (≥ 60 T) at baseline and follow-up were found on physical and psychological HRQOL measures (16.4%-30.9%). A higher proportion of the veteran caregiver group had clinically elevated scores on nine measures at baseline and seven measures at follow-up. Examining the number of clinically elevated scores simultaneously across all 17 measures, the service member caregiver group had multiple elevated scores (e.g., 4 or more: baseline = 25.5%, follow-up = 27.3%). A higher proportion of the veteran caregiver group had multiple clinically elevated scores for 13 comparisons at baseline (h = .35-.82), but reduced to eight comparisons at follow-up (h = .36-.63). In the service member caregiver group, the proportion of caregivers with clinically elevated scores at baseline and follow-up was equally dispersed across persistent and newly developed symptoms, but higher for persistent symptoms compared to developed symptoms in the veteran caregiver group. CONCLUSIONS: Many caregivers of service members reported clinically elevated scores across HRQOL domains and the prevalence increased over 2 years. More services for caregivers in the Department of Defense may be helpful in reducing the trajectory of newly developed symptoms long term. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Longitudinal health-related quality of life in military caregivers no longer providing care.

PURPOSE/OBJECTIVE: To examine health-related quality of life (HRQOL) in caregivers when providing care and no longer providing care to service members/veterans with traumatic brain injury. RESEARCH METHOD/DESIGN: Participants included 466 caregivers enrolled in a 15-year longitudinal study. During an annual follow-up evaluation, a subsample of caregivers self-identified as no longer providing care and were retained in the study as a No Longer Caregiving group (n = 48). Scores on HRQOL measures when providing care (baseline) and no longer providing care (follow-up) were examined. Scores on HRQOL measures were also compared with the remaining 418 caregivers (Caregiving group). RESULTS: The most frequent reasons for no longer caregiving were no longer being in a relationship with the SMV and the SMV had recovered/no longer required care. The No Longer Caregiving group at follow-up reported better scores on five measures compared to baseline, and three measures compared to the Caregiving group. There were no differences in the proportion of clinically elevated scores on HRQOL measures for the No Longer Caregiving group between baseline and follow-up. Compared to the Caregiving group, the No Longer Caregiving group reported a higher prevalence of clinical elevated scores on General Life Satisfaction at baseline and follow-up, and worse scores on Caregiving Relationship Satisfaction and the Couples Satisfaction Index at baseline. CONCLUSIONS/IMPLICATIONS: While some improvement in HRQOL was noted when caregivers were no longer providing care, many continued to report elevated scores. Services and supports are required for caregivers when providing care, but also when transitioning out of a caregiving role. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Health outcomes in caregivers of service members and veterans with traumatic brain injury enrolled in the U.S. Veterans Affairs Caregiver Support Program.

To explore health outcomes in caregivers of service members and veterans (SMV) with traumatic brain injury (TBI) enrolled in two programs within the U.S. Department of Veterans Affairs (VA) Caregiver Support Program (CSP) (General and Comprehensive Programs) and those not enrolled. Participants were 290 caregivers classified into three groups: (a) General Program (n = 34); (b) Comprehensive Program (n = 104); and (c) Not Enrolled (n = 152). Main outcome measures assessed caregiver health-related quality of life (HRQOL), SMV functional ability, and caregiver needs. Compared to the Not Enrolled group, the General, and Comprehensive Program groups reported worse scores on five of 25 caregiver HRQOL measures and had a higher proportion of elevated scores on two measures. The Comprehensive Program group reported worse scores on an additional seven HRQOL measures and a higher proportion of elevated scores on three measures compared to the Not Enrolled group. Over 20% of caregivers in each group reported clinically elevated scores on eight HRQOL measures. Few differences between caregiver groups were identified for unmet needs. In the total sample, eight HRQOL measures consistently emerged that were more strongly associated with caregiver needs. Caregivers enrolled in the VA CSP tended to report worse HRQOL and caring for a SMV with worse functional ability compared to those not enrolled. A better understanding of health care utilization for those not enrolled in the CSP and in need of help is required. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Unhealthy family functioning is associated with health-related quality of life among military spouse caregivers.

OBJECTIVE: The current study examines health-related quality of life (HRQOL) and family functioning in a sample of spouse caregivers assisting post-9/11 service members and veterans (SMV) following traumatic brain injury (TBI). METHOD: Participants were 316 spouse (and partner) caregivers of SMVs following a mild, moderate, severe, or penetrating TBI. Caregivers completed the Family Assessment Device General Functioning subscale, 24 HRQOL questionnaires, and the Mayo-Portland Adaptability Inventory (4th ed.; MPAI-4). The sample was divided into two family functioning groups: Healthy Family Functioning (HFF; n = 162) and Unhealthy Family Functioning (UFF; n = 154). Scores on HRQOL measures that generate T scores using normative data were classified as "clinically elevated," using a cutoff of > 60T. RESULTS: Compared with the HFF group, caregivers in the UFF group reported worse scores on all HRQOL measures and worse SMV functional ability on the MPAI-4 Adjustment Index and Anxiety, Depression, and Irritability/Anger/Aggression items (all ps < .001, ds = .41-1.36). A significantly higher proportion of the UFF group had clinically elevated HRQOL scores compared with the HFF group on the majority of measures (Hs = .24-.75). When examining all HRQOL measures simultaneously, the UFF group consistently had a significantly higher cumulative percentage of clinically elevated scores compared with the HFF group (e.g., ≥ 5 clinically elevated scores: UFF = 53.9% vs. HFF = 22.2%; H = .68). CONCLUSIONS: Caring for a SMV following TBI with comorbid mental health problems may have negative implications for their family functioning and the caregiver's HRQOL. Family-centered interventions could be beneficial for military families experiencing distress following SMV TBI and mental health comorbidity. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life.

STUDY OBJECTIVES: To examine the relationship between caregiver sleep impairment and/or service member/veteran (SMV) adjustment post-traumatic brain injury, with caregiver health-related quality of life (HRQOL). METHODS: Caregivers (n = 283) completed 18 measures of HRQOL, sleep impairment, and SMV adjustment. Caregivers were classified into 4 sleep impairment/SMV adjustment groups: 1) Good Sleep/Good Adjustment (n = 43), 2) Good Sleep/Poor Adjustment (n = 39), 3) Poor Sleep/Good Adjustment (n = 55), and 4) Poor Sleep/Poor Adjustment (n = 146). RESULTS: The Poor Sleep/Poor Adjustment group reported significantly worse scores on most HRQOL measures and a higher prevalence of clinically elevated T-scores (≥ 60T) on the majority of comparisons compared to the other 3 groups. The Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups reported worse scores on the majority of the HRQOL measures and a higher prevalence of clinically elevated scores on 7 comparisons compared to the Good Sleep/Good Adjustment group. Fewer differences were found between the Good Sleep/Poor Adjustment and Poor Sleep/Good Adjustment groups. The Poor Sleep/Poor Adjustment group reported a higher prevalence of severe ratings for SMV Irritability, Anger, and Aggression compared to the Good Sleep/Poor Adjustment group. CONCLUSIONS: While the presence of either caregiver sleep impairment or poor SMV adjustment singularly was associated with worse caregiver HRQOL, the presence of both sleep impairment and poor SMV adjustment was associated with further impairment in HRQOL. Caregivers could benefit from sleep intervention. Treatment of SMVs neurobehavioral problems may improve the SMV's recovery and lessen sleep problems, distress, and burden among their caregivers. CITATION: Brickell TA, Wright MM, Sullivan JK, et al. Caregiver sleep impairment and service member and veteran adjustment following traumatic brain injury is related to caregiver health-related quality of life. J Clin Sleep Med. 2022;18(11):2577-2588.

Post-Traumatic Stress Disorder Symptoms Are Related to Cognition after Complicated Mild and Moderate Traumatic Brain Injury but Not Severe and Penetrating Traumatic Brain Injury.

Although post-traumatic stress disorder (PTSD) has been associated with worse cognitive outcomes after mild traumatic brain injury (TBI), its impact has not been evaluated after more severe TBI. This study aimed to determine whether PTSD symptoms are related to cognition after complicated mild, moderate, severe, and penetrating TBI. Service members (n = 137) with a history of complicated mild/moderate TBI (n = 64) or severe/penetrating TBI (n = 73) were prospectively enrolled from United States Military Treatment Facilities. Participants completed a neuropsychological assessment one year or more post-injury. Six neuropsychological composite scores and an overall test battery mean (OTBM) were considered. Participants were excluded if there was evidence of invalid responding. Hierarchical linear regressions were conducted evaluating neuropsychological performance. The interaction between TBI severity and PTSD Checklist-Civilian version total score was significant for processing speed (ß = 0.208, p = 0.034) and delayed memory (ß = 0.239, p = 0.021) and trended toward significance for immediate memory (ß = 0.190, p = 0.057) and the OTBM (ß = 0.181, p = 0.063). For each of these composite scores, the relationship between PTSD symptoms and cognition was stronger in the complicated mild/moderate TBI group than the severe/penetrating TBI group. Within the severe/penetrating TBI group, PTSD symptoms were unrelated to cognitive performance. In contrast, within the complicated mild/moderate TBI group, PTSD symptoms were significantly related to processing speed (R2Δ = 0.077, ß = -0.280, p = 0.019), immediate memory (R2Δ = 0.197, ß = -0.448, p < 0.001), delayed memory (R2Δ = 0.176, ß = -0.423, p < 0.001), executive functioning (R2Δ = 0.100, ß = -0.317, p = 0.008), and the OTBM (R2Δ = 0.162, ß = -0.405, p < 0.001). The potential impact of PTSD symptoms on cognition, over and above the impact of brain injury alone, should be considered with service members and veterans with a history of complicated mild/moderate TBI. In addition, in research comparing cognitive outcomes between patients with histories of complicated-mild, moderate, severe, and/or penetrating TBI, it will be important to account for PTSD symptoms.

Factor analysis of the Caregiver Appraisal Scale in military TBI.

PURPOSE/OBJECTIVE: To (a) examine the factor structure of the original 47-item Caregiver Appraisal Scale (CAS) in caregivers of service members/veterans (SMVs) following traumatic brain injury (TBI) and (b) assess whether the CAS yields a similar factor structure in this population compared to caregivers of civilian adults following TBI. Research Method/Design: Participants were 287 caregivers (female = 96.2%; spouse = 87.8%; mean age = 38.6 years) of SMVs who sustained a mild, moderate, severe, or penetrating TBI, recruited from Walter Reed National Military Medical Center and via caregiver community outreach. Caregivers completed the CAS, Caregiver Questionnaire, and Mayo-Portland Adaptability Inventory-4 upon enrollment in the study. RESULTS: Principal component analysis (PCA) revealed four factors that explained 43.2% of the variance in CAS scores: Perceived Burden, Caregiving Relationship Satisfaction, Caregiving Ideology, and Caregiving Mastery. Thirty-seven of the 47 CAS items loaded significantly onto only one of the four factors (≥ .40). A secondary PCA was performed on these 37 items, resulting in a four-factor solution very similar to that of the 47-item solution, which explained 46.8% of the variance in the 37-item measure. All but one item loaded significantly on a factor corresponding to a conceptually similar construct. CONCLUSIONS/IMPLICATIONS: Military and civilian caregivers have overlapping and differing concerns. The findings support a 37-item four-factor model of caregiving stress appraisal that has the potential for use as an outcome measure for developing caregiver interventions. It may be as useful to administer a reduced 37-item measure of the CAS to caregivers as the original 47-item measure, but further development is required. (PsycINFO Database Record (c) 2019 APA, all rights reserved).