Evidence for the Effectiveness of Interventions for Caregivers of People With Chronic Conditions: A Systematic Review.

IMPORTANCE: Caregivers are pivotal in supporting the growing population of people with chronic conditions. Yet, engaging in the caregiver role involves the risk of poor outcomes. Caregiver interventions are needed that address poor outcomes while fostering engagement in role-related activities. OBJECTIVE: To evaluate the evidence for interventions to support caregivers of adults with chronic conditions. DATA SOURCES: Five databases were searched for studies of interventions for caregivers and patient-caregiver dyads published between 1995 and 2019. Study Selection and Data Collection: We reviewed the titles, abstracts, and full-text articles of the initial search results (N = 12,216 studies) according to a predetermined protocol. FINDINGS: Forty-eight studies met the inclusion criteria. Psychoeducation and education with skills training were the two caregiver intervention themes. Studies evaluating psychoeducation (n = 28) provided low strength of evidence for improved psychosocial outcomes. Within this theme, problem-solving and coping skills training were common intervention components associated with significant improvements in depression and quality of life. Studies evaluating education with skills training (n = 20) provided moderate strength of evidence for improved knowledge and low strength of evidence for improved psychosocial outcomes. Dyadic self-management education and hands-on training were common components associated with significant improvements in knowledge, quality of life, and burden or strain. CONCLUSIONS AND RELEVANCE: We found low strength of evidence to support the use of psychoeducation and education with skills training. Within these approaches, problem-solving and coping skills training, dyadic self-management education, and hands-on training show promise for improving caregiver outcomes. What This Article Adds: Findings of this systematic review are inconclusive with respect to psychoeducation and education with skills training leading to improved caregiver well-being. Within these broad approaches, the findings support the use of problem-solving and coping skills training, dyadic self-management education, and hands-on training to improve knowledge and well-being among caregivers of people with chronic conditions.

Factors associated with care partner identification and education among hospitalized persons living with dementia.

Objective: Care partners of persons living with dementia (PLWD) often feel unprepared to care for their loved ones. Improving PLWD care partner identification and education during hospital stays can improve preparedness. This retrospective EHR study investigated PLWD characteristics that may relate to care partner identification, education, and teaching methods during hospital stays. Methods: Encounters from a Midwestern academic healthcare system were used. Patients were over 18, had a documented dementia diagnosis, were admitted to the hospital for at least 24 h, and had information documented in care partner or education data fields (N = 7982). Logistic regressions assessed patient's demographics, care partner identification and education. Chi-square tests compared education teaching methods and patient discharge location. Results: PLWD's who were unmarried, discharged to other care facilities, or received the diagnosis "degeneration of nervous system due to alcohol" were associated with lacking care partner identification. Care partners of unmarried PLWDs or those with the diagnosis "Alzheimer's disease, unspecified" received less education. Multiple teaching methods were associated with discharge location. Conclusion: Multiple characteristics were related to PLWD care partner identification and education differences during hospital stays. Innovation: Novel analyses highlight need for a protocol to systematically prepare dementia care partners.

Implementing strategy training in Taiwan: perspectives of individuals with Acquired brain injury.

PURPOSE: Strategy training is a rehabilitation intervention that aims to enhance problem-solving skills with respect to daily activity-related challenges and has achieved favorable results in Western countries. This study explored the perspectives of individuals with acquired brain injury (ABI) in Taiwan who received strategy training. MATERIALS AND METHODS: Semi-structured interviews with community-dwelling adults with ABI were conducted, and reflective memos made by research team members were recorded. Interviews and memos were analyzed through thematic analysis. RESULTS: This study included 55 participants. The analysis of the participants' interview responses and memos yielded nine themes under three categories: 1) expectations regarding strategy training, 2) perceived benefits of strategy training, and 3) barriers affecting the process and outcomes of strategy training. CONCLUSIONS: All the participants endorsed strategy training through different gains. Most participants' expectations before the intervention were uncertain. Including family members into the strategy training is of key importance for a successfulness of their goals. The participants' experiences about strategy training were affected by various barriers (i.e., health and medical problems, the physical environment, and natural events). Clinicians and researchers should consider these expectations, benefits, and barriers when studying and implementing strategy training in non-Western contexts.IMPLICATIONS FOR REHABILITATIONStrategy training provides clients the opportunity to actively engage in their own goal setting and decision making.Strategy training increases the client's confidence in their ability to participate in the community, communicate, and perform daily living and physical activities.Therapists should consider the health conditions and physical environment of clients when helping them set goals and before facilitating their engagement in the community.Taiwanese family members play a crucial role in supporting acquired brain injury survivors in strategy training.

Supporting Mealtime Participation Among People Living With Dementia at Home: Challenges and Strategies for Caregivers.

BACKGROUND AND OBJECTIVES: Approximately 60% of people living with dementia at home are unable to routinely participate in mealtime activities (e.g., eating, safe food preparation), warranting assistance to ensure people with dementia meet their health and nutritional needs. The purpose of this study was to characterize these barriers to mealtime participation and identify potential caregiver-led strategies to enhance mealtime activities. RESEARCH DESIGN AND METHODS: We used a qualitative descriptive approach and obtained semistructured interview data from (a) allied health professionals and (b) community-based nutrition program providers who frequently serve people with dementia. Interview data were examined by means of directed content analysis and framework methodology until data saturation was reached. Codes from our analysis were categorized according to constructs drawn from the Socio-Ecological Model for Developing and Implementing Comprehensive Dementia Care. RESULTS: Data were obtained from 20 participants who attributed common mealtime participation barriers to: impairments in functional status, cognitive status deficits, a lack of caregiver knowledge and skills, and unsafe living conditions. Caregiver-led strategies to overcome these barriers included: reducing auditory and visual distractions, providing written cues to perform mealtime activities, eliminating clutter and fall risk hazards, and leveraging community-based nutrition program providers (e.g., home-delivered meal providers). DISCUSSION AND IMPLICATIONS: People with dementia face several eating and mealtime participation obstacles. Caregiver-led strategies implemented by family, friends, or community-based nutrition program providers may enhance mealtime activities at home. Findings point to opportunities to develop decision-making tools and resources for caregivers to optimize the health and nutrition of people with dementia.

Implementing CAPABLE With Care Partners Through an Area Agency on Aging: Identifying Barriers and Facilitators Using the Consolidated Framework for Implementation Research.

BACKGROUND AND OBJECTIVES: Community Aging in Place, Advancing Better Living for Elders (CAPABLE) is an evidence-based intervention to promote aging in place. Although CAPABLE has been implemented in more than 40 community sites, wide variation in implementation exists. Guided by the Consolidated Framework for Implementation Research (CFIR), this study sought to determine key barriers and facilitators that may influence CAPABLE implementation with older adult and care partner dyads through an area agency on aging (AAA). RESEARCH DESIGN AND METHODS: A formative evaluation was completed using qualitative data from the pilot of a Hybrid Trial Type 1 study implementing CAPABLE in an AAA. Multiple sources of data were collected, including 2 focus groups, field notes, a tracking log, and meetings with CAPABLE interventionists. Data were analyzed using a framework method and validated through a negative case analysis approach in NVivo 12 Pro. RESULTS: Fourteen dyads enrolled in the pilot and 6 completed the CAPABLE intervention. Key themes aligned with 10 constructs from 5 domains of the CFIR. Facilitators included adaptability of the intervention, cost, networks and communication, and knowledge and belief of individuals. Barriers included intervention complexity, client needs and resources, and executing the planned process. DISCUSSION AND IMPLICATIONS: Results enhance understanding of contextual factors that can influence the implementation of CAPABLE with care partners. Strategies to overcome barriers include simplifying recruitment materials and targeting older adults with recent onset of disability. The CFIR is a valuable resource for planning and evaluation of the implementation of evidence-based interventions to promote aging in place.

A Descriptive Qualitative Study of Foreign Caregivers of Older Adult Stroke Survivors.

BACKGROUND AND OBJECTIVES: With a growing aging stroke population and the changing structure of the society, the demand for foreign caregivers has rapidly increased in Taiwan and many other developed countries. However, little is known regarding the perception, values, and abilities of foreign caregivers and how those may influence their quality of care. This study aimed to explore and describe the experiences of Indonesian foreign caregivers, the largest migrant working population in Taiwan, who reside with and provide support to older adults with stroke and their families. RESEARCH DESIGN AND METHODS: By adopting a descriptive qualitative approach, we conducted semistructured interviews with 22 Indonesian caregivers (mean age: 36 years) who were providing care to community-dwelling older stroke survivors (age ≥ 65 years) in Taiwan. Data were analyzed through thematic analysis. RESULTS: Six themes were constructed from the interviews: (a) foreign caregiver's background, (b) foreign caregiver's perception of the health and functional status of stroke survivors, (c) foreign caregiver's values and preferences, (d) consequences of caring for stroke survivors, (e) skills/abilities/knowledge of foreign caregivers to provide stroke survivors with required care, and (f) potential resources that foreign caregivers can use. DISCUSSION AND IMPLICATIONS: Foreign caregivers described the positive and negative aspects of caring for stroke survivors. Differences in language, religion, culture, values, and expectations between foreign caregivers and stroke survivors influence the caregiving experience. These findings can help Taiwan and other developed countries to better support foreign caregivers providing critical care to older adults with stroke and their families.

How does culture influence the implementation of strategy training in stroke rehabilitation? A rapid ethnographic study of therapist perspectives in Taiwan and the United States.

PURPOSE: Strategy training is a promising stroke rehabilitation intervention commonly delivered in Western countries. We examined the perspectives of rehabilitation therapists who have delivered strategy training in Taiwan and the United States to understand the influence of culture on strategy training implementation. MATERIALS AND METHODS: In this rapid ethnographic study, the maximum variation sampling approach was used to recruit seven therapists in Taiwan and seven therapists in the United States with experience delivering strategy training. Data was collected from multiple sources, including interviews, study documents, therapist notes, and reflective memos. Interviews with the recruited therapists in Taiwan and the United States were conducted in Mandarin and English, respectively. Data were analyzed using a constant comparative approach. RESULTS: The following two themes were generated: (1) differences between conventional rehabilitation and strategy training, namely that conventional rehabilitation is therapist-directed and emphasizes impairment reduction, whereas strategy training empowers clients and focuses on real-life generalization, and (2) challenges in implementing strategy training in practice, including difficulty in achieving client buy-in and disengagement. CONCLUSIONS: Therapists from both countries shared similar perspectives on the perceived advantages of strategy training, such as enhancing client empowerment and engagement, and the generalization of strategies. Family involvement was more prominently discussed by therapists in Taiwan than by those in the United States.IMPLICATIONS FOR REHABILITATIONStrategy training differs from conventional rehabilitation in its emphasis on clients' life participation and empowerment, generalization of strategies, and enhancement of their engagement, confidence, and problem-solving skills.Therapists may face challenges related to client buy-in and disengagement as well as difficulties in establishing a therapeutic rapport at the beginning of strategy training because clients have different expectations from those of conventional rehabilitation.Cultural differences in norms and expectations and the clinical experiences of therapists may influence the delivery of strategy training to clients.Family support may influence the success of strategy training.Thoughtful conversations to reach a mutual understanding regarding the expectations of strategy training among clients, family, and rehabilitation practitioners are necessary prior to implementing strategy training.

Hippotherapy: a systematic mapping review of peer-reviewed research, 1980 to 2018.

PURPOSE: Comprehensively and systematically map peer-reviewed studies of hippotherapy published over 30 years, from 1980 through 2018, from the perspective of a phased scientific approach to developing complex interventions as a guide to future research and practice. METHODS: A systematic mapping review of research of hippotherapy was conducted. Searches of nine databases produced 3,528 unique records; 78 full-text, English-written studies were reviewed, the earliest of which was published in 1998. Data relevant to study aims were extracted electronically from these studies and analyzed using queries and pivot tables. RESULTS: Children with cerebral palsy and physical therapists were most prevalent as participants and providers. Equine movement was hippotherapy's core component and mechanism. Early-phase outcomes-oriented research predominated. "Hippotherapy" was ambiguously defined as treatment strategies and comprehensive professional services, even as interventions grew more distinctive and complex. A treatment theory and proof of concept related to motor outcomes were established, and efficacy research with comparison conditions emerged. CONCLUSIONS: Continuing research of complex interventions that integrate hippotherapy, equine movement as a therapy tool, is warranted. Attention to gaps in foundational scientific work concurrent with continued piloting and efficacy work will help to identify the most promising interventions worthy of replication, evaluation and widespread adoption.IMPLICATIONS FOR REHABILITATIONTo advance the evidence base of complex interventions that incorporate hippotherapy:•Proponents of hippotherapy need to define and represent hippotherapy to the public and in practice and research contexts as a therapy tool involving the use of the movement of horses by qualified professionals, rather than simply as a generic therapy with the help of a horse or simulated horse;•Providers of hippotherapy need to identify their professional degrees and certifications, and explicate their disciplinary perspectives that influence their selected components of intervention, related methods, and outcomes; and•Providers and researchers need to partner to develop an enablement theory of hippotherapy that links improved body functions with improved participation in everyday life and quality of life.

Hippotherapy Practice and Safety Patterns in the United States: A Descriptive Survey Study.

Objective: The use of equine movement as a therapy tool in a plan of care, or hippotherapy, has grown considerably over the past three decades. However, there is little evidence of safety rates and related practice patterns to guide key stakeholders such as clients, therapists, the health care team, and third-party payers. The purpose of this article is to describe the safety and practice patterns of contemporary use of hippotherapy. Design: A survey was distributed to occupational therapy (OT), physical therapy (PT), and speech-language pathology clinicians who incorporate hippotherapy into their practice. The survey included questions about clinicians' practice patterns, safety procedures, and rates of safety incidents. Results: Results indicate that hippotherapy is most often used by PT and OT clinicians for pediatric clients. Use of hippotherapy varies by geographic location, and frequency and duration vary widely. Clinicians most often contract their services to a program that provides a facility and horses. Recommended safety practices are widely adopted, and rates of safety incidents requiring basic first aid (0.05% of sessions) or off-site care (0.01% of sessions) are low. Emergency dismounts are frequently practiced and often effective in preventing an incident. Conclusions: Although there are inherent risks to incorporating horses into a therapeutic plan of care, these risks appear to be well managed by recommended safety practices. Results of this study can (1) help clinicians to make informed decisions regarding practice and safety procedures, (2) provide evidence of safety practices and incident rates to clients, members of the health care team, and third-party payers, and (3) maximize safety for clients who participate in hippotherapy.