Gender Differences in Longitudinal Associations Between Intimate Care, Resiliency, and Depression Among Informal Caregivers of Patients Surviving the Neuroscience Intensive Care Unit.

BACKGROUND/OBJECTIVE: Informal caregivers (e.g., family and friends) are at risk for developing depression, which can be detrimental to both caregiver and patient functioning. Initial evidence suggests that resiliency may reduce the risk of depression. However, gender differences in associations between multiple psychosocial resiliency factors and depression have not been examined among neuroscience intensive care unit (neuro-ICU) caregivers. We explored interactions between caregiver gender and baseline resiliency factors on depression symptom severity at baseline through 3 and 6 months post-discharge. METHODS: Caregivers (N = 96) of neuro-ICU patients able to provide informed consent to participate in research were enrolled as part of a prospective, longitudinal study in the neuro-ICU of a major academic medical center. Caregiver sociodemographics and resiliency factors (coping, mindfulness, self-efficacy, intimate care, and preparedness for caregiving) were assessed during the patient's hospitalization (i.e., baseline). Levels of depressive symptoms were measured using the Hospital Anxiety and Depression Scale at baseline, 3 months, and 6 months post-discharge. RESULTS: Baseline depressive symptoms predicted depressive symptoms at both 3- and 6-month follow-ups, with no difference at any time point in rates of depression by gender. At baseline, greater levels of coping, mindfulness, and preparedness for caregiving were individually associated with lower levels of concurrent depression regardless of gender (ps < 0.006). The main effect of baseline coping remained significant at 3-month follow-up (p = 0.045). We observed a trend-level interaction between gender and baseline intimate care, such that among male caregivers only, high baseline intimate care was associated with lower depression at 3-month follow-up (p = 0.055). At 6-month follow-up, we observed a significant interaction between caregiver gender and baseline intimate care, such that male caregivers reporting high intimate care reported lower symptoms of depression than females reporting high intimate care (p = 0.037). CONCLUSIONS: Results support implementation of psychosocial resiliency interventions for caregivers of patients admitted to the neuro-ICU early in the recovery process. Male caregivers may particularly benefit from strategies focused on increasing intimate care (e.g., physical and emotional affection with their loved one) and quality of the patient-caregiver dyadic relationship.

Lifetime expectancy and quality-adjusted life-year in Alzheimer's disease with and without cerebrovascular disease: effects of nursing home replacement and donepezil administration--a retrospective analysis in the Tajiri Project.

BACKGROUND: We previously demonstrated a positive correlation with nursing home (NH) replacement and donepezil (DNP) administration on lifetime expectancy after the onset of Alzheimer's disease (AD). However, the correlation with quality-adjusted life-year (QALY) remains to be elucidated, along with the additional impact of concomitant cerebrovascular disease (CVD). Based upon our recently reported health state utility values, we retrospectively analyzed the correlation with NH replacement and/or DNP administration on QALY and life expectancy in 'pure' AD (without CVD) and AD with CVD patients. METHODS: All outpatients at the Tajiri Clinic from 1999-2012 with available medical records and death certificates were included. The entry criteria were a dementia diagnosis (DSM-IV) and diagnoses of pure AD or AD with CVD (NINCDS-ADRDA), medical treatment for more than 3 months, and follow up to less than 1 year before death. The main outcomes were lifetime expectancy (months between the onset of dementia and death) and QALY. RESULTS: We identified 390 subjects, of whom 275 had the diagnosis of dementia that met the entry criteria, including 67 pure AD, 33 AD with CVD, and 110 VaD patients. For the AD patients, 52 had taken DNP and 48 had not received the drug due to treatment prior to the introduction of DNP in 1999 in Japan. For the pure AD group, there were positive correlation between NH and DNP and QALY, as well as lifetime expectancy. As for the AD with CVD group, only a correlation between DNP and lifetime expectancy was noted, with no correlation with QALY. CONCLUSIONS: We found positive correlations between DNP administration and NH replacement and lifetime expectancy and QALY after the onset of AD. However, concomitant CVD negated such a positive correlation with QALY. The findings suggest that QALY in AD is affected by CVD; thus, indicating the importance of CVD prevention.

Effect of Hierarchical Nursing Management in Patients with Hypertension Complicated with Cardiovascular and Cerebrovascular Risk Factors.

Hierarchical management is an essential component of nurse post management and an unavoidable tendency in nursing education. According to their existing condition, various hospitals around the country have actively tested the hierarchical usage and management model of clinical nurses, with some success. The application impact of hierarchical nursing care in patients with hypertension complicated by cardiovascular and cerebrovascular risk factors is the focus of this research. In a hospital, 300 patients with hypertension complicated by cardiovascular and cerebrovascular risk factors were chosen. All patients were split into two groups using the coin-throwing random method: the observation group received hierarchical nurse management and the control group received regular nursing management, with 150 cases in each group. The two groups' blood pressure, blood lipids, blood glucose, poor habits, rehospitalization rate, and cardiovascular and cerebrovascular problems were also examined. At the same time, the patients' poor mood and quality of life were assessed before and after the intervention. In the control group followed up for 1 year, the blood pressure compliance rate was 44.88%, the blood lipid compliance rate was 28.65%, the blood glucose compliance rate was 45.00%, the smokers with bad lifestyle habits were 26.57%, the overweight and obese were 23.5%, the high sodium was 31.67%, the rehospitalization rate was 15.48%, and the incidence of cardiovascular and cerebrovascular complications was 43.00%. The observation group's blood pressure, blood lipids, and blood sugar compliance rates rose substantially (P = 0.05) as compared to the control group. The occurrence of poor luck living habits, the rate of rehospitalization, and the incidence of cardiovascular and cerebrovascular complications were significantly reduced (P < 0.05). Before nursing intervention, there was no significant difference in the bad mood scores SAS, SDS, and quality of life between the two groups of patients (P > 0.05); after nursing intervention, compared with the control group, the observation group's bad mood scores were significantly reduced, physical factors, psychological factors, and total scores all increased significantly, and the difference was statistically significant (P < 0.05).

Palliative care needs of patients with neurologic or neurosurgical conditions.

BACKGROUND AND PURPOSE: Many patients with non-cancer diagnoses utilize palliative services. There is little data on the palliative care needs of patients with neurologic and neurosurgical disorders. METHODS: Retrospective chart review. Log sheets which contain all patients seen between January 2004 and 2007 by palliative medicine (PM) were reviewed. Patients with neurologic or neurosurgical disorders were identified and their in-patient charts and electronic records reviewed. Patients with cancer were excluded. RESULTS: A total of 1429 cancer patients were seen by PM. Neurologic or neurosurgical diseases were the second most common in patients seen by the PM service, in 177 cases. Forty-seven patients were excluded. Complete data was collected on 129 patients. Mean age was 70. Seventy-one (55%) were female. The most common neurologic diagnosis was ischemic stroke in 33 (26%). Seventy-five (58%) had symptoms recorded. Reasons for PM consultation included 'comfort measures' in 40 (39%) and 'hospice candidacy' in 38 (37%). The most common recommendation made by the PM service was morphine in 44 (42%). Sixty-three (49%) were deemed hospice appropriate. CONCLUSIONS: Our findings support the need for PM services for patients with various neurologic and neurosurgical disorders. Understanding these needs will allow for the tailoring of palliative care services to such patients.

User's demands to an emergency service and their welcoming in the health system.

This study aims to identify and analyze users' demands to emergency services, as well as to examine the work organization to welcome them in the health system. We carried out a case study with a qualitative approach. Data were collected through free observation by time sampling. Observation focused on the organization of the work process and on the care given to users who received some kind of care at the emergency service, highlighting their demands and their acceptance in the system. Users who demanded health services displayed different needs, ranging from the simple to the more complexes level. The work process was organized to meet some of these needs, aiming, within certain limits, to treat the main complaint and follow the health system hierarchy. Healthcare users were responsible for obtaining integral care. They journeyed alone, at their own risk, through different services, with no guidance or help from the healthcare system, as would be expected.

Comparison of two systems for stroke rehabilitation in a general hospital.

This study was designed to compare the effectiveness of stroke rehabilitation therapy in a specialized Stroke Unit with that provided on the medical service of a general hospital (Rhode Island Hospital). The 8-bed Stroke Unit is staffed by a multidisciplinary team, and a weekly conference is held for evaluation and planning. On the basis of data obtained from the hospital records, two groups of patients were studied: 224 who were treated in the Stroke Unit, and 110 who were evaluated and approved for admission to the Unit but were not accommodated. A rigid "first come, first served" policy for admission to the Unit was observed. Hypothesis testing was performed with reference to the patient's medical condition, socioeconomic status, demographic characteristics, and difficulties during hospital stay to determine whether the groups were comparable. A patient was considered to have improved if his condition decreased in severity between the time of admission to therapy and the time of discharge. Severity was rated as: mild (level one), moderate (level two), severe (level three), and profound (level four). No significant difference in rehabilitation results was found between the two treatment systems at severity levels two (moderate) and four (profound). However, the Stroke Unit attained significantly better results with level-three patients (severe stroke). This group received more sessions of physical therapy and remained in the hospital longer than did the level-three patients treated on the general medical service. Physicians referred patients selectively to the Stroke Unit, althoug the Unit had no policy of screening patients for admission, and this may have had some influence on the achievement of better results with level-three patients. Level-four patients did not do well in either setting.

Use of restraints and bedrails in a British hospital.

OBJECTIVE: To determine the prevalence of restraint and bedrail use in a British hospital. DESIGN: Cross-sectional observational study. SUBJECTS: Six hundred sixty-eight patients in the acute medical, surgical, and geriatric beds of a large British teaching hospital on a single night. MEASUREMENTS: Observed use of restraints and bedrails. Reasons for restraint use were determined by interviews with nursing staff and examination of the case notes. RESULTS: Fifty-six (8.4%) patients had bedrails raised. No other restraints were in use. Reported indications for bedrail use were: prevention of falls (52 patients), prevention of wandering (1), and patient request (3). In stepwise logistic regression analysis, bedrail use was associated significantly with agitated confusion, age 70 years or more, and stroke, while patients on the acute geriatric wards were significantly less likely to have bedrails raised. CONCLUSIONS: Restraint use is relatively uncommon in Britain. Nevertheless, inappropriate use of bedrails is a reason for concern.

Development and results of a questionnaire to measure carer satisfaction after stroke.

STUDY OBJECTIVE: To develop a carer satisfaction questionnaire for use as an outcome measure in stroke, to test the measure for reliability and validity, and to survey levels of carer satisfaction with services for stroke patients. DESIGN: Postal survey of carer satisfaction with stroke services was carried out using the questionnaire we developed and tested. Internal consistency was tested and construct validation was explored by examining correlations with other outcome measures (the Faces Scale, the Nottingham Health Profile, the short form of the Geriatric Depression Scale, and the patient's Barthel Index score). SETTING: Two adjacent districts in North East Thames Regional Health Authority. PARTICIPANTS: A total of 103 carers were identified from 219 people who had survived a stroke to six months. During the pilot stage, six of seven carers who were invited to participate in in depth interviews and 15 of 23 carers (65%) who were invited to completed the first draft of the questionnaire. MAIN RESULTS: The questionnaire was divided into two sections, one on inpatient services (Carer Hospsat) and one on services after discharge (Carer Homesat). The questionnaire had construct validity, providing significant correlations with the Faces Scale (Carer Hospsat r = 0.59, p < 0.00001 and Carer Homesat r = 0.68, p < 0.00001), the patients' Barthel score (Carer Hospsat r = 0.25, p = 0.01), and the patients' Nottingham extended Activities of Daily Living (ADL) scale (Carer Hospsat r = 0.31, p = 0.002). Internal consistency was high for both sections (Cronbach's alpha: Carer Hospsat 0.87, Carer Homesat 0.79). Most carers (77%) were satisfied with the care their relative or friend received while in hospital, but only 39% were satisfied with services after discharge. CONCLUSIONS: Carer satisfaction is an important outcome measure in stroke research. This study has shown that carers are dissatisfied with services after hospital discharge. Our questionnaire is valid, reliable, and sensitive and could be used to test interventions aimed at improving services.

Stroke rehabilitation.

Based on the number of patients involved, stroke dominates the field of neurologic rehabilitation. The prevalence of stroke in the United States population is 1.4 million. This represents a prevalence for stroke of 612 per 100,000 population, compared with 157 for Parkinson's disease, 50 for spinal-cord injury, 42 for multiple sclerosis, and 16 for head-injured survivors with neurologic sequelae. This article provides an overview of stroke rehabilitation and covers patient management for the acute phase, subacute phase, and chronic phase poststroke. Medical and nursing care are discussed throughout and physical, occupational, and speech therapy for patients in these three phases are explored.

Coping, caring and stress: a study of stroke carers and carers of older confused people.

The dementias and strokes are chronic conditions often occurring at older ages. Most sufferers are cared for at home and, in this context, many research studies have described high levels of stress experienced by their carers. The present study, looking mainly at spouse carers of stroke victims (N = 36) or older confused people (N = 37), examined the possibility that the ways in which carers cope may be associated with their levels of stress and depression. A number of measures of behaviour disturbance and coping were developed and utilized. Multiple regression analyses supported the involvement of some aspects of coping in relation to carer stress and depression, particularly the coping strategy of Non-confronting and a Quality of Coping index--the former being positively and the latter negatively associated with stress and depression. Implications for intervention work with carers of stroke victims or carers of older confused people are discussed.

The willingness of families caring for victims of stroke to pay for in-home respite care--results of a pilot study in Taiwan.

This contingent survey was designed to investigate the willingness of family caregivers of stroke victims to pay for in-home respite care. Between September 1996 and December 1996, a designated family member from each family of 174 vascular accident patients hospitalized in the Taipei Metropolitan Area, including two medical centers, received the first interview during preparation and planning for discharge of the patient from the hospital, and follow up interview in their own homes at the end of the second month after the patient was discharged from the hospital. A willingness to pay for in-home respite care was measured as the percentage of monthly family income which would be sacrificed to receive the respite care. Logistic regressions were used to perform multivariate analysis. The willingness to pay for respite care ranged from US$ 363 to 2182, and 42.5% of the family caregivers interviewed indicated a willingness to pay at least 50% of monthly family income for respite care. Family income was strongly associated with the amount of money that family caregivers were willing to pay for respite care. After results were adjusted for the effect of variance in income level, the degree of dependence of patients on the caregiver was significantly associated with the percentage of monthly family income for respite care. The more severe the physical dysfunction of patient, the higher the willingness to pay for in-home respite care utilization. Initially, respite care could be provided to families caring for patients with severe dysfunction, and then the scope enlarged to include caregivers taking care of patients with mild dysfunction.

The validity of a nursing assessment and monitoring of signs and symptoms scale in ICU and non-ICU patients.

PURPOSE: This study examined the validity of medical-record-based nursing assessment and monitoring of signs and symptoms (nursing surveillance) in predicting patients who were admitted to ICUs and those admitted to non-ICUs. The association of this assessment and monitoring with differences in an intermediate patient outcome, instability at discharge, was also explored. Patients admitted to either setting with a diagnosis of acute myocardial infarction, cerebrovascular accident, congestive heart failure, or pneumonia, were included in the study. METHOD: A secondary analysis was carried out using a subset of data originally collected for a quality-of-care study. Data from the medical records of 11,246 patients (52% female, 48% male) with a mean age of 76.4 years were used in the present study. RESULTS: ICU patients (n = 3969) were found to have a longer length of stay and to be sicker on admission than non-ICU patients (n = 7277). Overall, patients in the ICU received significantly higher nursing assessment and monitoring of signs and symptoms scores than non-ICU patients. Nursing assessment and monitoring of signs and symptoms scores were lower for patients discharged with greater instability for three of the four diseases (cerebrovascular accidents, congestive heart failure, and pneumonia).

Therapeutic Intervention Scoring System used in the care of patients in pentobarbital-induced coma to determine nurse-patient ratios.

BACKGROUND: Critical care patients generally require extensive interventions, thereby consuming a large percentage of healthcare resources. Induced pentobarbital coma for the management of increased intracranial pressure is one such intervention, required to maintain patient stability. Quantification of these interventions, as well as the amount of nursing work required, has not been addressed in the literature. OBJECTIVE: To use the Therapeutic Intervention Scoring System to analyze and quantify how interventions affect nurse-patient ratios in the management of patients in pentobarbital coma for refractory increased intracranial pressure. METHODS: The medical records of patients with subarachnoid hemorrhage from aneurysmal rupture and subsequent increased intracranial pressure, in whom pentobarbital coma was salvage therapy, were reviewed retrospectively. The Therapeutic Intervention Scoring System was used to quantify the number of interventions required before, during, and after coma induction. The data were analyzed and daily Therapeutic Intervention Scoring System scores correlated with serum pentobarbital levels. Typically, a critical care nurse can manage a patient caseload of 40 to 50 Therapeutic Intervention Scoring System points. By quantifying the interventions, the score reflected the amount of care required to manage the patient in barbiturate coma. RESULTS: The intensity of interventions correlated with the level of coma, length of time in coma, and associated complications. CONCLUSIONS: The scores indicated the intensity of interventions used in pentobarbital coma and the use of resources. Nursing care and complications involved with this therapy were quantified and nurse-patient ratios were established.

[Home health care and the social supports for community-dwelling stroke patients].

The stroke survivors often suffer various degrees of disability and require some forms of assistance in their activities of daily living, and continuing care for the community-dwelling stroke survivors. This article includes three components to explain the needs of continuing care for the stroke survivors: the significance of continuing care for the stroke survivors, current problems of social support systems and future perspective on continuing care for the stroke survivors.

Breastfeeding in the woman with a compromised nervous system.

An increasing number of women with physical limitations are choosing to conceive and are entering the health care system for the care of their pregnancies. These women are faced with the choice of how to feed the child. Although research specific to lactation and nervous system disorders could not be found, this paper reviews selected articles from the literature on three central nervous system disorders: spinal cord injury, multiple sclerosis, and stroke. Potential effects on breastfeeding are discussed.

The role of nursing in the rehabilitation of acute stroke patients: toward a unified theoretical perspective.

A review of existing literature indicates an uncertainty about the specific therapeutic role of nurses in the rehabilitation of stroke patients. Two different conceptualizations of the nursing role exist, but neither is related to specific rehabilitation goals and patient outcomes. A beginning theoretical account of the specific role of nursing in stroke recovery is offered as a structure to integrate the therapeutic aspects of the coordinating, maintenance, and training functions of the nurse. Existing research literature is reviewed to substantiate the account. Further research is needed to develop the specific content and focus of nursing in stroke recovery.

Constructing the reality of recovery: family home care management strategies.

Development of home health care programs for family caregivers is predicated on an understanding of problems caregivers encounter and ways in which they manage those problems. This article describes home care management strategies of family caregivers of stroke survivors. Qualitative analysis of interviews with a purposive sample of family caregivers indicated that caregivers of stroke survivors practice situational vigilance for the stroke survivor, create solutions for problems associated with functional losses of a stroke, construct the reality of recovery for themselves and the stroke survivor, and seek to find personal meaning in the caregiving experience. Implications for practice and future research are proposed.

Peer visitor support for family caregivers of seniors with stroke.

The objectives of this nationally funded intervention study were to: (1) implement a home visiting support program for family caregivers of seniors with a recent stroke using experienced peers; (2) monitor, describe, and evaluate the support intervention process; and (3) measure the impact of the peer support intervention on caregivers' perceptions of their social support, burden, stress, and competence and the use of health-care services by stroke survivors. This paper focuses on the first two objectives. Twenty family caregivers were visited initially by a health professional (nurse, occupational therapist) for assessment, and thereafter twice weekly for 12 weeks by a peer (experienced family caregiver). Transcripts of audiotaped post-intervention and delayed post-intervention (3 and 6 months) interviews with participants and the diaries/logs of professionals and peers were subjected to content analysis. Peer visitors offered emotional, informational, and affirmational support to family caregivers. Family caregivers reported that the intervention met their support needs, lessened some of their caregiving demands, and enhanced their confidence and ability to cope.

A comparison of the mealtime care given to patients by nurses using two different meal delivery systems.

This study explored the mealtime care given to stroke patients and general patients on the medical wards of two hospitals which operated different meal delivery systems. Overall, nurses in Hospital 1 (in which the patients' food was plated by catering staff in the main hospital kitchen) tended to be less involved in mealtimes than those in Hospital 2 (in which the nurses plated the food on the wards). This was particularly so for the qualified staff and applied to many aspects of mealtime care including meal trolley supervision, the serving and delivery of food, checking patients' well-being, observing their feeding difficulties, providing assistance during mealtimes, and observing the contents of discarded dishes. These differences were not related to staffing levels or the prevalence of feeding problems. It is possible, therefore, that a meal delivery system designed to free nurses from the 'non-nursing' duty of serving food may have an adverse effect on their involvement in other aspects of mealtimes.

Implications for nurses in approaches to the management of stroke rehabilitation: a review of the literature.

There is as yet no general agreement on how best to manage stroke rehabilitation in terms of the approaches to the management of this client group. Approaches include the Stroke Rehabilitation Unit (SRU), applying the principles of SRU management to general medical wards and the use of peripatetic stroke therapy teams. Each of these approaches has implications for nurses yet the contribution of nurses to the rehabilitation of stroke patients receives only scant attention in the literature. It is suggested that understating and undervaluing nursing leads to under use of this essential resource.