Nonpharmacological Interventions for Caregivers of Stroke Survivors
Providing care may be associated with psychological morbidity in informal caregivers. Because stroke is the leading cause of adult disability, people who provide informal care to stroke survivors are a useful group for studying the effects of interventions. A number of nonpharmacological interventions directed toward caregivers have been studied. We aimed to describe health effects of these interventions in a stroke context using systematic review and meta-analysis.
Materials and Methods
We searched the Cochrane Stroke Group Trials Register (last searched March 2011), the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library Issue 4, 2010), MEDLINE (1950–August 2010), EMBASE (1980–December 2010), CINAHL (1982–August 2010), AMED (1985–August 2010), PsycINFO (1967–August 2010) Science Citation Index (1992 to August 2010), and 6 other electronic databases. In an effort to identify further published, unpublished, and ongoing studies, we searched conference proceedings and trials registers, scanned reference lists of relevant articles, and contacted researchers and authors in the field.
We included randomized controlled trials recruiting informal caregivers of stroke survivors, with no restriction on language of publication or date of publication. Because there is no agreed definition of an informal caregiver, we used the study authors' definition. We focused on trials of interventions in which intention was to impact on caregivers' knowledge, attitudes, and behavior, or to reduce care-giving demands, for example, through the provision of external support services. The primary outcomes were any measure of informal caregiver stress and strain (for example, Caregiver Strain Index) and caregiver well-being. Secondary outcomes included global measures of stress or distress, anxiety, depression, satisfaction, and mortality.
Data Collection and Analysis
Two authors independently reviewed potential trials, selected trials for inclusion, extracted data, and assessed trial quality.
We included 8 trials (recruiting 1007 participants). Because the interventions were heterogeneous, we used a post hoc classification under 3 broad headings: support and information; vocational training; and psycho-educational interventions. Statistical and methodological heterogeneity precluded pooling results from all included studies.
For the primary outcome of stress and strain, there was no evidence of benefit for support and information or psycho-educational interventions. A single-center study (n=155) suggested that vocational training-type interventions may reduce stress and strain (mean difference, −8.67; 95% CI, −11.30 to −6.04; Figure). No benefit was seen across the secondary outcome measures of anxiety, depression, and health-related quality of life for support and information interventions or psycho-educational interventions.
Implications for Clinical Practice
Although many nonpharmacological interventions for stroke caregivers are intuitively attractive, there is currently insufficient evidence to support their use. However, the number of trials included in our analysis was modest, and there was substantial heterogeneity. Further trials are required. A focus on vocational training-type interventions seems justified because the limited evidence suggests potential for benefit.
Implications for Research
Our analysis highlights the opportunities for improvement in caregiver-related research. In particular, no study provided a clear or precise operational definition of the informal caregiver group. For consistency and to allow meaningful comparisons, we urge that future studies provide the operation definition of caregiver used for inclusion. These analyses of caregiver interventions are based on the assumption that care-giving has a direct causal relationship with adverse health states. This assumption may not be valid and further work exploring relationship between care-giving and outcomes is required.
This review1 is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2011, Issue 10. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review.
Sources of Funding
This work was supported by the Chief Scientist Office Scotland (grant CZF/1/39 to L.L.).
- Received November 14, 2011.
- Accepted November 21, 2011.
- © 2012 American Heart Association, Inc.