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Stress in medicine: Strategies for caregivers, patients, clinicians—The burdens of caregiver stress

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The number of people in the United States who spend a significant part of each week working as unpaid caregivers is considerable, and the toll exacted for such work is high. Understanding the profi le of the caregiver, the nature of the duties performed, the stress imposed by such duties, and the consequences of the stress can assist the clinician in recognizing the caregiver in need of intervention.

A PROFILE OF THE CAREGIVER

A recent survey estimated that more than 65 million Americans provide unpaid assistance annually to older adults with disabilities.1 The value of that labor has been estimated at $306 billion annually, or nearly double the combined cost of home health care and nursing home care.2,3

The typical caregiver is a woman, about 48 years old, with some college education, who spends 20 hours or more each week providing unpaid care to someone aged 50 years or older.1 The recipients of care often have long-term physical disabilities; mental confusion or emotional problems frequently complicate care.

Figure. Percentage of caregivers who assist with instrumental activities of daily living (IADL).1

Caregivers help patients with instrumental activities of daily living (IADL), in addition to helping with tasks such as getting dressed and bathing. IADL might include assisting with transportation, housework, grocery shopping, preparing meals, managing fi nances, giving medications, and arranging for paid services such as nursing care (Figure).1

PSYCHOLOGIC AND PHYSICAL COSTS

Caregiving may take a toll on the caregiver in a variety of ways: behavioral, in the form of alcohol or substance use4; psychologic, in the form of depression or other mental health problems5; and physical, in the form of chronic health conditions and impaired immune response.6 About three-fifths of caregivers report fair or poor health, compared with one-third of noncaregivers, and caregivers have approximately twice as many chronic conditions, such as heart disease, cancer, arthritis, and diabetes, compared with noncaregivers.2,7 Caregiving also exacts a financial toll, as employees who are caregivers cost their employers $13.4 billion more per year in health care expenditures.8 In addition, absenteeism, workday interruptions, and shifts from full-time to part-time work by caregivers cost businesses between $17.1 and $33.6 billion per year.9

The cost of caregiving is higher for women, who exhibit higher levels of anxiety and depression and lower levels of subjective well-being, life satisfaction, and physical health.10,11 The stress of caregiving has also been identified as a risk factor for morbidity among older (66 to 96 years old) caregivers, who have a 63% greater mortality than noncaregivers of the same age.12

PSYCHOSOCIAL STRESS, UNHEALTHY BEHAVIORS, AND ILLNESS ARE LINKED

Psychosocial stress is a predictor of disease and can lead to unhealthy behaviors such as smoking, substance abuse, overeating, poor nutrition, and a sedentary lifestyle; these, in turn, can lead to physical and psychiatric illness. Behaviors adopted initially as coping skills may persist to become chronic, thereby promoting either continued wellness (in the case of healthy coping behaviors) or worsening levels of illness (in the case of unhealthy coping behaviors).

McEwen and Gianaros13 have suggested that these stress mechanisms arise from patterns of communication between the brain and the autonomic, cardiovascular, and immune systems, which mutually influenceone another. These so-called bidirectional stress processes affect cognition, experience, and behavior.

An integrated model of stress that maps the bidirectional causal pathways among psychosocial stressors, resulting unhealthy behaviors, and illness is needed. Although the steps from unhealthy behaviors to illness are fairly well understood, the links from psychosocial stress, such as those exhibited by caregivers, to unhealthy behaviors are not as clear. Several mediators are under study:

  • Personality mediators can be either ameliorative (resilience, self-confi dence, self-control, optimism, high self-esteem, a sense of mastery, and finding meaning in life) or exacerbating (neuroticism and inhibition, which together form the so-called type D personality).
  • Environmental mediators include social support, financial support, a history of a significant life change, and trauma early in life, which may increase one’s subsequent vulnerability to unhealthy behaviors.
  • Biologic mediators may include prolonged sympathetic activation and enhanced platelet activation, caused by increased levels of depression and anxiety in chronically stressed caregivers.14

IMPLICATIONS FOR INTERVENTION

A significant percentage of caregivers do not need a clinician’s intervention to help them cope with stress or unhealthy coping skills. Among caregivers aged 50 years or older, 47% indicated in a recent study that the burden of caregiving is low (ie, 1 or 2 on a 5-point scale).1 Those who respond to stressors as challenges rather than threats tend to be resilient people who exert control over their lives, often through meditation or similar techniques, and have a strong social support network. Many report that caregiving provides them with an opportunity to act in accordance with their values and feel helpful rather than helpless.

Cognitive-behavioral interventions to alleviate stress-related symptoms appear to be more effective if offered as individual rather than group therapy. Teaching caregivers effective coping strategies, rather than merely providing social support, has been shown to improve caregiver psychologic health.15 Chief among the goals of intervention should be to alter brain function and instill optimism, a sense of control and self-esteem.13

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