Thanks to generous funding from the Health
Research Board, we at UCC Dept. Psychiatry & Neurobehavioural Science and the APC
Microbiome Institute were able to host an international research seminar. This
was a chance for some leading researchers in the areas of caregiving stress to
discuss their research and ideas.
Shireen Sindi of the Karolinska Institute
in Sweden set the scene for our discussion of stress. She touched on classic
work from the late sixties by Mason, highlighting key factors for producing a
stress response, such as a stressor's unpredictability, its unfamiliarity and a
person’s sense of control (or lack thereof). This work has since been borne out
in a large review by Dickerson & Kemeny, who found that release of cortisol
tended to be most clearly associated with such aspects of stress.
Dr Sindi made the interesting point that
people may often lack insight into their own chronic stress levels, particularly in the case of physiological
stress. This raises the question of whether self-report and physiological
measures may show less concordance when tapping into more long-term stress.
Speaking of long-term stress, she pointed out evidence that chronic stress in
childhood may lead to very difficult-to-reverse changes in the amygdala (a
region of the brain associated with processing emotion such as fear).
Brent Mausbach from the University of California
at San Diego opened by highlighting a classic finding from Schulz and
colleagues, indicating that caregivers were at increased risk for mortality at
follow-up, specifically those with high levels of caregiver strain. He then
discussed some of his own findings, looking at caregivers and whether they had
depression and/or distress with challenging behaviours in the patient, with cardiovascular
disease (CVD) as the outcome. Those who suffered from both depression and high
distress in their caring role had an increased risk for CVD-a rather startling result.
Professor Mausbach went on to discuss some
really interesting results from his group following caregivers over time in
terms of measures of inflammation and clotting; interleukin-6 and D-dimer were
higher in dementia caregivers compared to controls, and also increased at a
sharper rate. These biological markers are associated with heightened risk of
CVD, so these findings neatly suggest a biological mechanism as to how psychosocial stress can lead to negative health effects over time.
It wasn’t all bad news; he also highlighted
promising preliminary data on treatment. The team at San Diego used behavioural
activation (getting people to engage more in activities they enjoyed) as a way
to treat depression in caregivers, thereby treating CVD risk. This behavioural
activation approach, which allowed carers to develop their own tailored intervention, led to
greater improvement than a typical intervention (education and support).
Kathryn Lord brought things back to basics, challenging assumptions underlying work in the area of caregiver stress, particularly the concept of “challenging behaviour”. Lord suggested
that the classification of a given behaviour as challenging risks ignoring the perspective
of the patient, who may act as they have genuine grievances with how they are
being cared for. Dr Lord posited that a person-centred approach to care should
inquire into the meaning of a patient’s behaviour, and whether they are trying to
communicate something about their environment.
Dr Lord also warned of being too ready to
attribute any behaviour that causes others difficulty to dementia. Patients
with dementia can have pre-existing issues with others that can pre-date the
dementia that can nonetheless be missed by care workers (or indeed family
caregivers).
Like Brent Mausbach, Dr Lord had some very nice
intervention data from a randomised clinical trial for family carers using the
START program. This program was developed by the Livingston team at UCL in the
US, and Dr Lord’s team adapted this program for a UK population. Although it
only lasted 8 weeks, START reduced the risk of depression at follow-up years
later in the carers who completed it. It was also cost-effective; interestingly
carer’s health costs actually went up in START group (perhaps due to increased
health-seeking behaviour), but the patients’ health costs went down by more
than the increase seen in the carers.
Noted intellectual-about-town Andrew P.
Allen wrapped things up, highlighting similar themes in
his own research that chimed with previous speakers, including immune data suggesting increased inflammatory cytokines in carers compared to controls, as well as a positive impact of psychosocial
interventions for carers (with cognitive performance as the outcome). He also
tied this area in with the brain-gut axis, mentioning evidence of altered
microbiota in major depression, evidence from France of increased prevalence of
IBS in carers as well as the potential for probiotic supplementation to
attenuate stress.
Related posts:
HRB seminar on carer stress
He ain't heavy, he's my carer
