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Clinician Article

Evidence for stroke family caregiver and dyad interventions: a statement for healthcare professionals from the American Heart Association and American Stroke Association.



  • Bakas T
  • Clark PC
  • Kelly-Hayes M
  • King RB
  • Lutz BJ
  • Miller EL
Stroke. 2014 Sep;45(9):2836-52. doi: 10.1161/STR.0000000000000033. Epub 2014 Jul 17. (Review)
PMID: 25034718
Read abstract Read evidence summary Read full text
Disciplines
  • Physical Medicine and Rehabilitation
    Relevance - 7/7
    Newsworthiness - 6/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 5/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 5/7
  • Neurology
    Relevance - 5/7
    Newsworthiness - 5/7
  • Hospital Doctor/Hospitalists
    Relevance - 4/7
    Newsworthiness - 3/7
  • Internal Medicine
    Relevance - 4/7
    Newsworthiness - 3/7

Abstract

Stroke is a leading cause of severe, long-term disability. Most stroke survivors are cared for in the home by a family caregiver. Caregiver stress is a leading cause of stroke survivor institutionalization, which results in significant costs to the healthcare system. Stroke family caregiver and dyad intervention studies have reported a variety of outcomes. A critical analysis of 17 caregiver intervention studies and 15 caregiver/stroke survivor dyad intervention studies was conducted to provide evidence-based recommendations for the implementation and future design of stroke family caregiver and dyad interventions.


Clinical Comments

Family Medicine (FM)/General Practice (GP)

The Abstract is far from helpful and the text seems a bit "woolly"; however, there are take home messages if you delve. Notably, interventions aimed at the caregiver exclusively rather than patient and caregiver seem to perform better for caregiver outcomes; exclusively psychological interventions are less good than more holistic support incorporating skills development and problem-solving. As rightly said, the economic benefits by reducing institutionalisation costs are potentially great so this is an area to continue work to clarify the cost effectiveness of different interventions, apart from the ethical imperative to ease distress and foster well-being.

General Internal Medicine-Primary Care(US)

As a busy PCP, I find these results interesting but they do not change my practice. It's standard of care in my community to engage patient care givers with options. The challenge is finding payor benefits.

Internal Medicine

The paper´s idea is really good, but the elaboration wasn't the best.... one problem with using the p value as a cut-off point is the pitfalls of the “p value” can mislead the interpretation; there are others approaches that they could have done to evaluate the treatments (Minimal Clinically important difference, etc). They could have used other approaches to create and evaluate the quality of evidence (GRADE). The tool that they have used is not the best in explain the quality of the evidence. The authors of the article reflected on the high heterogeneity of the studies, and the difficulty of create a good judgments and recommendations, but they restricted the evidence to only one language (English). In the methods, they didn't clarify if they will try to perform a statistical summaries of the studies. The search strategy does not explain if they used Mesh terms or boolean. The conclusion of papers seems to be the discussion of the results.

Neurology

The paper is a "dog's breakfast" of information, and difficult to digest. Studies are variable in design and power and the populations are heterogeneous, making research of stroke outcomes difficult. However, there are some useful points to be gleaned, e.g., individualized programs are preferable and skill-building interventions are superior to psychological rehab. Clearly more work is needed, but some lessons have been learned.

Physical Medicine and Rehabilitation

This is a thorough systematic attempt to provide recommendations on an important topic, supporting carers of people with stroke. Unfortunately it is not necessarily useful to clinicians. First, it is out-of-date. The search ended Oct 2012 but it was published in July 2014, 21 months later. Second, and consequently, it does not mention the large (n = 928) study that replicated the study that this review uses. The replication study showed no benefit from the intervention. Third, the article is detailed but not easily read. It is difficult to extract simple important messages. There is no abstract or summary. It may help researchers, but it will not help clinicians.

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