Stress perceived by caregivers due to the home care situation
Caregiver burden is the stress which is perceived by caregivers due to the home care situation. The subjective burden is considered to be one of the most important predictors of negative outcomes from the home care situation.
Definition.
The concept of caregiver burden was introduced in the 1960s, distinguishing between objective and subjective aspects of caregiving. Objective burden arises from specific caregiving tasks, while subjective burden typically stems from the emotional strain caused by the excessive demands and potential embarrassment associated with caring for recipients. Various other terms, such as "caregiver role fatigue", "spousal burnout", and "role engulfment", are also used to describe this phenomenon. Despite the variation in terminology, these terms consistently depict a situation where caregivers lack sufficient physical and mental resources to meet the needs of the care recipient. This burden is not solely related to the actual duties imposed by care recipients but is shaped by the emotional context of the caregiving situation and the availability of resources.
Theory.
From a scientific perspective, caregiver burden is a theoretical construct. The conceptual basis for the appraisal of the care situation is the Transactional Model of Lazarus and Folkman.
The subjective evaluation of the care situation (stressor) by the caregivers is critical for the development and maintenance of subjective burden.
According to the Transactional Model, people deal with stressful situations by appraisals of stressor and resources. The primary appraisal deals with the individual meaning of the specific stressor, which is the care situation in this case. The secondary appraisal analyzes the own abilities and resources to cope with that situation. On this basis, the individual coping efforts are used to deal with the stressful situation. As per Carver, these efforts can focus on problem management or emotional regulation. Dysfunctional strategies are possible, too. Studies found that a high caregiver burden often comes along with dysfunctional strategies what means activities which don’t solve the problem but worsen it (e.g. self-criticism, substance abuse).
The (dis)balance between burden/vulnerabilities and resources of the caregiver determines the consequences of a care situation. Home care can result in positive as well as negative experiences.
Regardless of the caregiver burden, relatives can experience benefits - positive consequences - of the home care situation. This may be the feeling of being needed or the knowledge that they have acquired new skills etc.
Causes.
Caregiver burden comes out when the caregiver perceives the home care situation as a negative experience. Caregivers are typically not trained. Caring is a serious challenge for them. An intensive adaptation to the care situation is necessary.
The caregiver burden can be based on a variety of aspects of the care situation (e.g. lack of recovery time, challenging behavior of the care requiring person, limitation of social activities and contacts). Studies showed that four aspects are particularly burdensome:
Measuring.
The assessment of caregiver burden enables to judge the situation of the caregiver. The correct measurement of subjective burden is necessary to draw conclusions about the effectiveness of family interventions.The care situation is an important, highly specific stressor which should be treated with specific interventions. A measurement with general stress-scales is therefore not useful, because in this case the score represents all kind of stress, indiscriminately of its origin. Valid, economic and internationally standardized measurement tools for the specific stressful situation of family caregivers are therefore inevitable.
A number of burden scales have been developed, which includes the Zarit Burden Interview, the Caregiver Strain Index and the Cost of Care Index, Burden Scale for Family Caregivers, Caregivers' Daily Issues.
Impact.
Negative outcomes are often not determined by the specifics of the caregiving situation itself, but by the reaction and response of the caregiver. The term “caregiver burden” refers to the high level of stress that some caregivers may feel in response to the situation. A study that investigated a variety of factors and their association with caregiver burden in Amyotrophic Lateral Sclerosis (ALS), found that it was more subjective factors (i.e. the caregiver’s quality of life and psychological distress), rather than objective ones (such as the caring situation or the condition of the patient) that were associated to burden. Because the caregiver burden may be felt strongly by one person and not at all by another, regardless of the caregiving situation, it is considered to be subjective and it may be called the “subjective burden”. The subjective burden is considered to be one of the most important predictors of negative outcomes from the home care situation.
Impact on health.
Pinquart and Sörensen (2003) researched the health of caregivers compared to the health of non-caregiving relatives. The researchers found that while caregivers are generally only slightly less physically healthy than non-caregiving relatives, they reported depressive symptoms significantly more often, pointing to a negative effect on their mental health.This meta-analysis did not consider the impact of subjective burden. In addition, a recent published paper showed a high frequency of depression and anxiety levels in caregivers of adult people with epilepsy. In another extensive meta-analysis Pinquart and Sörensen could show that the subjective burden is an important predictor of the health of carers.
Risk of mortality.
Studies found an increased mortality of caregiving spouses. This effect was only found for spouses who felt burdened due to the care situation. Thus, it is not the home care per se that is a risk but the subjective burden.
Without consideration of the caregiver burden, the mortality of caregivers is even slightly reduced compared to non-caregivers.
Caring style.
People who experience caregiver burden can display a wide range of behaviors towards the person in need of care, from loving devotion to abusive behavior (which can manifest as neglect and/or mistreatment). The most common form of abusive behavior is verbal aggression, mainly due to challenging behaviour of the person in need of care. Researchers found that people experiencing caregiver burden are more likely to display abusive behavior and other negative caring styles toward the individuals they care for than those who are not experiencing caregiver burden. 
Ending home care.
The caregiver burden often influences the caregiver's decision to eventually institutionalize (or, "put someone in a nursing home"). Caregiver burden is particularly associated with the care of people with dementia, meaning that the likelihood of institutionalization is especially heightened in those experiencing caregiver burden who care for people suffering from dementia. In the care of people with dementia, there is consistent evidence: The higher the caregiver burden, the more likely is the institutionalization.
Interventions.
Due to the high importance of the caregiver burden with regard to the care giving process, it is necessary to develop interventions to reduce this burden and to examine their effectiveness. Successful interventions should be available to as many caregivers as possible. "The usefulness of an intervention is the multiplication of effectiveness and usage." (Elmar Gräßel) It is therefore necessary both to develop interventions and to improve and to find ways to strengthen the awareness and use of these interventions.
Interventions and services.
Unburdening interventions for caregivers should consider four central aspects:
There are different supporting services, e.g. caregiver counselling, professional training, self-help groups, ambulant nursing services or technical help like intelligent light to preserve the autonomy of the person in need of care.
Among the technical tools available to caregivers are mobile applications. Caregivers can use these applications to track the health status of care recipients, educate themselves about caregiving, and exchange experiences with other caregivers. Currently, these apps mainly focus on services directly related to caregiving, such as providing information on caregiving, offering consultations, supporting the care receiver socially, and delivering training on caregiving. There is potential for these apps to further incorporate features that focus on the caregiver's personal health, social connections, sharing experiences, and financial security.
Another effective relief is the support given to caregivers by family members, friends and acquaintances. They provide emotional and instrumental support and are an important source to access supporting services.
A 2021 Cochrane review found that remotely delivered interventions including support, training and information may reduce the burden for the informal caregiver and improve their depressive symptoms. However, there is no certain evidence that they improve health-related quality of life. The findings are based on moderate certainty evidence from 26 studies.
References.
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