Psychological difficulties of LVAD patients and caregivers: A follow up over one year from discharge.

BACKGROUND: After the rehabilitation program, patients with left ventricular assist device (LVAD) are discharged home, but the adaption to the daily life with the implant is challenging, both with practical and psychological consequences. Literature is lacking detailed information about the quality of life of LVAD patients and caregivers after discharge to home. OBJECTIVE: This study aimed at evaluating the post-discharge outcomes of both LVAD patients and their caregivers in terms of quality of life, affectivity, and psychological health. METHODS: In this observational follow-up study, LVAD dyads discharged home from 1 year to 6 years were re-contacted by phone and received by mail an envelope with self-report questionnaires. Responses of 39 complete dyads of patients (mean age 68.59 ± 4.31; males: 92.31%) and their caregivers (mean age 61.59 ± 11.64; males: 17.95%) were analyzed. RESULTS: Patients and caregivers reported the moderate levels of anxiety, depression, and caregiver strain, and Illness denial and conscious avoidance were associated between them. The couples often reported that the LVAD has impairments for their sleep and for their affective-sexual relationship. Caregivers often reported impairment in social life and self-care. DISCUSSIONS: Despite the satisfaction for the medical and territorial assistance, patients showed psychological difficulties such as anxious and depressive symptoms and caregivers tend to neglect themselves. Even after a long time from discharge to home, the psychological distress of LVAD patients and caregivers is still considerable. Structured and continuous psychological interventions are required to support their psychological health overtime after the discharge to home.

Psychological Differences Among Healthcare Workers of a Rehabilitation Institute During the COVID-19 Pandemic: A Two-Step Study.

Introduction: Healthcare workers facing the threatening COVID-19 can experience severe difficulties. Despite the need to evaluate both the psychological distress and positive protective resources, brief and reliable assessment tools are lacking. Aim: Study 1 aimed at developing a new assessment tool to measure psychological distress and esteem in healthcare workers during the COVID-19 pandemic. Study 2 aimed to explore and compare the psychological reactions of healthcare workers of the COVID-19 and the non-COVID-19 wards. Methods: In Study 1, psychologists created 25 items based on their clinical experience. A preliminary qualitative evaluation selected the best 15 items for the new tool (CPI-HP) assessing the COVID-19 psychological impact with 2 scales: psychological distress and esteem. The CPI-HP was administered to 110 healthcare professionals to study its psychometric properties and the internal structure with exploratory graph analysis and confirmatory factor analysis. Study 2 compared two groups of healthcare professionals of the COVID-19 and non-COVID-19 departments. Results: In Study 1, the CPI-HP showed satisfying psychometric properties, and the two-factor structure was confirmed with good fit indices. In Study 2, the two groups of healthcare workers showed comparable levels of psychological distress and resilient coping, but the COVID-19 group displayed significantly higher esteem and appreciation of the experience. Discussion: All operators showed high psychological distress during the emergency, but the COVID-19 group reported higher resources, probably due to stronger group cohesion and greater esteem, perceived meaning, and own work value. Conclusion: Assessing the psychological distress and resources of healthcare professionals with specific tools is important. Psychological interventions should promote their psychological health.

The Psychological Experience and Intervention in Post-Acute COVID-19 Inpatients.

PURPOSE: COVID-19 patients faced first-hand the life-threatening consequences of the disease, oftentimes involving prolonged hospitalization in isolation from family and friends. This study aimed at describing the psychological intervention to address the psychological difficulties and issues encountered by the hospitalized post-acute COVID-19 patients in a rehabilitation setting. PATIENTS AND METHODS: Patients' demographics, medical diagnosis, and neuro-psychological information were collected from March 2nd to May 12th, 2020. The main psychological issues and intervention strategies were collected. RESULTS: A total of 181 patients were hospitalized during this period. Among them, the 47.5% underwent psychological assessment (N=86; age: 74.58±13.39; 54.7% females). The most common psychological issues were acute stress disorders (18.6%), anxious and demoralization symptoms (26.7%), depression (10.5%%), and troublesome grief (8.1%). Once recovered from COVID-19, many patients were discharged home (38.4%), some received further rehabilitation in non-COVID-19 wards (41.9%), mostly due to pre-existent diseases (72.2%) rather than to COVID-19 complications (27.8%). CONCLUSION: A great number of the hospitalized post-acute COVID-19 patients showed psychological issues requiring psychological intervention, the most common were anxiety, demoralization, acute stress, depression, and grief. The proposed psychological treatment for hospitalized COVID-19 patients was conducted in a Cognitive Behavioral framework. In particular, during the COVID-19 pandemic, psychological intervention is an important part of rehabilitation in the post-acute phase of the illness to reduce distress symptoms and improve psychological health.

Gender differences and long-term outcome of over 75 elderlies in cardiac rehabilitation: highlighting the role of psychological and physical factors through a secondary analysis of a cohort study.

BACKGROUND: Despite cardiac rehabilitation for elder people already showed its usefulness, to date it is still not clear the impact of gender and of psychological constructs in influencing the rehabilitation outcomes. AIM: This study aimed at exploring the gender differences of great elders (over 75 years old) in cardiac rehabilitation, with particular attention to the impact of physical and psychological conditions, as depressive symptoms, on long-term post-discharge outcomes. DESIGN: A cohort study design was used and a secondary analysis was conducted. SETTING: Cardiac rehabilitation unit of a postacute rehabilitation Institute. POPULATION: Elderly patients over 75 years old admitted to the cardiac rehabilitation program. METHODS: Psychological and functional variables, such as Barthel Index, BMI, quality of life, and depression measured at admission and discharge from CR were matched with mortality information up to 4 years, used as long-term outcomes. RESULTS: A total of 523 patients, 228 females and 295 males, with a mean age of 76.27 years±3.46 were progressively enrolled. Barthel index at admission and discharge was higher for males than females, 74.10±17.31 vs. 68.90 SD±16.81 (P<0.001), and 95.45±10.64 vs. 92.95±13.03 (p=0.021), respectively, while the relative change from admission to discharge Δ% of Barthel was higher for females 0.25±0.18 than for males 0.21±0.17 (P<0.05). Compared to males, either at admission or discharge females presented more severe depressive symptoms (5.21±3.46 vs. 3.86±2.79, P<0.001; 4.15±3.21 vs. 2.93±2.45, P<0.001) and a worse quality of life (10.58±2.15 vs. 9.55±2.24, P<0.001; 7.5±1.63 vs. 7.02±1.08, P=0.018). Cox proportional analysis revealed that female gender, depression at discharge, Barthel, and Comorbidity Index were associated with higher hazard and shorter survival time. On the other hand, higher BMI was associated with lower hazard and longer survival time. CONCLUSIONS: Elderly women following a CR program present more disability, depression, and a worse QoL than men. Obviously, these characteristics influence the length of hospitalization but with significant improvement. Despite the frail-gender paradox regarding survival, after CR program women have a higher risk of mortality than men. Depression has a significant negative impact on elderly psychophysical health. CLINICAL REHABILITATION IMPACT: Gender-specific and individualized rehabilitation programs should be implemented by considering the discussed physical and psychological risk factors. Further insight about gender differences among over 75 elderlies in CR is provided, this knowledge may be useful for clinicians scheduling recovery plans to promote elderlies' psychological and physical health. Psychological interventions should be implemented to relieve the depressive symptoms among elders.

Psychophysical health of elderly inpatients in cardiac rehabilitation: a retrospective cohort study.

BACKGROUND: Elderlies in cardiac rehabilitation show a particular frailty due to specific aging issues, thus specific professional psychophysical care is required. AIM: This study aimed at evaluating the effect of a cardiac rehabilitation program enhanced with psychological support on the psychophysical health of elderly subjects aged ≥75. Moreover, the association of psychophysical conditions with the long-term post-discharge course of medical events was examined. DESIGN: This retrospective cohort study was conducted on elderly patients aged ≥75 admitted from 2015 to 2019 to a cardiac rehabilitation program including psychological support. SETTING: The cardiac ward and the psychology unit of a post-acute clinical rehabilitation Institute. POPULATION: A total of 523 elderly inpatients (44% females), aged ≥75 years (mean 79.7±3.46 years), admitted to a cardiac rehabilitation ward due to heart disease. METHODS: Psychological and functional variables such as depression, quality of life, and Barthel Index were measured at hospitalization and at discharge. The medical events after discharge such as emergency department accesses and rehospitalizations were registered. RESULTS: Cardiac rehabilitation showed significant improvements both in elderlies' psychological and physical health. Higher depression levels predicted a worse post-discharge course. Patients who received psychological intervention accessed emergency department and were re-hospitalized significantly later than the others. CONCLUSIONS: Cardiac comprehensive rehabilitation can significantly improve the psycho-physical health of elderly subjects aged ≥75 who benefit of psychological support. Psychological support can enhance the psychophysical health of great elder inpatients in cardiac rehabilitation. CLINICAL REHABILITATION IMPACT: Given the associations with short and long-term outcomes, health professionals should take care of the psychological conditions of elderlies (e.g., depression) by integrating psychological interventions in cardiac rehabilitation in order to promote the elderlies' psychophysical conditions, quality of life, as well as more favorable medical outcomes.

Exploring illness denial of LVAD patients in cardiac rehabilitation and their caregivers: A preliminary study.

Implantable left ventricular assist devices (LVADs) are increasingly used for patients with heart failure. Despite this evidence, the psychological processes affecting implanted patients and their caregivers are only marginally studied. While common emotional reactions, such as anxiety and depression already receive attention, very little is known about the course of caregiver strain, illness denial, and their reciprocal relation. This preliminary study aims at exploring these critical topics in a cardiac rehabilitation setting, besides offering indications for future research. A total of 44 LVAD patients and caregivers were administered specific questionnaires at admission and discharge from cardiac rehabilitation. Overall, questionnaires completed at discharge showed a positive improvement in the emotional measures used. However, they also showed a worsening in the illness denial measure. We suggest that the denial process may prepare patients and caregivers in returning home. Moreover, we conclude that studying only the common emotional reactions may limit the understanding of the psychological process adaptation to severe illness.

Development and psychometric properties of a short form of the Illness Denial Questionnaire.

BACKGROUND: Coping with chronic illness can be overwhelming for patients and caregivers, and may be inhibited by the denial mechanism, and therefore, denial represents a critical issue for health professionals. Assessing illness denial is far from easy, and brief tools suitable for medical settings are lacking. In this paper, the development of a short form of the Illness Denial Questionnaire (IDQ) for patients and caregivers is presented. METHODS: In study 1, the IDQ was administered to 118 patients and 83 caregivers to examine the internal structure of denial; then the properties of the items (DIF, fit, and difficulty) were evaluated according to the Rasch model in order to select the best items for the Illness Denial Questionnaire-Short Form (IDQ-SF). Study 2 included 202 participants (113 patients and 89 caregivers). The internal structure of the IDQ-SF was tested via confirmatory factor analysis (CFA). Reliability and concurrent validity were also studied using the Anxiety and Depression Questionnaire-Reduced Form (AD-R). RESULTS: The CFA showed a two-factor structure encompassing "Denial of negative emotions" and "Resistance to change". Results of the Rasch analyses led to the selection of 4 items for each dimension. The resulting IDQ-SF (8 items) showed a two-factor structure as well as good reliability and concurrent validity with AD-R. CONCLUSION: The IDQ-SF represents a valid tool for quickly evaluating the core of illness denial in patients and caregivers. This brief and easily administrable questionnaire allows health professionals to outline the presence and severity of illness denial in order to set individually tailored interventions.

Interventions for Psychological Health of Stroke Caregivers: A Systematic Review.

Background: The increasing number of stroke patients (SPs) requires informal caregivers to bear a high burden of responsibilities and heavy (di)stress. Moreover, these issues could lead to the development of serious psychological problems (e.g., depressive and/or anxious) that in turn could give rise to poor health-related quality of life outcomes. However, although the value of psychological interventions has been widely recognized for SPs, the scientific literature lacks an updated synthesis of interventions addressing the psychological health of their caregivers. Aim: The aim of this review is to summarize the interventions for the psychological health of stroke caregivers and provide a resume of literature-based evidence of their efficacy. Method: A literature review from 2005 to date was conducted in three online databases: PubMed, Scopus, and Google Scholar. Eligibility criteria for studies were (A) English language, (B) caregivers and patients aged 18 years or above, (C) SP's caregiver beneficiating of a specific intervention, and (D) outcome measures addressing depressive and/or anxiety symptomology, quality of life, well-being, or burden. Results: Across the selected 45 studies, substantial differences are observable in three main categories: (a) type of intervention (b) techniques, and (c) operators. Interventions' advantages and results are discussed. Overall, studies using psychological techniques, such as cognitive-behavioral therapy, coping skill-training, and problem-solving therapy, showed their usefulness and efficacy in reducing the caregivers' depressive and anxious symptoms, and burden. Interventions led by psychologists and tailored to meet caregivers' specific needs showed more positive outcomes. Conclusion: This review underlines the usefulness of psychological interventions aimed at reducing the psychological burden, such as anxious and depressive symptomatology, of SPs' informal caregivers. Hence, psychological interventions for caregivers should be integrated as part of the stroke rehabilitation process to improve informal caregivers' and patients' quality of life and well-being.

Does a Comprehensive Inpatient Rehabilitation Program Improve Patients' and Caregivers' Emotional State in LVAD Patients?

Few studies evaluated the effect of cardiac rehabilitation programs on perceived emotional and health status of left ventricular assist device (LVAD) patients, and none explored their effect on caregivers' strain. We enrolled 119 adult LVAD patients, together with their caregivers (n = 91), in two Rehabilitation Institutes that provided inpatient multidisciplinary activities. At admittance and prior to discharge they completed questionnaires evaluating patient emotional state and subjective perception of health status, caregiver strain, and patient and caregiver perception of the VAD. Six months after discharge, patients and caregivers were contacted again and asked specific questions about their quality of life. Patients' state anxiety and depression symptoms significantly diminished at discharge (0.000), whereas their perception of general health status rose (0.000). Caregivers' perceived strain also significantly decreased (0.001) and the perceived device management skill grew both for patients and caregivers (0.000). A substantial amount (36%) of psychologically frail patients and caregivers, although improving their emotional condition, never reached that of the less frail subjects. At the 6-month follow-up, both patients and caregivers appeared stable in evaluating respectively their general health and their caregiving-related strain, compared to discharge. Our data show that a comprehensive inpatient rehabilitation program improves the emotional state of LVAD patients and of their caregivers, even in psychologically frailer subjects. Team approach makes patients and caregivers self-confident about device management, increasing their knowledge, clarifying their doubts, and encouraging them to handle the difficulties met during the rehabilitation period, suggesting strategies to cope with daily life at home.

Illness denial questionnaire for patients and caregivers.

PURPOSE: Interest in assessing denial is still present, despite the criticisms concerning its definition and measurement. We tried to develop a questionnaire (Illness Denial Questionnaire, IDQ) assessing patients' and caregivers' denial in relation to their illness/disturbance. PATIENTS AND METHODS: After a preliminary study, a final version of 24 dichotomous items (true/false) was selected. We hypothesized a theoretical model with three dimensions: denial of negative emotions, resistance to change, and conscious avoidance, the first two composing the actual Denial and the last representing an independent component of the illness denial behavior. The IDQ was administered to 400 subjects (219 patients and 181 caregivers) together with the Anxiety-Depression Questionnaire - Reduced form (AD-R), in order to assess concurrent validity. Confirmatory factor analysis (CFA), internal consistency indices (Cronbach's α and McDonald's ω), and test-retest analysis were performed. RESULTS: CFA and internal consistency indices (Cronbach's α: 0.87-0.96) indicated a clear and meaningful three-factor structure of IDQ, for both patients and caregivers. Further analyses showed good concurrent validity, with Denial and its subscale negatively associated with anxiety and depression and avoidance positively associated with anxiety and depression. The IDQ also showed a good stability (r from 0.71 to 0.87). CONCLUSION: The IDQ demonstrated good psychometric properties. Denial of negative emotions and resistance to change seem to contribute to a real expression of denial, and conscious avoidance seems to constitute a further step in the process of cognitive-affective elaboration of the illness.

Preliminary report on left-ventricular assist devices: are patients' and caregivers' psychosocial needs adequately addressed?.

OBJECTIVES: Patients implanted with a Left Ventricular Assist Device (LVAD) constitute a new population of chronic heart failure (HF) patients requiring continuous medical support and representing heavy costs - both direct and indirect - for the healthcare system. If there is consensus about the increased survival, the psychosocial outcomes, in terms of psychological wellbeing, behavioral and social functioning of both patients and caregivers, are still unclear. Overall, it is not clear if local health and social services are equipped to support them in their needs. We conducted an observational study on the psychosocial characteristics and needs of LVAD patients. METHODS: Twenty-seven patients admitted for rehabilitation after implantation, and their caregivers were recruited. On admission, patients and caregivers were administered questionnaires assessing anxiety, depression, quality of life, level of social complexity and were interviewed about their social resources. At discharge, patients were re-assessed by questionnaires and patients/caregivers received a follow-up phone-interview after 8-12 months. RESULTS: LVAD patients' emotional well-being and subjective quality of life improved during the rehabilitation stay and they confirmed their satisfaction with LVAD at follow-up. Problems emerged concerning the inadequate health and social assistance that LVAD patients receive once home. More than 50% of patients showed substantial social complexity, the burden of which fell on the caregivers, whose strain hardly declined over time, remaining at a level requiring psychological attention. CONCLUSIONS: Technological advances that improve LVAD patients' survival should be rapidly followed by adequate interventions by policy makers to improve also the local health/social assistance provided and to address patients and caregivers psychosocial needs over time.

When LVAD Patients Die: The Caregiver's Mourning.

Left ventricular assist devices (LVADs) have progressively evolved, particularly in the last 10 years, to serve patients affected by severe heart failure as a bridge to transplant or destination therapy. The survival rate and quality of life of pre- and postimplant patients, as well as caregivers' perceptions and distress, are under investigation by the scientific community. But what caregivers think and feel after the loss of their loved one has not so far been examined. We contacted 16 principal caregivers of deceased LVAD patients by telephone. They were asked to evaluate their experience with LVADs and were administered a specific questionnaire about their mourning, the Caregiver Mourning Questionnaire (CMQ), to evaluate their perceptions of the physical, emotional, and social support-related problems that they had experienced during the previous 3 months. Positive aspects reported by the caregivers were the patient's overall subjective well-being and increased survival. Negative aspects were the difficulty to manage infections and the driveline, and the incomplete autonomy of the patient. Half of the caregivers reported not being preadvised about many of the problems they would face. The CMQ revealed that numerous caregivers had health problems, difficulty in sleeping, eating disorders, lack of energy, and loneliness. Use of psychotropic drugs and regrets about how they assisted their loved one also emerged. In conclusion, caregivers of LVAD patients may experience complicated mourning. Our data support in particular the need for an early intervention of palliative care which could prevent or reduce complicated mourning.

Communication in a medical setting: can standards be improved?

Do standards exist to improve communication in a medical setting? What are the minimal requirements to make our communication with patients and their family clear and simple? International literature, as well as psychology, philosophy, and even our brain structure offer ways to improve communication. We reflected about what is preventing effective communication in the medical setting and how/from where should we set about improving it.

Update on the family strain questionnaire: a tool for the general screening of caregiving-related problems.

BACKGROUND: The growing prevalence of chronic diseases and home-based treatments has led to the introduction of a large number of instruments for assessing the caregiving-related problems associated with specific diseases, but our Family Strain Questionnaire (FSQ) was designed to provide a basis for general screening and comparison regardless of the disease. We here describe the final validation of its psychometric characteristics. METHODS: The FSQ consists of a brief semi-structured interview and 44 dichotomic items, and has now been administered to 811 caregivers (285 were simultaneously administered other questionnaires assessing anxiety and depressive symptoms). After a factorial analysis confirmed the 5-factor structure identified in previous studies (emotional burden, problems in social involvement, need for knowledge about the disease, satisfaction with family relationships, and thoughts about death), we undertook correlation and reliability analyses, and a receiver operating characteristics curve analysis designed to determine the cut-off point for the emotional problems identified by the first factor. Finally, univariate ANOVA with Bonferroni's post-hoc test was used to compare the disease-specific scores. RESULTS: The validity and reliability of the FSQ is good, and its factorial structure refers to areas that are internationally considered as being of general importance. The semi-structured interview collects information concerning the socio-economic status of caregivers and their convictions/interpretations concerning the diseases of their patients. CONCLUSIONS: The FSQ can be used as a single instrument for the general assessment of caregiving-related problems regardless of the reference disease. This makes it possible to reduce administration and analysis times, and compare the problems experienced by the caregivers of patients with different diseases.

Advanced cancer at home: caregiving and bereavement.

BACKGROUND: The advanced and terminal phases of cancer are being increasingly treated at home with the aid of palliative care teams. It is well known that caregivers are overburdened emotionally, financially and physically, and some studies have demonstrated that this overload extends beyond the period of mourning. Identifying caregivers at risk of bereavement maladjustment is a useful means of ensuring prompt psychological and social assistance, and optimising the available resources. METHODS: One hundred and eleven caregivers of home-treated patients with advanced/terminal cancer were recruited by the palliative care unit operating in their place of residence. After giving their informed consent, all of the caregivers were asked to complete questionnaires designed to evaluate various emotional, financial and social aspects. Three, six and 12 months after the decease of their patients, the caregivers were contacted again and asked to complete other questionnaires aimed at assessing their emotional reactions and bereavement-related problems. RESULTS: The 12-month follow-up was completed by 93 caregivers. Their bereavement maladjustment problems correlated with their perception of emotional distress and the caregiving-related problems detected at the time of referral, particularly among females. Spouses, subjects aged over 61 years and those perceiving a substantial emotional burden proved to be at greater long-term risk. CONCLUSIONS: The identification of overburdened caregivers and those at risk of long-term bereavement maladjustment may facilitate the programming of ad hoc interventions that could reduce inherent health and social costs. Palliative care teams can usefully include someone to identify such caregivers by means of inexpensive and objectively predictive instruments.

Caregiving-related needs analysis: a proposed model reflecting current research and socio-political developments.

The present authors have developed a model for assessing caregiving-related problems and needs, the Economic, Social, Psychological and Educational Requirements Table (ESPERT). The model was based on an analysis of the international literature concerning caregiving-related problems, and current specific European and Italian legislation, as well as the authors' own research results (which also permitted them to design a specific instrument for the general assessment of caregivers). This paper describes the socio-psychological and socio-political background prompting the development of the model, the general instrument for the assessment of caregivers and an example of its use in a sample of caregivers of cancer patients. In the example study, 80 caregivers of cancer patients were asked to complete questionnaires evaluating their state and trait anxiety, depressive symptoms, personality traits, and specifically, their neuroticism or emotional instability, caregiving strain and the degree of satisfaction with their lives. In addition to the specific information obtained about this group of caregivers, the present results show that the completion of the ESPERT makes it possible to identify the proportion of subjects at economic, social and emotional risk, and to decide rapidly what kind of resources/interventions can be implemented, bearing in mind the most balanced cost-benefit ratio.