Research suggests that caregivers are

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1 Grand Rounds Elliot J. Roth, MD, Editor The Prevalence of Injury for Stroke Caregivers and Associated Risk Factors Jeanne Hayes, Paula Chapman, Linda J. Young, and Maude Rittman Background: A vast body of research has shown that the emotional and physical demands of caregiving may lead to increased stress and burden. However, it is unknown whether these factors are associated with increased risk for injuries among caregivers. Purpose: Stroke survivors and their caregivers (N = 275) were surveyed using existing measures to explore the prevalence of physical injuries among caregivers and the types of injuries and factors associated with caregiver injury. Methods: Caregiver measures included items from the National Alliance for Caregiving (NAC) survey and the short form of the Center for Epidemiologic Studies Depression Scale (CES-D). Veterans completed items on health and functioning from the Behavioral Risk Factors Surveillance Survey (BRFSS). Results: We found that stroke caregivers who experience high burden levels and/or depression are considerably more likely to experience an increased risk for injury. Further, the vast majority of injured caregivers indicated that their injury interfered with their ability to provide care for the veteran. Conclusion: This suggests that injury on the part of the family caregiver may lead to the veteran s placement in a skilled nursing facility and lead to increased costs for the Department of Veteran s Affairs. Key words: burden, caregivers, depression, HRQoL, injury, stroke Research suggests that caregivers are susceptible to poorer physical health as a consequence of their exposure to chronic stress. 1,2 Providing care to a physically disabled person, 3 5 greater involvement in dependent care (e.g., toileting, bathing), 5,6 and more time spent providing care increases the likelihood that a caregiver will experience strain and/or burden. 7 Increased caregiver burden and/or strain, in turn, have been associated with poor caregiver outcomes such as difficulty coping with stress, increased worry about the care recipient, decreased social involvement, and poor physical health. 8 Further, caregivers report more infections, 9 experience slower wound healing, 10,11 and face an increased risk for hypertension 7,12 and coronary artery disease 13 than persons not in the caregiver role. Elderly caregivers who reported increased strain and/or burden had mortality risks that were 63% higher mortality than non-caregiving controls. 14 Caregivers also experience more physical problems and more days in which physical activity is limited or requires significant effort in comparison to persons not in the caregiving role. 15 The most frequently identified physical symptoms related to caregiving are fatigue, backache, and headache; and these symptoms are reportedly experienced at least once or twice a month. 16 Poor physical and mental health has also been reported among stroke caregivers 17,18 : the strongest predictor of declining health-related quality of life among stroke caregivers was a high level of caregiver burden. 17 It is widely accepted that providing care to a family member or friend often leads to increased strain and can negatively impinge on mental and physical health, but the relationship between physical and emotional strain and the risk for injury has only recently been explored. The literature related to caregiver injuries has largely focused on Jeanne Hayes, PhD, is Research Scientist, Kansas City VA Medical Center, Kansas City, Missouri. Paula Chapman, PhD, is Research Health Scientist, James A. Haley VA Medical Center, Tampa, Florida. Linda J. Young, PhD, is Professor, Department of Statistics, University of Florida, and Statistician, VA Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida. Maude Rittman, PhD, is Chief Nurse for Research, North Florida/South Georgia VA Medical Center, Gainesville, Florida. Top Stroke Rehabil 2009;16(4): Thomas Land Publishers, Inc. doi: /tsr

2 Prevalence of Injury for Caregivers 301 paid, professional caregivers, such as nursing staff or aides, 19,20 with physical injuries among nursing personnel reaching epidemic levels. 21,22 A recent study found a 30% incidence rate for self-reported accidents experienced by stroke family caregivers in a 6-month period, with injury severity ranging from minor (i.e., bumps, scrapes, bruises, etc.) to serious (i.e., falls and/or trips, etc.). 23 It is reasonable to assume that family caregivers face the same or greater potential for physical injury as paid, professional caregivers. Many have not been properly trained in the body mechanics of lifting and transferring techniques. Family caregivers are also typically older and report significant sleep deprivation, 24 and many experience poor health themselves. 25 The inability to effectively cope with the stressors associated with caregiving can have negative outcomes for family caregivers. The literature demonstrates that caregiving can precipitate stressors such as psychosocial distress, relationship changes and care responsibilities, or changes in employment status, for example, that may or may not be successfully managed and can result in positive or negative caregiver outcomes. The stress and coping model provides a useful framework for understanding how caregiver injury, coupled with other mediating factors such as burden and depression, can lead to an interruption or cessation in caregiving activities. 26,27 Family caregivers provide an estimated 80% of home care services to persons 50 years old and older. 28 Stroke is the leading cause of longterm disability in the United States 29 and the second most frequent cause of death. 30 Because of the physical, emotional, and cognitive deficits associated with stroke, stroke caregivers experience significant caregiving demands. Caregiver injury can limit or curtail the important role that family caregivers play in the health care system. The primary purpose of this study was to examine the prevalence of injury among stroke caregivers and identify factors associated with injury. We explored the prevalence and types of injuries stroke caregivers identified and examined the relationship between the occurrence of caregiver injuries and the context in which care was provided (i.e., the caregiver s relationship to the veteran, whether the caregiver resided with the veteran or separately, whether the caregiver was employed outside the home, and the veteran s impairment level). Our specific aims were to (a) examine the prevalence of injury among stroke caregivers; (b) identify the type of injuries and the extent to which injuries required the caregiver to seek medical attention, miss work, or interfere with providing care; and (c) explore the factors associated with caregiver injuries. Methods This study was part of a larger project that used a cross-sectional design and survey methodology to understand caregiver and veteran characteristics and moderating variables that inform caregivers response(s) to caregiving and, ultimately, caregiver outcomes (e.g., health-related quality of life). 31,32 The Veterans Integrated Service Network (VISN) represents a system of care organized into 22 regions that are based on geographic location. Veterans receiving care in VISNs 8 (Florida and Puerto Rico), 11 (Indiana and Michigan), 15 (Kansas and Missouri), and 16 (Arkansas, Louisiana, Mississippi, and Oklahoma) were included in our study if they met the following study criteria: (a) experienced a new, first-time stroke in fiscal years ; (b) lived in the community; and (c) could identify an informal caregiver who provided assistance with at least one activity of daily living who agreed to participate in the survey. Caregiver inclusion criteria were the following: (a) identified by the veteran as the person who provides the most assistance; (b) provides assistance to the veteran with at least one activity of daily living (ADL) or independent activity of daily living (IADL); (c) is 18 years of age or older; and 4) consents to participate in a telephone survey. Of those meeting the inclusion criteria, veterans and caregivers who were unwilling or unable to participate in the telephone survey were excluded from the study. The complete research protocol for this study was approved by the Veteran s Affairs (VA) Subcommittee on Clinical Investigation and the University of Florida Health Science Center Institutional Review Board (UF IRB). Consistent with human studies procedures at the time, informed consent procedures were included in the survey script for the veteran and the caregiver and were completed electronically by the University of

3 302 TOPICS IN STROKE REHABILITATION/JULY-AUG 2009 Florida Survey Research Center (UFSRC) prior to study participation. Procedures The VA Functional Status Outcomes Database (FSOD) was used to identify veterans who had sustained a first-time stroke in fiscal years in VISNs 8, 11, 15, and 16. If available, veteran s gender, age, and race/ethnicity were obtained from the FSOD. To minimize the possibility that veterans identified in the FSOD included false positives (veterans erroneously identified as having a stroke), the stroke impairment group identified in the FSOD was filtered using Reker s 33 high specificity and sensitivity diagnostic algorithms. This information was then merged with the Beneficiary Identification and Records Locator Subsystem (BIRLS) Death File to remove those veterans who had subsequently died. The resulting data file was used to query the Patient Treatment Main File (PTF Main) database for diagnostic codes for veteran s co-morbidities and demographic information (e.g., sex, race, marital status, date of birth, age, period of military service, and state, county and zip code of residents), if these data were not available from the FSOD. Next, staff from the VA Office of Physical Medicine and Rehabilitation phoned veterans to request their permission to be contacted by the study coordinator, who then screened veterans to determine eligibility status and their desire to participate. Participants Veterans and caregivers who indicated a desire to participate were contacted by staff at the UFSRC, the survey contractor, to schedule a telephone interview. The veteran interview took approximately minutes, whereas the caregiver interview took between minutes. Once the telephone surveys were completed, the encrypted files were transferred to the VA Rehabilitation Outcomes Research Center for data analysis. Initially, 400 veteran-caregiver dyads were identified and gave permission for their contact information to be sent to UFSRC. Sixty-four veteran-caregiver dyads could not be reached by the UFSRC or declined to participate when contacted. Further, 10 veteran-caregiver dyads were not eligible for inclusion in the study because it was discovered that the veteran had multiple strokes. Completed surveys were obtained for 336 veterans, but only 275 dyads (veterans and their caregivers) completed the telephone interview, yielding a 71% response rate (275 of the 390 eligible dyads). However, only veteran-caregiver dyads with complete data (observed or imputed) were considered for the multivariate analyses (n = 212). The final veteran sample included 57.6% non-hispanic Whites (n = 159), 16.7% African Americans (n = 46), 22.1% Hispanics (n = 61), and 3.6% other (n = 10). Veterans were predominantly male (99.3%), with a mean age of years (SD = 10.51). Similarly, the caregiver sample included 59.9% non-hispanic Whites (n = 161), 16.7% African Americans (n = 45), 21.1% Hispanics (n = 57), and 2.3% (n = 13) other. Caregivers were predominantly female (90.9%), with a mean age of years (SD = 12.87). Measures National Alliance for Caregiving (NAC) Survey 34 The primary measure used to assess injuries was obtained from the NAC survey, an existing survey with comparative national data. We obtained the following information from the NAC survey: caregivers demographics (age in years, gender, high school education or greater, and race, including Caucasian, African American, Hispanic, and other), relationship to the patient (spouse/partner, other), living situation (resides with caregiver), employment status (works outside the home), hours of care provided weekly, burden level, and whether the caregiver sustained an injury and if the injury interfered with the caregivers ability to care for the veteran or work. We used the NAC five-level classification system to assess caregiver objective burden. Objective burden is a composite of hours of care and type of care provided (number of ADLs and IADLs) and is scored from low (1) to high burden (5). Per NAC instructions, caregivers scores on two indices (hours per week and type of care) were summed, resulting in assignment to one of seven

4 Prevalence of Injury for Caregivers 303 levels (2, 3, 4, 5, 6, 7, or 8). The seven levels were collapsed into five, with level 1 being the least intense level of caregiving and level 5 being the most intense. Behavioral Risk Factors Surveillance Survey (BRFSS) 35 The BRFSS is a state-based random-digit dialed telephone survey that provides comparative national data. Items pertaining to limitations experienced by the veteran were taken from the BRFSS, including emotional and physical limitations, as well as the veterans need for assistance with personal care and whether the veteran used assistive devices or any special equipment. CES-D short form The short form of the Center for Epidemiologic Studies Depression Scale (CES-D) was utilized to assess symptoms of depression among caregivers. The short form CES-D is valid, reliable, and sensitive to change over time with a cutoff of 8 for clinically meaningful depressive symptoms. 36 This scale has been used in general, patient, and older adult populations including veterans. 37 The brief measure has good predictive accuracy when compared to the full-length 20-item version of the CES-D. 36 Cronbach s alpha reliability for this sample was Data analysis Data were analyzed using SPSS for Windows version 14.1 (SPSS, Inc., Chicago, IL). Values were imputed for missing data by stratifying outcome variables by race and gender and then using mean imputation for each of the strata. If more than 10% of the items on a scale were missing, imputation was not considered. Only veteran-caregiver surveys with either observed or imputed data for all variables (n = 212) were used in the multivariate analyses. Descriptive and summary statistics (frequencies and means) were computed to identify the proportion of caregivers who sustained injuries as a result of their caregiving activities, to identify the types of injuries sustained by family caregivers, to determine the extent to which injuries required the caregiver to seek medical attention or to miss work, and to determine whether the injury interfered with providing care. Chi-square tests of significance and Student t test (two-tailed) comparisons were used to examine differences in burden level and to compare other characteristics between injured and noninjured caregivers. Logistic regression was utilized to determine predictors of caregiver injury. Prior to conducting main analyses, preliminary analyses were conducted to assess missing data and the assumptions of normality and homogeneity of variances. Histograms and normality probability plots indicated no potential problems. Potential multicollinearity among the predictors was explored using correlations, and no issues were found. Significance of the predictors was assessed using Wald s chi-square statistic and a 5% significance level. Results Injured caregivers reported a mean age of years (SD = 13.83), while noninjured caregivers reported a mean age of (SD = 12.57) years (Table 1). Roughly half of injured caregivers were Caucasian (53%), compared to about 62% of noninjured caregivers. Approximately 58% of the injured caregivers and 68% of the noninjured caregivers had a high school education or greater. Finally, about 26% of injured caregivers worked outside the home while 40.0% of noninjured caregivers reported employment outside the home. This was the only significant difference found between injured and noninjured caregivers (p =.037). Caregiver injury and the caregiving context About 24% of caregivers (n = 66) reported experiencing injuries in the prior year while providing care to a veteran. About 65% of injured caregivers received a level 4 or level 5 burden score compared to 43% of noninjured caregivers, while noninjured caregivers were concentrated at lower burden levels compared to injured caregivers (p <.001). To further delineate this,

5 304 TOPICS IN STROKE REHABILITATION/JULY-AUG 2009 Table 1. Caregiver injury by caregiver characteristics and the caregiving context Total sample (n = 275) Injured (n = 66) Not injured (n = 209) Statistical test and p value Caregiver characteristics Mean age (SD) (12.87) (13.83) (12.57) t(269) = 0.83, p =.406 Gender, n (%) χ 2 (1) = 0.145, p =.704 Women 251 (90.9) 61 (92.4) 190 (90.9) Education, n (%) χ 2 (1) = 2.152, p =.142 < High school graduate 94 (34.8) 28 (42.4%) 66 (32.5%) High school graduate or greater 176 (65.2) 38 (57.6%) 137 (67.5%) Race/ethnicity, n (%) χ 2 (3) = 7.34, p =.062 Caucasian 161 (59.9) 35 (53%) 125 (61.9%) African American 45 (16.7) 10 (15.2%) 35 (17.3%) Hispanic 57 (21.2) 21 (31.8%) 36 (17.8%) Other 6 (2.2) 6 (3.0%) Caregiving context Relationship to veteran χ 2 (1) = 0.001, p =.990 Spouse/partner, n (%) 204 (73.9) 49 (74.2) 155 (74.2) Other, n (%) 72 (26.1) 17 (25.8) 54 (25.8) Employment status χ 2 (1) = 4.37, p =.037 Caregiver employed, n (%) 99 (36.4) 17 (25.8) 82 (40) Living situation χ 2 (1) = 0.145, p =.704 Resides with veteran, n (%) 252 (91.3) 61 (92.4) 190 (90.9) Mean hours of caregiving week (SD) (40.46) (45.3) (38.82) t(227) = 2.325, p =.021 Mean CES-D (SD) 8.01(6.29) (7.37) 7.12 (5.91) t(260) = 4.07, p<.001 Burden level χ 2 (4) = 18.32, p<.001 Level 1 42 (16.3%) 4 (6.2%) 38 (19.8%) Level 2 47 (18.3%) 5 (7.7%) 42 (21.9%) Level 3 44 (17.1%) 14 (21.5%) 30 (15.6%) Level 4 88 (34.2%) 27 (41.5%) 61 (31.8%) Level 5 36 (14.0%) 15 (23.1%) 21 (10.9%) Mean healthy days in prior month a (SD) (11.45) (11.34) (27.0) t(230) = 3.914, p<.001 Mean HRQoL (SD) b 3.10 (1.15) 2.73 (1.11) 2.96 (1.27) t(271) = 1.44, p =.151 Cares for a veteran who..., n (%) Has physical/emotional/mental problems 219 (80.2) 49 (74.2) 169 (80.9) χ 2 (1) = 0.676, p =.411 Uses special equipment 182 (66.9) 52 (78.8) 130 (62.2) χ 2 (1) = 5.35, p =.021 Needs help with personal care 108 (39.3) 36 (54.5) 72 (34.6) χ 2 (1) = 8.33, p =.004 Needs help with routine needs 167 (60.9) 46 (69.7) 121 (58.5) χ 2 (1) = 2.66, p =.103 a The survey question related to health days was obtained from the NAC survey (2005). Health days in the prior month is a composite variable that includes the number of days in the prior month for which the caregiver reported poor physical and/or mental health. It is calculated by subtracting the total number of unhealthy physical days in the prior month, and then subtracting from the derived figure the total number of unhealthy mental health days with a minimum of 0 days. b The survey question pertaining to general Health Related Quality of Life (HRQoL) was taken from the NAC survey. It is typically scored from 1 to 5, with the anchors of excellent to poor. For our analyses, we reverse coded the responses, so that a higher score indicates better HRQoL. follow-up single-degree-of-freedom comparisons (chi-square tests) were conducted to examine differences between burden levels. Results indicated that caregivers who reported an injury were more likely to report higher burden. Injured caregivers reported more hours of care each week (p =.021), experienced more depressive symptoms (p <.001), and had fewer healthy days in the prior month (p <.001) compared to noninjured caregivers. Injured caregivers were also more likely to care for veterans who required the use of special equipment (p =.021) or who needed assistance with personal care (p =.004) compared to noninjured caregivers.

6 Prevalence of Injury for Caregivers 305 Injury type and outcome Types of injuries reported by caregivers are listed in Table 2. Over half of injured caregivers experienced a back injury (39 of 66; 59%). The next two most common injuries sustained were knee (4 of 66; 6.1%) and arm injuries (4 of 66; 6.1%), with the remaining injuries encompassing a variety of other physical conditions (Table 2). Over half (53%) of injured caregivers (n = 35) indicated that the injury they sustained interfered with their ability to care for the veteran, and 85% of injured caregivers sought medical treatment for the injury (n = 55). Twenty-eight percent (n = 17) of injured caregivers indicated that the injury interfered with their ability to work: this represents 100% of injured caregivers who worked outside the home (Table 1). Factors associated with caregiver injury Predictors of caregiver injury were examined using logistic regression. After adjusting for co-variates such as caregivers age, education, race, employment status outside of the home, and veterans limitations (physical, mental, or emotional), potential predictors evaluated in the modeling process were number of hours of care provided per week, caregiver general health, caregiver burden, and depression. Results are presented in Table 3. After controlling for co-variates, both burden (β = 0.482, p =.008) and depression (β = 0.098, p =.001) were significant predictors of caregiver injury (Nagelkerke R 2 = 23.8%). Caregivers who suffered an injury were 1.62 times more likely to experience higher burden levels and 1.10 times more likely to be depressed compared to caregivers who were not injured. Table 2. Injury type and outcome in injured caregivers (n = 66) Injury n (%) Type Back 39 (59) Knee 4 (6) Arm 4 (6) Other 19 (29) Outcome Interfered with ability to provide care 35 (53) Interfered with ability to work (n=60) 17 (28) Table 3. Binary logistic regression of factors associated with caregiver injury Variables p Odds ratio 95% CI Caregiver age Employment status Caregiver race Veterans limitations Caregiver education Caregiving hours/week Depression Caregiver general health a Caregiver burden a Caregiver general health was captured by grouping caregivers who reported experiencing 2 or more days in which physical or mental health was good (range 2 30) into the not low HRQoL category, and caregivers who experienced 0 or 1 days in which physical or mental health days were good were categorized as having low HRQoL. The survey questions from which these data were derived were obtained from the NAC (2005) survey, specifically items related to healthy days. Health days in the prior months is calculated by subtracting the total number of unhealthy physical days and unhealthy mental health days, with a minimum of 0 days. Discussion and Conclusion Our study offers preliminary evidence of a relationship between stroke caregiver injury and stressors, with 24% of caregivers surveyed reporting an injury related to caregiving during the previous year. The results indicated that there was a 62% increase in the risk for injury among caregivers with greater burden. This is compelling in light of findings that injured caregivers reported that the injury interfered with the ability to care for the veteran and/or work. Further, caregiver depression was associated with increased risk for injury. Results are similar to findings reported recently by Hartke and colleagues, 23 who examined the incidence of self-reported injuries of any kind in a 6-month period. Characteristics associated with injury suggest that some caregivers may be prone to injury. For example, injured caregivers were also less likely to work outside the home, provide more care than noninjured caregivers on a weekly basis, report fewer healthy days, and to care for a veteran with more limitations. Finally, high impairment levels on the part of the care recipient were associated with greater risk for injury among caregivers. Many persons providing care to an older adult experience significant health care issues of their own and have limited access to social support and other needed services.

7 306 TOPICS IN STROKE REHABILITATION/JULY-AUG 2009 Findings suggest the need for clinical providers and program administrators to document the prevalence of injuries among family caregivers and to identify opportunities for intervention. Caregiver respite programs, efforts to reduce caregiver stress and burden through psychoeducational counseling and education programs, and information on injury prevention may prove helpful. Training programs specifically designed to help family caregivers reduce physical injuries could be incorporated into existing caregiver education programs. Efforts to prevent injury among professional nursing staff have shown promise. Nelson and colleagues found that those nurses receiving injury prevention training reported 18% fewer lost work days post intervention. 20 Close to a third of injured caregivers in our sample indicated they had requested training and/or information on how to avoid injuries (20 of 66; 30%), and 35% of those who requested assistance received it (n = 7). 31 Although these numbers seem small, caregiver injuries are likely to lead to increased health care costs for stroke survivors, including long-term and rehabilitative care, and their caregivers: the vast majority of respondents who reported an injury indicated that the injury interfered with the ability to provide care for the veteran. Informal care networks play an increasingly important role in the formal care system as it relates to stroke and other chronic health care conditions. The economic costs of injury are a critical consideration for families, health care providers, and policy makers. Findings indicate that the potential for injury among family caregivers is deserving of focused attention. Future research should identify characteristics of vulnerable caregivers and aim to determine how physical, mental, and emotional health contribute to the potential for injury using a longitudinal study design and a larger cohort. The limitations of our research include use of a veteran-only sample, which limits the ability to generalize study findings; a cross-sectional study design, making it difficult to ascertain whether injury precipitated burden and/or depression; and retrospective self-reporting of caregiver injuries over a 1-year time frame. Further, we recruited veterans (and their caregivers) whose index stroke occurred between 2000 and Therefore, the potential for problems with recall is significant. Acknowledgments This study was funded by the VA Health Services Research and Development Service (HSR&D), Nursing Research Initiative (NRI #05-246) through the Rehabilitation Outcomes Research Center Research Enhancement Award Program (RORC REAP) at the North Florida/South Georgia Veterans Health System, Gainesville, Florida. The contributions and support of Kimberly Findley, RN, project coordinator, are greatly appreciated. REFERENCES 1. Pruchno RA, Kleban MH, Michaels JE, et al. Mental and physical health of caregiving spouses: development of a causal model. J Gerontol. 1990;45: Gallant MP, Connell CM. Predictors of decreased self-care among spouse caregivers of older adults with dementing illness. J Aging Health. 1997;9: Bethoux F, Calmels P, Gautheron V. Quality of life of the spouses of stroke patients: a preliminary study. Int J Rehabil Res. 1996;19(4): Hartke RJ, King RB. Telephone group intervention for older stroke caregivers. Top Stroke Rehabil. 2003; 9(4): van den Heuvel ET, de Witte LP, Schure LM, et al. Risk factors for burn-out in caregivers of stroke patients, and possibilities for intervention. Clin Rehabil. 2001;15(6): Bakas T, Burgener SC. Predictors of emotional distress, general health, and caregiving outcomes in family caregivers of stroke survivors. Top Stroke Rehabil. 2002; 9(1): Bugge C, Alexander H, Hagen S. Stroke patients informal caregivers. Patient, caregiver, and service factors that affect caregiver strain. Stroke. 1999; 30(8): Wyller TB, Thommessen B, Sødring KM, et al. Emotional well-being of close relatives to stroke survivors. Clin Rehabil. 2003;17(4): Kiecolt-Glaser JK, Dura JR, Speicher CE, et al. Spousal caregivers of dementia victims: longitudinal changes in immunity and health. Psychosocial Med. 1991; 53(4): Grant I, Adler KA, Patterson TL, et al. Health consequences of Alzheimer s caregiving transitions: effects of placement and bereavement. Psychosocial Med. 2002;64(3): Vedhara K, Cox NK, Wilcock GK, et al. Chronic stress in elderly careers of dementia patients and

8 Prevalence of Injury for Caregivers 307 antibody response to influenza vaccination. Lancet. 1999;353: Kiecolt-Glaser JK, Glaser R. Chronic stress and mortality among older adults [comment]. JAMA. 1999;282(23): Vitaliano PP, Scanlan JM, Zhang J, et al. A path model of chronic stress, the metabolic syndrome, and coronary heart disease. Psychosocial Med. 2002;64: Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA. 1999; 282(23): Schulz R, Bookwala J, Fleisser K, et al. Psychiatric and physical morbidity effects of dementia caregiving: prevalence correlates and causes. Gerontology. 1995;35(6): Sanford JT, Johnson AD, Townsend-Rocchiccioli J. The health status of rural caregivers. J Gerontol Nurs. 2005; 31(4): 25 31; quiz Morimoto T, Schreiner AS, Asano H. Caregiver burden and health-related quality of life among Japanese stroke caregivers. Age Ageing. 2003;32(2): van Exel NJ, Koopmanshap MA, van den Berg B, et al. Burden of informal caregiving for stroke patients. Identification of caregivers at risk of adverse health effects. Cerebrovasc Dis. 2005;19(1): Gallagher S. Caregiver injury. Bariatric Times. 2005; 2(1): Nelson A, Matz M, Xhen F, et al. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int J Nur Stud. 2006;43: US Department of Labor. Bureau of Labor Statistics, Available at: displayarticle.php/article1509.html. Accessed December 14, Rogers B. Health hazards in nursing and health care: an overview. In: Charney W, Fragala G, eds. The Epidemic of Health Care Worker Injury: An Epidemiology. New York: CRC Press; 1999: Hartke RJ, King RB, Heinemann AW, et al. Accidents in older caregivers of persons surviving stroke and their relation to caregiver stress. Rehabil Psychol. 2006;51(2): Williams AM. Caregivers of persons with stroke: their physical and emotional well being. Qual Life Res.1993;2: Pruchno RA, Potashnik SL. Caregiving spouses: physical and mental health perspective. J Am Geriatr Soc. 1989;37: Goode KT, Haley WE, Roth DL, et al. Predicting longitudinal changes in caregiver physical and mental health: a stress process model. Health Psychol.1998;17: Pearlin LI, Mullan JT, Semple SJ, et al. Caregiving and the stress process: an overview of concepts and their measures. Gerontologist, 1990;30: Schumacher KL, Stewart BJ, Archbold PG, et al. Family caregiving skill: development of the concept. Res Nurs Health. 2000; 23(3): AHCPR. Clinical Practice Guideline: Post Stroke Rehabilitation. Washington, DC: US Department of Health and Human Services; Martinez-Vila E, Pablo I. The cost of stroke. Cereb Dis. 2004;17(suppl 1): Sberna Hinojosa M, Rittman MR. Stroke caregiver information needs: a comparison of mainland and Puerto Rico caregivers. J Rehabil Res Dev. 2007;44(5): Rittman M, Hinojosa MS, Findley K. Subjective sleep, burden, depression, and general health among caregivers of veterans poststroke. J Neurosci Nurs. 2009;41(1): Reker DM, Hamilton B, Duncan P, et al. Stroke: who s counting what? J Rehabil Res Dev. 2001;38(2): National Alliance for Caregiving and the American Association of Retired Persons (NAC and AARP). Caregiving in the US NAC and AARP Available at: data/04finalreport.pdf 35. Behavioral Risk Factor Surveillance System. Behavioral Risk Factor Surveillance System questionnaire (BRFSS) Available at: brfss/technical_infodata/surveydata/2000/ qcoremod_00.rtf 36. Andresen EM, Patrick DL, Carter WB, et al. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med. 1994;10(2): Kilbourne AM, Justice AC, Rollman BL, et al. Clinical importance of HIV and depressive symptoms among veterans with HIV infection. J Gen Intern Med. 2002; 17(7):

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