[ARTICLE] The impact of post-stroke fatigue on work and other everyday life activities for the working age population – a registry-based cohort study – Full Text

Abstract

Introduction

Life after stroke is a comprehensive area that involves engagement in meaningful everyday activities, including work, and can be adversely affected by post-stroke fatigue. This study investigates post-stroke fatigue, its development over time, and its impact on return to work and other everyday life activities. In addition, we investigated whether post-stroke fatigue could predict functioning in everyday life activities one year after stroke.

Material and methods

This prospective registry-based study includes 2850 working age (18 – 63 years) patients registered in the Swedish Stroke Register (Riksstroke) during year 2017 and 2018. Post-stroke fatigue and everyday activities were analyzed 3- and 12-months post-stroke.

Results

The mean age of the included participants was 54 years and the majority, 65%, were men. Three months post-stroke, 43% self-reported fatigue, at 12-months the proportion increased to 48%. About 90% of the patients were independent in basic ADL at 3-month. Dependence in complex activities one year post-stroke was significantly associated with fatigue. Not experiencing fatigue one year after stroke could predict positive functioning in everyday activities, increasing the chance of returning to work (OR = 3.7) and pre-stroke life and everyday activities (OR = 5.7).

Conclusion

Post-stroke fatigue is a common persistent disability that negatively impacts complex activities; therefore, fatigue needs to be acknowledged and addressed long term after discharge.

KEY MESSAGES

• People of working age who experience post-stroke fatigue encounter difficulties with complex rather than basic activities.
• Post-stroke fatigue may be developed when reclaiming complex activities; thus, long term routine assessments after discharge are recommended.
• Interventions addressing post-stroke fatigue are warranted, as the absence of post-stroke fatigue increases the chance of returning to everyday life, including work.

Introduction

When planning rehabilitation to promote health after a stroke, it is crucial to consider the individual’s ability to function in various activities of daily life [Citation1]. Prior research has shown a growing incidence of stroke in the working age population [Citation2,Citation3], with one in six stroke patients in Sweden aged between 20 and 64 years [Citation4]. Returning to work after a stroke is a significant objective of rehabilitation for many working age individuals [Citation5], as it can enhance their health, autonomy, quality of life, and perceived participation [Citation6,Citation7]. Nevertheless, attempting to return to work while coping with post-stroke limitations can cause frustration, fear, and anxiety [Citation8,Citation9]. To achieve a sustainable work situation, it is essential to manage different areas of daily life as a cohesive whole, such as family life, household duties, and work responsibilities [Citation10,Citation11]. A lack of practical support in everyday life, such as childcare and household chores, can pose a barrier to returning to work [Citation10]. Even after attaining a high level of physical recovery, individuals who have suffered a stroke often encounter difficulties in reintegrating into the workforce and maintaining employment [Citation12,Citation13]. From a societal perspective, return to work is economically advantageous as the indirect societal costs associated with productivity loss are immense. For people between 18 and 63 years old, the average indirect costs during the first year after the onset of stroke amount to about 17400 euros per person and in the second year 12200 euros per person [Citation14].

A symptom that has been identified as a crucial barrier to returning to work for both men and women is post-stroke fatigue (PSF) [Citation15,Citation16]. For people returning to work within the first year after stroke, PSF has been rated as the greatest impairment barrier [Citation5]. Fatigue can be defined as disproportionate mental or physical fatigue and lack of energy triggered by simple activities, where fatigue does not improve with normal rest [Citation17]. Due to the large heterogeneity in studies regarding time and type of assessment, stroke diagnosis, and where the studies were conducted, the prevalence of PSF varies between 42% and 62% [Citation18]. However, the underlying mechanisms of PSF remain unknown. The experience of PSF in the recovery process at different time points can be explained by several factors. The early onset of PSF could be explained by biological factors such as stroke severity; later, in the recovery process, PSF could be associated with psychological and behavioral factors [Citation19]. A differential diagnosis of PSF is depression, and previous studies have demonstrated correlations between depression and PSF [Citation19–21]. Although PSF and depression are related, they should be considered as two separate sequelae of stroke [Citation22]. Female sex has been found to be associated with PSF [Citation21,Citation23]. Evidence is inconclusive regarding the correlation between age and PSF, as both young and old age have been found to be possible predictors of PSF [Citation17].

Post-stroke fatigue has been identified as one of the most challenging impairments to manage in everyday life following a stroke according to qualitative studies [Citation8,Citation24]. Moreover, individuals under the age of 70 years have ranked PSF as the most important research area related to life after stroke [Citation25]. Rushing back to work too early or extending work hours too quickly after stroke may lead to increased PSF [Citation26]. Working age individuals normally engage in complex activities as part of their everyday lives, including work, family life, childcare, and transportation, which necessitate planning, multitasking, and problem-solving skills. Still, many people return to work and at the same time trying to regain meaningful activities in everyday life after stroke. However, few studies have focused on the role of work as an integral part of everyday life post-stroke. Therefore, it is essential to investigate the temporal aspect of PSF and its relationship with everyday activities, including work. In addition, there is a need to expand the existing knowledge base on PSF and everyday life using larger ­sample sizes.

This study investigates post-stroke fatigue, its development over time, and its impact on return to work and other everyday life activities. In addition, we investigated whether post-stroke fatigue could predict functioning in everyday life activities one year after stroke. […]

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[Abstract] Tele-rehabilitation on independence in activities of daily living after stroke: A Matched Case-Control Study

Abstract

Objectives

To compare independence in activities of daily living (ADLs) in post-acute patients with stroke following tele-rehabilitation and matched in-person controls.

Materials and Methods

Matched case-control study. A total of 35 consecutive patients with stroke who followed tele-rehabilitation were compared to 35 historical in-person patients (controls) matched for age, functional independence at admission and time since injury to rehabilitation admission (<60 days). The tele-rehabilitation group was also compared to the complete cohort of historical controls (n=990). Independence in ADLs was assessed using the Functional Independence Measure (FIM) and the Barthel Index (BI). We formally compared FIM and BI gains calculated as discharge score – admission scores, efficiency measured as gains / length of stay and effectiveness defined as (discharge score-admission score)/ (maximum score-admission score). We analyzed the minimal clinically important difference (MCID) for FIM and BI.

Results

The groups showed no significant differences in type of stroke (ischemic or hemorrhagic), location, severity, age at injury, length of stay, body mass index, diabetes, dyslipidemia, hypertension, aphasia, neglect, affected side of the body, dominance or educational level. The groups showed no significant differences in gains, efficiency nor effectiveness either using FIM or Barthel Index.

We identified significant differences in two specific BI items (feeding and transfer) in favor of the in-person group. No differences were observed in the proportion of patients who achieved MCID.

Conclusions

No significant differences were seen between total ADL scores for tele-rehabilitation and in-person rehabilitation. Future research studies should analyze a combined rehabilitation approach that utilizes both models. […]

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[ARTICLE] Myoelectric Arm Orthosis Assists Functional Activities: A 3-Month Home Use Outcome Report – Full Text

ABSTRACT

Objective

The objective was to compare task performance in individuals with upper limb impairments with and without a myoelectric arm orthosis.

Design

Three-month observational study. Participants met at four time points after receiving their myoelectric orthosis (2-Weeks, Month-1, Month-2, Month-3) to complete four standardized common daily tasks.

Setting

Nationwide sessions completed remotely over videoconference calls at home. There were no specific clinic affiliations.

Participants

Adults with upper limb impairment due to stroke who were in the process of being fit with a myoelectric arm orthosis as a first-time user.

Interventions

The orthosis was a custom-fabricated myoelectric arm orthosis called the MyoPro®.

Main Outcome Measures

Functional tasks were completed at each session with and without the MyoPro. Participants were evaluated on their success and the time required to complete each functional task. Longitudinal mixed and longitudinal mixed logistic regression models were analyzed.

Results

Eighteen individuals with chronic arm weakness due to stroke were included in the analysis. Statistically significant and clinically meaningful improvements were observed on the functional tasks in the participants’ homes. By three months, participants successfully used the MyoPro to accomplish the tasks, reduced the amount of time spent to complete the tasks, and had a higher probability of success as compared to at two weeks. With the MyoPro, participants showed significant improvement in overall task completion and completed the tasks in a significantly decreased time as compared to without the MyoPro.

Conclusions

The MyoPro provides a stabilizing support to the weak arm of individuals after stroke and enables individuals to use their impaired arm to complete functional tasks independently in the home environment.

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Figure 1. Each component of the tasks shown by a participant. (A) Pickle, (B) Bag, (C) Bowl, and (D) Towel.

[ARTICLE] Upper Limb Function Recovery by Combined Repetitive Transcranial Magnetic Stimulation and Occupational Therapy in Patients with Chronic Stroke According to Paralysis Severity – Full Text

Abstract

Repetitive transcranial magnetic stimulation (rTMS) with intensive occupational therapy improves upper limb motor paralysis and activities of daily living after stroke; however, the degree of improvement according to paralysis severity remains unverified. Target activities of daily living using upper limb functions can be established by predicting the amount of change after treatment for each paralysis severity level to further aid practice planning. We estimated post-treatment score changes for each severity level of motor paralysis (no, poor, limited, notable, and full), stratified according to Action Research Arm Test (ARAT) scores before combined rTMS and intensive occupational therapy. Motor paralysis severity was the fixed factor for the analysis of covariance; the delta (post-pre) of the scores was the dependent variable. Ordinal logistic regression analysis was used to compare changes in ARAT subscores according to paralysis severity before treatment. We implemented a longitudinal, prospective, interventional, uncontrolled, and multicenter cohort design and analyzed a dataset of 907 patients with stroke hemiplegia. The largest treatment-related changes were observed in the Limited recovery group for upper limb motor paralysis and the Full recovery group for quality-of-life activities using the paralyzed upper limb. These results will help predict treatment effects and determine exercises and goal movements for occupational therapy after rTMS.

1. Introduction

Motor paralysis after stroke limits patients’ activities of daily living (ADL) and reduces their quality of life [1,2]. Recently, noninvasive brain stimulation therapy has been developed to improve patients’ motor paralysis and ADL, and its effectiveness has been demonstrated [3,4]. The treatment of upper limb motor paralysis involves modulation of interhemispheric inhibition and induction of neuroplasticity in the cerebrum. A novel intervention using repetitive transcranial magnetic stimulation (rTMS) in combination with intensive occupational therapy (NEURO) has recently been developed [5]. In patients with stroke hemiplegia, high-frequency rTMS has been applied to the hemisphere ipsilateral to the paralysis to increase excitability [6], and low-frequency rTMS has been applied to the contralateral hemisphere to decrease interhemispheric inhibitory connections [7,8] with the damaged cortex [9]; thus, both high-frequency rTMS and low-frequency rTMS have been applied [10]. Repetitive currents are induced in the brain cortex to produce long-term changes in cortical excitability. In acute patients, high-frequency (10 Hz) rTMS applied to the impaired motor cortex activates it, improving paralysis [11,12]. In occupational therapy after rTMS, the patients in whom the activation of the interhemispheric inhibitory motor cortex has been adjusted are prescribed repetitive joint movements. The aim is to promote use-dependent plasticity in the brain and to subsequently restore motor paralysis and improve ADL [13]. NEURO is an effective treatment for improving upper limb dysfunction and impairments in ADL in chronic stroke patients 6 months after stroke onset. Its therapeutic effect has been shown to be unaffected by stroke type (cerebral hemorrhage or cerebral infarction) [14].

The goal of NEURO is to improve the quality of movement of the patient’s paralyzed upper limb by allowing it to be used in ADL. Since the effectiveness of NEURO depends on the severity of motor paralysis, therapists determine the exercises and target movements based on the patient’s pre-treatment upper limb function assessment score. The Fugl–Meyer Assessment of the Upper Extremity (FMAUE) and the Action Research Arm Test (ARAT) are used to assess upper limb motor function outcomes in NEURO [15]. These evaluation methods have been shown to have high accuracy and clinical usefulness. A previous study has been conducted to estimate post-treatment scores from the pre-NEURO FMAUE score [16]. The ARAT is a functional upper limb assessment tool used in patients with post-stroke hemiplegia and is characterized by its ability to reflect the patient’s activity [17]. Since the ARAT consists of object manipulation and reaching tasks, the occupational therapist (OT) plans exercises by estimating the ADLs in which the patient can use their hands based on the obtained assessment results. As the ARAT score correlates with the Motor Activity Log, which investigates the use of the paralyzed limb in ADLs, OTs helping patients improve their activity limitations can use it as a reference value for exercises and goal-setting [18,19]. Therefore, it can be inferred that predicting treatment effects with ARAT is more advantageous than using FMAUE in setting treatment goals and planning effective ADL exercises for patients. If ARAT scores are found to improve with NEURO, it will be easier for OTs to pre-determine the content of ADL exercises and develop achievable ADL goals.

Patients with mild-to-moderate motor paralysis with FMAUE scores ≥43 have higher interhemispheric inhibition from the healthy hemisphere to the affected hemisphere. It is predicted that the therapeutic effect of upper limb practice in the presence of rTMS-induced changes in synaptic transmission efficiency is dependent on motor paralysis severity [20]. If the post-treatment effects according to motor paralysis severity can be predicted using pre-treatment ARAT scores, the target movements for patients could be set with high accuracy. Recently, a treatment method using a brain-computer interface (BCI) was developed for the rehabilitation of stroke patients, and its effectiveness has been reported [21,22]. Even for new intervention methods, it is better to formulate exercises adapted to the severity of paralysis and recovery. Therefore, the results obtained in this study can be used as data to plan the most appropriate practice for patients in terms of future new intervention methods. As a result, this study aimed to estimate the amount of change in ARAT scores for each level of motor paralysis severity, classified according to the ARAT score before NEURO. […]

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[Conference Paper] Development of Interactive Hand Rehabilitation Tools Based on Activities of Daily Living – Full Text PDF

Abstract

Hand rehabilitation aims to improve patients’ hand and arm skills, improve adherence to training and increase their participation in activities of daily living (ADLs). A novel way of achieving this is to employ ADL-based interactive rehabilitation tools and show patients how their improved skills can be transferable to daily tasks. Hence, in this paper, we report the results of a set of studies carried out with six healthy individuals and two physiotherapists to discover the potential of integrating ADLs into interactive hand rehabilitation tools. Consequently, we designed two interactive drinking-based concepts and tested those with three stroke patients. We found that ADL-based training couples particularly well with functional training. Still, selecting appropriate functional exercises that match the ADL is an essential task to transfer training outcomes to a functional setting. Based on our findings, this paper highlights that ADL-based interactive hand rehabilitation training must minimally deviate from the original ADLs.

Overview of identified grasps

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[PDF] Enabling self-management following stroke: A checklist for patients, families, and caregivers

Introduction

Heart & Stroke is committed to supporting people who have experienced a heart condition, stroke,
and vascular cognitive impairment. People with these conditions, their family members, and
caregivers, demonstrate incredible resilience as they find ways to adapt and manage living with
these conditions. Teaching self-management skills and providing timely information and education
are key components of success for people with lived experience across the full continuum of care.
This checklist is designed to support those who are transitioning home after a stay in hospital by
offering guidance to people recovering from stroke and their families and caregivers.
It provides tips to help guide recovery after stroke while aligning to Canadian Stroke Best Practice
Recommendations. People are encouraged to use this list to discuss different aspects of recovery
with their stroke care team.
Recovery is a process that can last months and even years after a stroke. It is important to
challenge your body every day, but to do so safely and remember that everyone’s recovery is
different. The tips listed here are a starting point to support your journey. It is important to also
check back regularly with your therapists for additional support as needed.
For more information and strategies to support your recovery, please View PDF

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[Abstract] Monitoring Arm Movements Post-Stroke for Applications in Rehabilitation and Home Settings

Abstract

Optimal recovery of arm function following stroke requires patients to perform a large number of functional arm movements in clinical therapy sessions, as well as at home. Technology to monitor adherence to this activity would be helpful to patients and clinicians. Current approaches to monitoring arm movements are limited because of challenges in distinguishing between functional and non-functional movements. Here, we present an Arm Rehabilitation Monitor (ARM), a device intended to make such measurements in an unobtrusive manner. The ARM device is based on a single Inertial Measurement Unit (IMU) worn on the wrist and uses machine learning techniques to interpret the resulting signals. We characterized the ability of the ARM to detect reaching actions in a functional assessment dataset (functional assessment tasks) and an Activities-of-Daily-Living (ADL) dataset (pizza-making and walking task) from 12 participants with stroke. The Convolutional Neural Network (CNN) and Random Forests (RF) classifiers had a Matthews Correlation Coefficient score of 0.59 and 0.58 when trained and tested on the functional dataset, 0.50 and 0.49 when trained and tested on the ADL dataset, and 0.37 and 0.36 when trained on the functional dataset and tested on the ADL dataset, respectively. The latter is the most relevant scenario for the intended application of training during a clinical visit for monitoring movements in the in-home setting. The classifiers showed good performance in estimating the time spent reaching and number of reaching gestures and showed low sensitivity to irrelevant arm movements produced during walking. We conclude that the ARM has sufficient accuracy and robustness to merit being used in preliminary studies to monitor arm activity in rehabilitation or home applications.

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[Abstract] Smart daily-used objects for hand rehabilitation after stroke

Abstract

Objective: By designing interactive activities of daily living (ADL)-based smart objects for home hand rehabilitation for people with stroke, our objective is to provide a better understanding of how daily activities and objects can facilitate rehabilitation. This way we can bypass the need for intrinsic motivation and offer functional hand exercises at home, that are seamlessly integrated into ADL.

Design: We applied a pilot study following a research-through-design approach combined with a user-centred design to evaluate a handle used as add on to cooking utensils.

Setting: We applied this research within a focus group setting within a rehabilitation centre.

Participants: Two adult people with stroke (male, aged over 40) participated. They both had a mildly impaired hand function due to stroke.

Interventions: Not applicable

Main Outcome Measures: Both participants interacted with the prototype handle and experienced via a “wizard of Oz” approach some of the future features of the prototype. Additionally, they were asked to evaluate the usability of the idea of using daily objects as means for rehabilitation at home and expressed their opinion about the future features of such devices.

Results: Both participants recognised the value of daily objects for home stroke hand rehabilitation. They mentioned that they would prefer objects that promote bi-manual activities (or a multitude of activities via a modular design) and the importance of monitoring their progress and even adding elements of competition between participants.

Conclusions: This pilot test showed that our idea for seamless home rehabilitation with the use of smart daily objects is promising. In this work, we will present the results of the follow-up studies that we carried out with more people with stroke, after implementing the suggestions of the participants.

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[ARTICLE] Handling fatigue in everyday activities at five years after stroke: A long and demanding process – Full Text

Abstract

Background

Fatigue is common and can be challenging after stroke.

Aim

To explore how post-stroke fatigue (PSF) was experienced and handled among people with stroke in their performance of everyday activities and in participation in social activities five years after stroke.

Methods

Nine persons who perceived PSF one year after stroke onset were interviewed five years later. The interviews were analysed using qualitative content analysis.

Results

Most participants experienced PSF even five years after stroke and reported longstanding difficulties in everyday activities. Handling fatigue—a long slow process with invisible adjustments in everyday life emerged as the theme. By implementing new strategies in everyday life their PSF lessened over time. Understanding among significant others as to how PSF appears and providing information about PSF early after stroke was perceived important.

Conclusion

This study adds new knowledge regarding experiences of PSF and long-term support needs. Even if PSF still was reported the participants experienced improvements in everyday life through the application of new strategies. Information about PSF and strategies for managing everyday life should be provided during rehabilitation.

Significance

This study is one out of only a few focussing on long-term PSF and adjustment to its consequences in everyday life.

Introduction

Every year, about 25,700 people suffer from stroke, which is currently considered to be one of the largest public health challenges in Sweden [1]. Common consequences of stroke are varying degrees of motor impairment, loss of sensitivity, and language or visual impairment. Other impairments that people might suffer from after a stroke include depression, cognitive and/or perceptual difficulties.

Research reports varying prevalence of post stroke fatigue (PSF). In a literature review, Cumming et al. [2] found the prevalence of PSF to be between 25% and 85%, has also been found to persist long after stroke [3,4]. In another literature review Duncan [5] reports of both declining and increasing experience of PSF at a later stage, 1–3 years after stroke. PSF was found to be a significant problem [6] which can be disabling and interfere with everyday life [4,7,8]. It is described as a subjective feeling of profound fatigue and lack of mental and/or physical energy that arises after exertion and comes on suddenly [6,9]. PSF does not seem to be associated with general cognitive functioning [10]. Intellect can be completely unaffected, but cognition can be affected when PSF occurs, which can lead to difficulties in performing simple activities within a reasonable timeframe. Consequently, PSF impacts everyday life as individuals with the condition struggle to cope with everyday activities, which may result in increased dependency [8,9].

There is still limited knowledge as to why PSF occurs, and which treatments can be effective. One review study found an association between PSF and depression and anxiety [10] however, it has not been possible to demonstrate a temporal relationship i.e. that people with depression and anxiety before stroke should have a higher risk for PSF. A co-occurrence between PSF and attention disorders has also been discussed [3,5,10]. Naess et al. [11] suggested that PSF has a multifactorial aetiology and therefore may require person-centred treatment.

A Cochrane study concerning intervention aimed at reducing PSF found insufficient evidence for the effect of interventions designed to reduce PSF prevalence and severity. The studies in the review (five pharmacological interventions, one fatigue education program and one mindfulness-based program) were small and the samples were heterogeneous [12]. Some qualitative studies [7–9], focussing on the experience of living with PSF, suggested interventions like education about PSF, advice about daily routines, and long-term follow up.

In occupational therapy, it is assumed that being engaged in activities/occupations is an integral part of human nature. Being active and participating in everyday life is described as a prerequisite for health [13] and through performing activities people will sustain and improve their health [14]. According to Hammel et al [15] participation in everyday occupations embraces the observed performance of activities accompanied with the subjective experience of participation. Participation in everyday occupations/activities involves choosing, performing and engaging in activities valued and desired by a person [15]. Suffering from a stroke can cause difficulties in performing activities that are perceived as meaningful to the person due to the limitations that the illness brings. Involvement in doing is seen as the mechanism that can contribute to change and enable participation in valued activities despite the consequences of injury or illness [14].

Knowledge is currently limited about the long-term consequences of PSF. Recent studies have focussed the time up to maximum two years after stroke, several restricted to one year. Prevailing qualitative studies describe the experiences of living with PSF [6,9,16] as dealing with a unique tiredness which impacts family life, work, and social life. Their experience of PSF was different from earlier experience of fatigue. The participants described a sense of loss of control they were unprepared for, and they sought for the reason why. The studies report that participants first strove to handle the PSF by fighting it but later began to accept changed options and develop new routines in life [5]. A study of people 6, 12 and 24 months after stroke detected evolving strategies to handle everyday life [6]. There is a need for more knowledge and understanding as to how people experience and handle PSF long time after stroke. This knowledge could contribute to development of interventions to reduce PSF. […]

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[ARTICLE] Relationship between Activities of Daily Living of Home-Based Rehabilitation Users and Caregiver Burden-Induced Depression: A Retrospective Study – Full Text

Abstract

This study was aimed at determining the cutoff values of activities of daily living (ADL) and the combination of related factors associated with high caregiver burden that induces depression among caregivers. The study participants included 50 pairs of home-based rehabilitation users and their primary caregivers. They were classified into two groups: high-burden and low-burden groups according to the short version of the Japanese version of the Zarit Caregiver Burden Interview score of ≥13 or ≤12, respectively. The cutoff values of ADL and the combination of related factors associated with high caregiver burden were examined using the receiver operating characteristic curve and decision tree analyses. The cutoff value associated with high caregiver burden was 5 points for the controlling bladder item of the Barthel index (BI) (sensitivity: 90%, specificity: 70%). Regarding the decision tree, the controlling bladder item of BI (≤5 or 10 points) was selected as the first layer and the recipient’s age (≤78 or ≥79 years) as the second layer. High caregiver burden was identified in 85.7% of the caregivers in whom the score of controlling bladder of BI was ≤5 points and the patient was aged ≤78 years. A score of ≤5 points for the controlling bladder item of BI along with young recipient age was associated with high caregiver burden that induces depression among caregivers. This approach is useful to identify caregivers with high caregiver burden who are at risk for depression.

1. Introduction

The health of family caregivers is crucial for older and disabled people to continue to live at home. Occupational therapists who provide home-based rehabilitation services should support the patients and pay attention to the mental state of family caregivers, reduce the burden of care, and provide necessary support. A large-scale population-based study on 4128 family caregivers of community-dwelling older people under the Long-Term Care Insurance program in Japan reported that 34.2% of the family caregivers were at risk for depression [1]. Furthermore, caregiver depression was associated with high caregiver burden in a large-scale survey in Japan [2] and in a meta-analysis study [3]. Additionally, Arai and Zarit [2] reported that a cutoff score of 13 points in the short version of the Japanese version of the Zarit Caregiver Burden Interview (J-ZBI_8) was associated with depression [4, 5]. Therefore, appropriate support is needed to maintain the J-ZBI_8 score below 13 points to prevent the incidence of depression among caregivers.

Caregiver burden is associated with various elements, including patient factors, caregiver characteristics, and the relationship between patients and caregivers. Patient factors include age [6–8], gender [7], educational level [9, 10], functional disability [7, 11], cognitive impairment [9, 12, 13], and poor activities of daily living (ADL) [10, 12–15]. Occupational therapists are often involved in ADL. Additionally, eating [16], grooming [17, 18], dressing [12, 17, 18], mobility [19, 20], transfer [21], bathing [12, 16, 18], and bowel and bladder management [7, 12, 17, 20, 22–24] have been reported to be associated with caregiver burden. However, to the best of our knowledge, the level of assistance and ADL items that increase the caregiver burden is unknown. Further, the combination of factors associated with high caregiver burden remains elusive.

Therefore, this study was aimed at determining the cutoff values of ADL and the combination of related factors associated with high caregiver burden that induces depression among caregivers. The findings will be useful for occupational therapists to determine ADLs that should be prioritized for intervention based on the caregiver burden. It may also be useful to identify caregivers at risk for depression. […]

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