The relationship between caregiving burden and hospital anxiety and depression in relatives of elderly patients transferred from intensive care unit to the ward

Abstract

Background

This study was conducted to determine the relationship between caregiving burden and hospital anxiety and depression in relatives of elderly patients transferred from intensive care unit to the ward.

Methods

This is a descriptive and correlational study. Correlation between caregiving burden and hospital anxiety and depression was assessed by using the “Caregiving Burden Scale (CBS)” and the “Hospital Anxiety and Depression Scale (HADS)”.

Results

The mean age of the participants (n = 107) was 47.67 ± 13.02 years. The mean CBS score of the participants was 20.19 ± 10.71. The participants’ mean hospital anxiety score was 10.63 ± 4.33, and the mean depression score was 10.46 ± 3.25. The CBS scores of the participants who were women, had children, had difficulty in caregiving, and had patients in internal medicine clinics were found to be statistically significant. The anxiety scores of the participants whose patients were in internal medicine clinics and were semi-dependent were significantly higher. Also, the depression scores of the participants who had difficulty in caregiving were found to be significantly higher (p < 0.05). Positive and a very weak correlation was found between the CBS and anxiety sub-dimensions of HADS, and a similarly weak correlation was found between the CBS and depression sub-dimensions of HADS (r = 0.189, p = 0.006; r = 0.260, p < 0.001, respectively).

Conclusion

A positive correlation was found between the caregiving burden in relatives of patients and levels of hospital anxiety and depression.

Introduction

Intensive care units are special areas where life-threatening patients are closely monitored, treated, and provided with continuous care. The fact that healthcare professionals with special training and skills are employed in these units and that patients can be monitored with advanced technological devices creates a sense of trust in patients and their relatives in intensive care [1–2]. With the transfer of a patient from the intensive care unit to the ward room, changes in clinical and healthcare personnel, decreased frequency of patient follow-up and care, and various concerns about the patient’s health status can lead to uneasiness and anxiety in relatives of the patient [3–4]. Studies in the literature report that the transfer process causes anxiety, fear, restlessness, and stress in relatives of the patient [3, 5–6].

Patients transferred from intensive care to the ward require more complex care than other hospitalized patients [7]. In most countries, caregiving is performed by family members [8]. While all patient care needs in the intensive care unit are handled one-on-one by intensive care nurses, a change occurs that increases the care responsibility of the patient’s relatives when the patient is transferred to the ward [3]. Ghorbanzadeh et al. (2021) reported in their study that both patients and their families experience care shock during the intensive care unit transition [4].

With the increasing elderly population worldwide, the rate of elderly people admitted to intensive care units is also increasing rapidly [9]. Providing care to elderly patients transferred from intensive care to the ward can be a very challenging process. Especially elderly patients need more care due to reasons such as advanced age, potential comorbidities, and uncertainties about the patient’s care needs, which can cause caregiver burden [10–11].

Evaluation of caregiver burden is very important in terms of coping with the psychological problems experienced by caregivers and alleviating the caregiver burden they feel. There is little literature about the experiences of relatives of intensive care unit patients during care transitions. This study was conducted to determine the caregiver burden of elderly patients transferred from the intensive care unit to the ward and to evaluate its relationship with hospital anxiety and depression.

Research questions

Relatives of elderly patients transferred from intensive care to the ward;

• - What is the level of caregiving burden?

• - What is the level of hospital anxiety and depression?

• - Is there a relationship between caregiving burden and hospital anxiety and depression?

Methods

Design

This is a descriptive and correlational study.

Participant and setting

The study was conducted in a tertiary care center from August 2022 to September 2022. The sample size was determined by performing a power analysis with the G*Power (v3.1.9.7) program. The analysis was carried out with a significance level of 0.05 (α), and a minimum sample size of 96 was found in the calculation to obtain 80% statistical test power (1-β). The relatives of 107 patients transferred from intensive care to the ward were included in the study.

Inclusion criteria for the study: caregiver over the age of 18, caregiver having no communication problems, caregiver being 65 years or older, caregiver being directly responsible for the patient’s care, caregiver not having a cognitive, mental, or psychiatric disorder, and acceptance of participation in the study. Exclusion criteria for the study: caregiver being under the age of 65 and caregiver being paid or not directly responsible for the patient’s care.

Measures

The data of the study were collected using the “Data Gathering Form”, which was created in light of the literature, the “Caregiver Burden Scale (CBS)”, and the “Hospital Anxiety and Depression Scale (HADS)”.

Data Gathering Form

The form included 22 questions in two sections: information about the caregiver (socio-demographic information, previous caregiving status, satisfaction with caregiving, difficulty in caregiving, etc.) and information about the patient receiving care (socio-demographic information, diagnosis, additional diseases, independence in daily living activities, etc.).

Caregiving burden scale (CBS)

It was developed by Zarit, Reever, and Bach-Peterson in 1980 [12] and was adapted to the Turkish language by Inci and Erdem [13]. It is a scale used to assess the stress experienced by those who care for an individual or an elderly person in need of care. It consists of 22 statements that determine the effect of caregiving on the individual’s life. The scale has a Likert-type assessment ranging from 0 to 4. The minimum score is 0, and the maximum score is 88. A high CBS score indicates that the distress experienced is high. The Cronbach’s alpha value for the CBS scale was 0.95 in the original study. In this study. Cronbach’s alpha value for the CBS was 0.74.

Hospital anxiety and depression scale (HADS)

This scale was developed by Zigmond and Snaith in 1997 [14] and was adapted to the Turkish language by Aydemir et al. [15]. It comprises two subscales and a total of 14 items, seven of which are about anxiety symptoms and seven about depression symptoms. Each item on the scale, which is a four-point Likert scale, is scored between 0 and 3. A score between 0 and 21 points can be obtained from both subscales. The cut-off points of the scale are 10 points for the anxiety subscale and 7 points for the depression subscale. Individuals who score above these scores are considered at risk. The Cronbach’s alpha values for the HADS scale were 0.85 for the anxiety subscale, 0.77 for the depression subscales, and 0.81 for general HADS in the original study. In this study, Cronbach’s alpha values for the HADS scale were 0.65 for the anxiety subscale, 0.65 for the depression subscales, and 0.74 for general HADS.

Ethical consideration

Appropriate permissions were obtained from the institution where the study was conducted. Ethics Committee approval was obtained from the University Istanbul Kültür Institutional Review Board (IRB date and number: 28.07.2022/2022.120). Informed consent was obtained from patients who met the study criteria. The participants were assured that their responses would remain anonymous and confidential. The study conforms with the ethical principles outlined in the Declaration of Helsinki.

Statistical analysis

Data were evaluated using descriptive statistics, Student t-test, and one-way analysis of variance (ANOVA). Benferroni correction was applied in post-hoc analyses. Relationships between variables were analyzed using Pearson correlation analyses. For all tests, two-sided p-values < 0.05 were considered significant. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 20.0 for Windows (SPSS Inc., Chicago, IL, USA).

Results

The majority of the participants in the study were female (67.3%), married (87.9%), previously provided care in the hospital (57.9%), satisfied with providing care (93.5%), and stated that they had difficulty in caregiving (51.4%) (Table 1). The majority of the participants were the children of the patients they provided care for (66.4%). The majority of the patients receiving care were male (57.9%), hospitalized in the internal medicine clinic (57.0%), diagnosed with heart failure (36.4%), with chronic diseases (99.1%) and semi-dependent (72.9%) (Table 2).

Table 1.

Socio-demographic characteristics of caregivers

Variables	Mean ± SD (Min-Max)
Age (year)	47.67 ± 13.02 (20–81)
Duration of stay with in the same place (year)	13.20 ± 17.15 (0–50)
Duration of hospital care (day)	10.28 ± 15.73 (0–72)
	N = 107	%
Gender
Female Male	72 35	67.3 32.7
Marital status
Married Single	94 13	87,9 12,1
Education level
Primary school High school Postgraduate	67 21 19	62.6 19.6 17.8
Having children
Yes No	87 20	81.3 18.7
Working status
Working Not working	41 66	38.3 61.7
Presence of chronic disease
Yes No	45 62	42.1 57.9
Degree of relationship
Spouse Children Other	28 71 8	26.2 66.4 7.4
Significant others
Yes No	48 59	44.9 55.1
Stay with in the same place
Yes No	75 32	70.1 29.9
Presence of previous hospital care
Yes No	62 45	57.9 42.1
Please to give care
Yes Hesitant	100 6	93.5 6.5
Difficulty in caregiving
Yes Hesitant No	55 11 41	51.4 10.3 38.3
HADS-Anxiety
0–10 puan ≥ 11 puan	59 48	55.1 44.9
HADS-Depression
0–7 puan ≥ 8 puan	13 94	12.1 87.9
	Mean ± SD (Min-Max)
CBS	20.19 ± 10.71 (0–54)
HADS Anxiety Depression	10.63 ± 4.33 (3–21) 10.46 ± 3.25 (4–21)

CBS: Caregiving Burden Scale, HADS: Hospital Anxiety and Depression Scale

Table 2.

Socio-demographic characteristics of care recipients

Variables	Mean ± SD (Min-Max)
Age (year)	72.02 ± 6.83 (65–89)
Hospitalization within the last year	2.75 ± 2.95 (0–20)
	N = 107	%
Gender Female Male	45 62	42.1 57.9
Marital status Married	100	100.0
Education level Primary school ≥ High school	99 8	92.5 7.5
Admission clinic Medicine Surgery	61 46	57.0 43.0
Presence of chronic disease Yes No	106 1	99.1 0.9
Chronis disease* CVD DM CKD COPD CVA	90 65 19 14 1	84.1 60.7 17.8 13,1 0.9
Dependency level Independent Semi-dependent Totally dependent	25 78 4	23.4 72.9 3.7

CKD: Chronic Kidney Disease, COPD: Chronic Obstructive Pulmonary Disease, CVD: Cardiovascular Disease

DM: Diabetes Mellitus, CVA: Cerebrovascular Accident *More than one option is marked

The mean CBS score of the participants was 20.19 ± 10.71. The participants’ mean hospital anxiety score was 10.63 ± 4.33, and the mean depression score was 10.46 ± 3.25. (Table 1). The CBS scores of the participants who were female, had children, had difficulty in caregiving, and whose patients were hospitalized in the internal medicine clinics were found to be statistically significant. The anxiety scores of the participants whose patients were in internal medicine clinics and were semi-dependent were significantly higher. Also, the depression scores of the participants who had difficulty in caregiving were found to be significantly higher (p < 0.05) (Table 3).

Table 3.

Factors affecting caregiver burden and hospital anxiety and depression in relatives of patients

	CBS	p	HADS
			Anxiety	p	Depression	p	Anxiety Normal n (%)	High risk for Anxiety n (%)	p	Depression Normal (%)	High risk for Depression n (%)	p
Age (year) 20–50 ≥ 51	19.25 ± 10.37 21.52 ± 11.15	0.28	10.87 ± 4.02 10.27 ± 4.77	0.49	10.67 ± 3.16 10.16 ± 3.39	0.42	35 (59.3) 24 (40.7)	28 (58.3) 20 (41.7)	0.91	7 (53.8) 6 (46.2)	56 (59.6) 38 (40.4)	0.69
Gender Female Male	21.57 ± 10.82 17.34 ± 10.03	0.05	10.74 ± 4.57 10.40 ± 3.86	0.70	10.53 ± 3.37 10.31 ± 3.04	0.75	39 (66.1) 20 (33.9)	33 (68.8) 15 (31.2)	0.77	8 (61.5) 5 (38.5)	64 (68.1) 30 (31.9)	0.75
Marital status Married Single	20.52 ± 10.91 17.77 ± 9.07	0.38	10.53 ± 4.36 11.31 ± 4.25	0.54	10.35 ± 3.30 11.23 ± 2.89	0.36	54 (91.5) 5 (8.5)	40 (83.3) 8 (16.7)	0.19	12 (92.3) 1 (7.7)	82 (87.2) 12 (12.8)	1.0
Education level Primary school High school Postgraduate	20.43 ± 10.93 21.90 ± 12.37 17.42 ± 7.42	0.40	10.91 ± 4.58 9.90 ± 3.75 10.42 ± 4.14	0.63	10.78 ± 3.60 9.90 ± 2.32 9.94 ± 2.76	0.42	35 (59.3) 15 (25.4) 9 (15.3)	32 (66.7) 6 (12.5) 10 (20.8)	0.22	8 (61.5) 2 (15.4) 3 (23.1)	59 (62.8) 19 (20.2) 16 (17.0)	0.82
Having children Yes No	21.18 ± 11.12 15.85 ± 7.47	0.01	10.68 ± 4.40 10.40 ± 4.11	0.79	10.48 ± 3.36 10.35 ± 2.81	0.87	48 (81.4) 11 (18.6)	39 (81.2) 9 (18.8)	0.98	11 (84.6) 2 (15.4)	76 (80.9) 18 (19.1)	1.0
Working status Working Not working	19.05 ± 10.56 20.89 ± 10.81	0.38	10.44 ± 4.32 10.74 ± 3.37	0.72	10.34 ± 3.00 10.53 ± 3.42	0.77	24 (40.7) 35 (59.3)	17 (35.4) 31 (34.6)	0.57	6 (46.2) 7 (53.8)	35 (37.2) 59 (62.8)	0.55
Presence of chronic disease Yes No	22.44 ± 11.46 18.55 ± 9.89	0.07	10.67 ± 5.08 10.60 ± 3.75	0.93	10.93 ± 3.67 10.11 ± 2.89	0.19	24 (40.7) 35 (59.3)	21 (43.8) 27 (56.2)	0.74	5 (38.5) 8 (61.5)	40 (42.6) 54 (57.4)	0.77
Degree of relationship Spouse Children Other	22.03 ± 10.75 19.83 ± 11.10 16.87 ± 5.59	0.43	10.11 ± 5.07 11.08 ± 4.01 8.37 ± 3.89	0.18	10.18 ± 3.60 10.62 ± 3.67 9.62 ± 2.82	0.60	16 (27.1) 37 (62.7) 6 (10.2)	12 (25.0) 34 (70.8) 2 (4.2)	0.45	3 (23.1) 9 (69.2) 1 (7.7)	25 (26.6) 62 (66.0) 7 (7.4)	0.96
Significant others Yes No	20.32 ± 11.30 19.87 ± 9.31	0.83	10.51 ± 4.12 10.91 ± 4.85	0.68	10.39 ± 3.00 10.62 ± 3.82	0.75	43 (72.9) 16 (27.1)	32 (62.7) 16 (33.3)	0.48	8 (61.5) 5 (39.5)	67 (71.3) 27 (28.7)	0.52
Stay with in the same place Yes No	21.08 ± 10.90 19.46 ± 10.58	0.43	10.48 ± 4.98 10.74 ± 3.76	0.76	10.69 ± 3.48 10.27 ± 3.07	0.51	26 (44.1) 33 (55.9)	22 (45.8) 26 (54.2)	0.85	4 (30.8) 9 (69.2)	44 (46.8) 50 (53.2)	0.27
Presence of previous hospital care Yes No	20.66 ± 11.03 19.53 ± 10.33	0.58	10.69 ± 4.62 10.53 ± 3.95	0.84	10.56 ± 3.38 10.31 ± 3.10	0.68	35 (59.3) 24 (40.7)	27 (56.2) 21 (43.8)	0.74	6 (46.2) 7 (53.8)	56 (59.6) 38 (40.4)	0.35
Please to give care Yes Hesitant	20.49 ± 10.83 15.86 ± 8.05	0.19	10.64 ± 4.36 10.43 ± 4.24	0.90	10.48 ± 3.31 10.14 ± 2.41	0.73	56 (94.9) 3 (5.1)	44 (91.7) 4 (8.3)	0.69	12 (92.3) 1 (7.7)	88 (93.6) 6 (6.4)	1.0
Difficulty in caregiving Yes Hesitant No	23.93 ± 11.87 13.82 ± 9.88 16.88 ± 6.90	< 0.001	10.98 ± 4.64 10.82 ± 4.12 10.10 ± 3.99	0.61	11.20 ± 3.61 10.09 ± 2.12 9.56 ± 2.77	0.04	29 (49.2) 6 (10.2) 24 (40.7)	26 (54.2) 5 (10.4) 17 (35.4)	0.85	6 (46.2) 1 (7.6) 6 (46.2)	49 (52.2) 10 (10.6) 35 (37.2)	0.81
Admission clinic of patient Medicine Surgery	21.90 ± 11.77 17.91 ± 8.71	0.04	11.56 ± 4.57 9.39 ± 3.69	0.008	10.80 ± 3.70 10.00 ± 2.50	0.18	28 (47.5) 31 (52.5)	33 (68.8) 15 (31.2)	0.02	9 (69.2) 4 (30.8)	52 (55.3) 42 (44.7)	0.34
Dependency level of patient Independent Semi-dependent Totally dependent	29.50 ± 12.04 20.76 ± 11.00 16.92 ± 8.56	0.06	6.50 ± 4.73 11.41 ± 4.27 8.84 ± 3.68	0.005	11.50 ± 4.04 10.82 ± 3.28 9.16 ± 2.78	0.06	19 (32.2) 37 (62.7) 3 (5.1)	6 (12.5) 41 (85.4) 1 (2.1)	0.03	5 (38.5) 8 (61.5) 0 (0.0)	20 (21.3) 78 (72.9) 4 (4.3)	0.32

CBS: Caregiving Burden Scale, HADS: Hospital Anxiety and Depression Scale, Student t test, ki-kare, Fisher’s exact test, ANOVA

Participants were divided into three groups according to their difficulty in caregiving to their relatives. The ANOVA test revealed a significant difference between the groups in terms of CBS and HAD scores. Post-hoc analyses were conducted to determine which groups differed. CBS scores of participants who stated that they had difficulty in caregiving to their relatives were found to be significantly higher than the other two groups. CBS scores of participants in this group were also higher than participants who stated that they did not have difficulty in caregiving. HAD scores of participants who stated that they had difficulty in caregiving to their relatives were higher than those who did not have difficulty in caregiving (Table 3).

Participants were divided into three groups according to the dependency level of the patients they were caring for. A significant difference was found between the groups in terms of HAD scores. Post-hoc analyses were conducted to determine which groups differed. The anxiety scores of participants caring for semi-dependent patients were found to be higher than those caring for independent patients (Table 3).

Positive and a very weak correlation was found between the CBS and anxiety sub-dimensions of HADS, and a similarly weak correlation was found between the CBS and depression sub-dimensions of HADS (r = 0.189, p = 0.006; r = 0.260, p < 0.001, respectively). (Table 4).

Table 4.

Relationship between caregiver burden and hospital anxiety and depression in relatives of patients

		HADS
		Anxiety	Depression
CBS	r	0.189	0.260
	p	0.006	< 0.001

CBS: Caregiving Burden Scale, HADS: Hospital Anxiety and Depression Scale

r: correlation coefficient; using Pearson’s corelation analyses

Discussion

Difficulty in caregiving is a situation that is difficult for a family member who is elderly, has a chronic disease, has a disability, or is caring for someone else [13]. It is reported in the literature that the caregiver’s age, gender, willingness to provide care, education level, coping skills, beliefs, social support, duration of care, and cultural characteristics of the society affect the burden of caregiving [16–18].

In most countries, caregiving is performed by family members [8]. In Turkey, caregiving is generally provided informally by family members, and this is perceived as a family responsibility [13]. It is very difficult for the caregiver to adapt to this situation that inevitably arises suddenly after intensive care. Therefore, significant physical, psychological, social, economic, and spiritual problems arise in the caregiver and can become a burden with intense stress [4, 13]. The fact that the caregiver is the patient’s spouse, previous relationships, and the caregiver’s health problems can contribute to anxiety and depression [16].

When the studies in the literature are examined, it is seen that the caregivers are mostly women and the spouses of the patients [2, 8]. In this study, women were the majority, but the majority of the caregivers were the children of the patients. The fact that the majority of the women in the study can be explained by the tendency of women to take on the role of caregiver. The fact that the majority of the caregivers are the children of the patients can be associated with the fact that the spouses of the patients may also be old due to the average age of the patient population.

In many cultures, caregiving is seen as a job for the female gender. In addition, women’s responsibilities other than caregiving (childcare, work life, etc.) also increase the tendency to anxiety and depression. In a meta-analysis of 93 studies, it was emphasized that the burden of caregiving is perceived more intensely in women [17]. In a study conducted by Ay et al. (2017) with individuals providing care to elderly patients, the perceived burden of care was found to be higher in men [16]. The CBS scores of the female and child caregivers in this study were found to be statistically significantly higher. Those who stated that they had difficulty providing care also had higher CBS and depression scores.

When the literature is examined, it has been reported that care burden is more common in relatives of individuals with chronic diseases such as cardiovascular diseases, stroke, chronic renal failure, and Alzheimer’s [16–19]. The fact that these patients need more help in their daily life activities, need support from others when fulfilling their self-care needs, and the difficulties of both physical and psychological processes brought about by the disease may cause caregivers to experience more care burden. In this study, CBS scores were significantly higher in relatives of patients hospitalized in internal medicine clinics, and the anxiety risk of individuals was also determined to be high. We believe that the fact that patients hospitalized in internal medicine clinics are chronic patients, have repeated hospitalizations, and have difficult disease management affects the caregiver burden of caregivers.

In the study conducted by Gök Metin and Helvacı on heart failure patients, it was found that the care burden perceived by family members who provide care was low [18]. The CBS score average in this study was also found to be low (20.19 ± 10.71). The care burden of family members changes in parallel with the recovery process of the patients. In this context, it can be associated with the short duration of care received by the patients in the study and the cultural perception of caregiving as a duty and/or loyalty to the spouse or child.

In the study of Zaybak et al. (2012), it is stated that the increase in the level of dependency causes an increase in the caregiver burden [20]. In the study of Çetinkaya and Donmez, the caregiver burden and anxiety levels were found to be higher in caregivers of dependent and semi-dependent individuals than in caregivers of independent groups [19]. In this study, it was seen that the increase in the dependency level of the patients did not affect the CBS score but increased the hospital anxiety score. We think that the small number of fully dependent patients in the study affected this result.

Positive and a very weak correlation was found between the CBS and anxiety sub-dimensions of HADS, and a similarly weak correlation was found between the CBS and depression sub-dimensions of HADS. Similar studies in the literature indicate that an increase in caregiver burden is associated with an increase in anxiety and depression [16–17, 19]. It was determined that this study was parallel to the literature, but the effect level was found to be low. This result was associated with providing short-term care to patients.

Limitation

This study has several limitations. A limitation of this study is that this is a survey and, as such, is prone to selection bias. Second, this was a single-center, observational study with a relatively small sample size. Third, HADs scores were evaluated only once, and patients changes in the follow-up period were not assessed.

Conclusion

As a result of the study, caregiver burden levels of caregivers were found to be low, and hospital anxiety and depression levels were found to be moderate. It was determined that caregiver burden was higher in participants who were women, had children, had difficulty in caregiving, and had patients in internal medicine clinics. Participants whose patients were in internal medicine clinics and were semi-dependent had higher anxiety scores, and participants who had difficulty in caregiving had higher depression scores.

It is recommended that more and more comprehensive studies be conducted on the burden of caregiving in the relatives of elderly patients. In addition, planning strategies to reduce the caregiver burden will be very beneficial, especially in terms of spouse/family support, which plays an important role in the process of managing the disease of chronically ill and elderly individuals.

Author contributions

The conception and design of the study: ST, FY; acquisition of data: FY; analysis and interpretation of data: ST,; drafting the article or revising it critically for important intellectual content: ST, FY; final approval of the version to be submitted: ST, FY.

Funding

No financial support was received in the conduct of this research.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due privacy reasons but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Appropriate permissions were obtained from the institution where the study was conducted. Ethics Committee approval was obtained from the Istanbul Kültür University Institutional Review Board (IRB date and number: 28.07.2022/2022.120). Informed consent was obtained from patients who met the study criteria. The participants were assured that their responses would remain anonymous and confidential. The study conforms with the ethical principles outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.