Stressed Out Caregivers Are Using ER Visits for Respite, Study Finds

Emergency room staff call it a “pop drop” – when a disabled older person comes in for medical attention, but it seems like the person who takes care of them at home is also seeking a break from the demands of caregiving.

It’s been hard to actually study the phenomenon. A new University of Michigan study suggests that tired family caregivers are associated with greater ER visits and higher overall health care costs for the person they care for.

In a paper in the new issue of the Journal of the American Geriatrics Society, the team reports their findings from a study of 3,101 couples over the age of 65, each with one spouse acting as caregiver for their disabled partner.

The researchers looked at the Medicare payments and emergency department visits for the disabled spouses in the six months after the caregiver spouses took standard tests to measure their fatigue, mood, sleep habits, health and happiness.

Even after they took into account many factors, the researchers found that in just those six months, emergency department visits were 23 percent higher among patients whose caregivers had scored high for fatigue or low on their own health status.

Patients with fatigued or sad caregivers also had higher Medicare costs in that same time period: $1,900 more if the caregiver scored high for fatigue, and $1,300 more if the caregiver scored high for sadness, even after all other factors were taken into account.

The cost of unpaid help

“Many of us who work in clinical settings feel that patients with high home caregiving needs, such as dementia, often rely on the medical system as a source of respite for their spouses or other caregivers, because other respite isn’t paid for,” says lead author Claire Ankuda, M.D., M.P.H. “But there hasn’t been a lot of data about it, and only recently has our society been talking about caregivers and potential ways to incentivize and support them as a way of keeping patients living at home.”

Ankuda, who led the study during her time at in the Robert Wood Johnson Clinical Scholars program at U-M’s Institute for Healthcare Policy and Innovation, is now training in palliative care at the Icahn School of Medicine at Mount Sinai.

“Informal caregivers, including spouses, enable older adults with functional disability to stay out of the nursing home and live at home where they’d prefer to be,” says senior author Deborah Levine, M.D., M.P.H., an assistant professor of internal medicine and neurology at U-M.

We need to do a better job of identifying and supporting caregivers experiencing distress, in order to help caregivers feel better and hopefully improve outcomes in older adults with disability.” Deborah Levine, M.D., M.P.H.

Long-term data gives key insights

The couples in the study were all taking part in the long-term Health and Retirement Study, conducted by the U-M Institute for Social Research on behalf of the National Institutes of Health. Ankuda, Levine and their colleagues probed HRS data because it allowed them to correct for factors that other, short-term studies can’t – such as the baseline level of Medicare costs, demographic differences including income and education, and even whether the couples have adult children living nearby.

The findings add hard new data about the link between caregivers’ own experiences and the amount the Medicare system pays to take care of those the caregivers take care of at home.

Nearly 15 million older adults get help with everyday activities from spouses and other family or friend caregivers. In the new study, the researchers included couples where one spouse got help from the other with activities such as bathing, dressing, walking, getting into or out of bed, shopping, cooking, and taking medications.

Helping with these tasks on a daily basis, without pay or respite, can take a toll on the caregiver’s own health, wellness and mental state – which can lead to burnout. Medicare does not offer payment or formal respite coverage for family or friends who take regular care of older adults – and only covers home care by certified agencies under certain circumstances.

More research & services needed

Ankuda notes that studies on the impact of supporting family caregivers more formally are just beginning to produce results.

Meanwhile, health policy researchers are beginning to suggest that it may make fiscal sense to incentivize home caregiving, to keep seniors from needing more expensive nursing home care.

“I definitely think there are specific services that could help caregivers, if we can identify those people who are highest risk and provide a basic level of support such as an around-the-clock geriatric care call line that could help caregivers feel less isolated and talk to a nurse about whether, for example, to go to the emergency department,” Ankuda says. “This is a high-cost, vulnerable population.”

Formal respite care, peer support groups and other options could also help stave off fatigue and sadness – and the hospital staff who notice “pop drop” practices could help steer caregivers to such options. So could the primary care clinicians who take care of both the disabled spouse and the caregiver.

Because the new study takes into account the level of Medicare spending for the disabled spouse in the six months before their caregiver was interviewed, it may actually underestimate the impact of caregiver fatigue, she notes.

Indeed, before the authors corrected for the full range of factors, they documented that Medicare costs were lower for patients whose spouse-caregivers who reported being happy or rested. They also saw higher costs among patients whose caregivers had higher depression scores on a standard mood questionnaire.

One factor that wasn’t associated with higher costs in the new study was the caregiver’s score on a standard measure of sleep habits. Sleep disruption is harder to quantify in older people, Ankuda notes. But the measurement of fatigue, which can result from both the strain of caregiving and poor sleep, was clearly associated with both higher rates of emergency department visits and higher overall costs.

Children From Adversity: Interview with Travis Lloyd

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Children from adversity is a term often used to describe children who have experienced childhood traumas, abuse, and/or stressful conditions which could dwarf their emotional and physical growth. When we think of children from adversity, we tend to imagine children heading down the wrong path towards prison, and we often hear the horror stories of the foster care system going wrong.

What about the successes, and those who defy the odds of escaping their circumstances? Recently, I had the opportunity to interview Travis Lloyd, an artist, and motivational speaker, who had to navigate his way through many foster homes and group homes in order to get where he is today.

The experience and knowledge of a child from adversity is a valuable resource helping professionals should be utilizing more often as a source of expertise. Are we adequately measuring, identifying, and using as resources children from adversity who have escaped their childhood circumstances in order to determine what’s working and what’s not?

Children from adversity who are able to flourish despite their environment often display resiliency and survival skills many researchers still can not predict. Fortunately, Travis is using the skill sets he has developed in order to help others. I ran across Travis on Twitter when I viewed a YouTube video someone tweeted me, and I had to share his story with you.

SWH: Tell us a bit about your background, and what lead to your current role as a motivational speaker.

Travis: I have a story of Achieving Success Against All Odds, which is the mantra that I’ve built my speaking platform on.  This stems from beating the odds of the negative statistics related to foster care.  As far as my young mind could tell, I had a fairly normal life as a child. All of that changed when my parents divorced around the age of 9.  My parents had a rough divorce, as far too many people can relate to.  My father ended up in county jail due to the physical altercations and my mother wasn’t quite able to hold things together so she ended up hospitalized for her emotional instability.  My sister is six years older than me and struggled to cope as a teen.  She ended up running the streets and doing drugs so she went to drug treatment.

I ended up in two foster homes for a couple of months before my mother, sister and I relocated to Iowa, where my mother’s family is from.  Middle school was a struggle between a constantly unstable home life and bouncing in and out of a few group homes.  My aunt and uncle made a difference in my life by taking me out of that environment and giving me a permanent home to live in when I was about 14.  I stabled out in high school, but still struggled with some identity issues when I went away to college.  I started as a business major, but switched to nursing to have a guaranteed good income upon graduating.  I started a career as an ER nurse at the same time as taking custody of my 9 year old nephew.  I wasn’t satisfied working long hours in a high stress environment so I sought other ways to spend my time.  I ended up volunteering for a foster care empowerment program where after only 3 weeks I became the regional program facilitator.  Soon after that, I realized there was a need for people to speak and inspire foster youth and launched my first website.

SWH: When you are sharing your story, what is the reoccurring narrative or feedback you receive from your audiences?

Travis: People often share comments like “your message was very inspiring and encouraged me to stay true to my dreams. I really feel like you touched the hearts of every single person in the room.” I always get a few people who said that they started crying.  Most of these people are the ones who can relate to the childhood struggles or have a close friend or family member who has been through similar things.  They love seeing that “its possible” to overcome and succeed.

SWH: What do you believe are some of the biggest barriers and challenges facing our youth?

Travis: A lack of inspiration for dreaming and a lack of encouragement from the adults in their lives.  There’s a difference between being supportive through providing basic needs versus providing all of the unconditional love and compassion that encourages someone to never see a glass ceiling.  The majority of our youth haven’t had the basics of how to be successfully demonstrated to them.  It’s hard to do something that you’ve never seen before.  And if you don’t have a dream, or feel like your dreams are unrealistic, then what’s the point in staying on the grind?

SWH: How do you feel hip-hop helps you to reach youth who have difficulty opening up to adults?

Travis: I see how drastic of a difference there is with the varied approaches to youth on a regular basis.  I actually still work part time as a mental health crisis worker.  I do psychiatric evaluations for people who are suicidal, homicidal, psychotic, or otherwise in emotional distress.  Sometimes I run into teens who won’t talk to the police officers or any of their friends or family.  When I am able to take off my “professional” hat and talk in their language they almost always start to open up to me.  Sometimes I’ll even spit something a-cappella or encourage them to share something creative of their own.  It is pretty simple.  People open up to people they can relate to. Being able to relate to people from different ages, cultures, and socioeconomic backgrounds is key.

SWH: What future aspiration do you have, and where do you hope this path leads you?

I plan to expand the reach of the message “Achieving Success Against All Odds” into books, audiobooks, hophop CD’s, and training videos.  I recently released my first ever music video for the song “Take Me Away” and plan to produce several more music videos with inspirational messages related to topics that are relevant to youth, social service, child welfare, and mental health advocacy.  As this brand grows, I will expand my company Changing Lives Entertainment to hold hip hop events that make a difference and have a speaker’s bureau for speakers in various markets with similar goals.  Sometime down the road, I will go back to grad school and potentially pursue a doctoral program.  I also have a dream of being the next Dr. Phil.

You can learn more about Travis Lloyd by visiting www.travislloyd.net or visit him on Twitter at @travislloyd

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