Journal Scan: Exploring the toll of pet caregiver burden
Natalie Stilwell, DVM, MS, PhD
Dr. Natalie Stilwell provides freelance medical writing and aquatic veterinary consulting services through her business, Seastar Communications and Consulting. In addition to her DVM obtained from Auburn University, she holds a MS in fisheries and aquatic sciences and a PhD in veterinary medical sciences from the University of Florida.
Owners of chronically and terminally ill pets have a high risk of caregiver burden, but newer tools are refining the ability of veterinary teams to detect this burden in their clients.
Why they did it
Caregiver burden refers to the strain of caring for a chronically ill, disabled or elderly family member. The complex effects of caregiver burden can include heightened stress levels, depression, anxiety and decreased quality of life. While this topic is well studied in human medicine, less is known about the toll a pet's illness can take on its owner.
Spotlight on suicide
September is National Suicide Prevention Month-a chance for mental health advocates, prevention organizations, survivors, allies and communities to unite to promote suicide prevention awareness-and it's no secret that this is a huge issue in the veterinary profession. This month we're focusing on this important subject in a special dvm360 Spotlight Series; watch for them online and in print. In the meantime, if you're struggling with suicidal ideation or even just plain old burnout or depression, be sure to access our list of veterinary-specific mental health resources at dvm360.com/mentalhealthlist.
To learn more, researchers at Kent State University in Ohio conducted a series of studies to better understand the psychological effects of pets' chronic or terminal illness on their caregivers. The investigators used a variety of available assessment tools focusing on aspects of psychological and emotional wellbeing, as well as adherence to treatment recommendations, and compared scores between owners of healthy and ill pets.
In a separate phase of the study, they collaborated with veterinarians from Tufts University and the University of Pennsylvania to refine available techniques for assessing veterinary client wellbeing, including validation of an abbreviated questionnaire for potential application in veterinary clinical settings. By helping practitioners anticipate caregiver burden, this tool could be used to facilitate greater communication and ultimately improve both patient care and client wellbeing.
What they did
The investigators recruited dog and cat owners via email and social media to participate in the study. All participants were at least 18 years old, English-speaking and active clients at a single, local general small animal practice. The investigators obtained data on the participants' age, gender, education level, race, income, and number and species of household pets. For owners of ill animals, additional data on disease diagnosis and duration were recorded. The number of veterinarian-client contacts was also tallied, then categorized either as billable (e.g. office visits, veterinary care, and follow-ups initiated by veterinary staff) or nonbillable (e.g. phone calls and emails initiated by the client).
Three of the six assessment tools used in the study included established cutoff scores for clinically relevant levels of caregiver burden, depression or anxiety. These included an adapted version of the Zarit Burden Interview (ZBI) for pet owners, which assessed level of caregiver burden via questions about the pet's disease, daily routine and perceived quality of life. The Center for Epidemiologic Studies Depression Scale (CES-D) and Generalized Anxiety Disorder 7-item Scale (GAD-7) measured symptoms of client depression and anxiety, respectively.
The remaining assessment tools consisted of the Perceived Stress Scale (PSS), the Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF), and the Pet Owner Adherence Scale (POAS) assessing the owner's perception of illness and adherence to recommended treatments. (A modified version of the POAS was administered to owners of healthy animals.) Although these three assessment tools did not include distinct cutoff values, higher scores generally implied signs consistent with caregiver burden.
For statistical analyses, investigators matched each owner of an ill dog or cat with a control owner of a healthy pet. Pairs were matched based on animal species and client age and gender.
What they found
The ill and healthy pet owner groups each included 62 respondents. Nearly all participants were white women, with a mean age of 48 years. The two groups were similar in education level, race, income and number of pets. However, chronically and terminally ill pets were significantly older than healthy pets, with mean ages of 11.3 and 8.5 years, respectively. Most illnesses were related to internal medicine (56%) or oncology (23%), with neurology, dermatology, orthopedics and cardiology each representing less than 10% of cases. Sixty-six percent of illnesses were classified as chronic, whereas 34% were terminal.
ZBI results showed that 44% of respondents with an ill pet had high caregiver burden, compared with 8% of owners with healthy pets. Also, average ZBI scores were higher for owners of ill pets, indicating an increased risk of caregiver burden in owners of ill versus healthy pets. This group also reported significantly higher levels of stress, depression and anxiety, as well as decreased quality of life, compared with owners of healthy pets. The degree of caregiver burden intensified as stress, depression and anxiety levels increased and quality of life decreased.
Owners of ill pets had significantly higher numbers of billable and nonbillable contacts, compared with those with healthy pets; also, the number of nonbillable contacts rose with increasing degrees of caregiver burden. Burden possibly had a negative impact on the client's ability to comply with recommended treatments. Compared with those with no burden, for example, respondents suffering from caregiver burden noted more treatment challenges and a greater disruption in daily routine due to pet illness.
After surveying an additional 459 owners of chronically or terminally ill pets and 961 owners of healthy pets, the investigators confirmed that a shortened version of the ZBI assessment tool still correlated well with the PSS and Q-LES-Q-SF tools. The short-form ZBI, reduced from 18 to seven items in length, thus has potential for use during office visits to assess the risk of caregiver burden in veterinary clients rapidly and accurately. As part of the validation process, the researchers established reference values for pet owner–specific caregiver burden, thereby simplifying interpretation of survey results.
Caregiver burden is associated with impaired emotional and psychological wellbeing. Owners with caregiver burden likely increase the demand for billable and nonbillable veterinary services, compared with those without caregiver burden, thus increasing the overall workload of the veterinary team.
The shortened and recently validated veterinary-specific ZBI, at seven questions in length, has potential use during office visits. As the authors noted, veterinarians who are aware of client distress have the opportunity to help. By working together to address such issues as pain management, coping strategies and daily routine, the veterinarian and pet owner can both regain control of patient care and thus restore patient and owner quality of life.
1. Spitznagel MB, Cox MD, Jacobson DM, et al. Assessment of caregiver burden and associations with psychosocial function, veterinary service use, and factors related to treatment plan adherence among owners of dogs and cats.J Am Vet Med Assoc 2019;254(1):124-132.