Caregiver Stress: Understanding the Causes and Costs. Keynote Address Sarah Enos Watamura, Ph.D. University of Denver

Transcription

1 Caregiver Stress: Understanding the Causes and Costs Keynote Address Sarah Enos Watamura, Ph.D. University of Denver

2 How we wish the da we t.

3 How it feels like the da we t..

4 Toda s Goals Understand how stress affects your body Both how your legacy of stress influences who you are And how your current experience of stress influences your well-being What can you do about it?

5 Outline Understanding stress and its effects on the body What is your personal legacy of risk? Genetic and epigenetic Adverse childhood experiences Stress among caregivers Risk and resilience Stress Management tips!

6 Outline Understanding stress and its effects on the body What is your personal legacy of risk? Genetic and epigenetic Adverse childhood experiences Stress among caregivers Risk and resilience Stress Management tips!

7 tress as the Bod s Ph siologic Respo se, Not the Event/Situation Your physiologic response to events, situations, illnesses, physical perturbations, feelings etc. How you manage the challenge What causes short and long term observable body changes and implications for health Analogy: Your immune response to an infection Its how you manage the infection (fever, malaise, sickness behavior, swelling, activated lymph nodes etc.) AND its what can be observed in your body as a reaction to the infection, and can be the way an illness takes a toll on you

8 Why Consider Physiologic Stress A mechanism (or set of mechanisms) linking stress risk and later outcomes

9 Why Consider Physiologic Stress A mechanism (or set of mechanisms) linking stress risk and later outcomes Knowing how something happens gives us better targets for prevention and intervention

10 Why Consider Physiologic Stress A mechanism (or set of mechanisms) linking stress risk and later outcomes Knowing how something happens gives us better targets for prevention and intervention Ma allo a assess e t of a i di iduals starti g state History of stress exposure Genetic and epigenetic inheritance

11 Why Consider Physiologic Stress A mechanism (or set of mechanisms) linking stress risk and later outcomes Knowing how something happens gives us better targets for prevention and intervention Ma allo a assess e t of a i di iduals starti g state History of stress exposure Genetic and epigenetic inheritance Allows for variation in experience, perception, support Experienced Event/Thought /Situation Available Supports Prior Experience/ History Physiologic Stress Response

12 Physiologic Stress How Does tress Get U der the ki?

13 Physiologic Stress How Does tress Get U der the ki?

14 Physiologic Stress Response Whe the tiger e ters the roo, a as ade is i itiated i the brain to manage the threat

15 Physiologic Stress Response Whe the tiger e ters the roo, a cascade is i itiated i the brain to manage the threat At least for humans, the tiger can be just thinking about having to do something threatening imagining an anticipated or experienced conflict preparing to perform in public Preparing to enter a new environment

16 Ideal Stress Response Prompt activation, appropriate in degree Full recovery Stress onset Stress offset OR Active coping engaged

17 Function of the Stress Response Physiologic stress is largely about energy Handling a threat is metabolically very costly, whether the response is to fight or to flee

18 Function of the Stress Response Physiologic stress is largely about energy Handling a threat is metabolically very costly, whether the response is to fight or to flee Our stress systems divert energy from long-term processes to the immediate threat Away from digestion reproduction growth repair long-term immune processes (making antibodies for a secondary infection) Toward respiration glucose to burn increased heart rate to move energy to muscles short-term immune processes (trafficking white blood cells to the site of infection)

19 Two Stress-Response Systems Likely activated at the same time, the primary and secondary response help to manage threat

20 Two Stress-Response Systems Likely activated at the same time, the primary and secondary response help to manage threat First response: NE/SAM Sympathetic nervous system Parasympathetic nervous system Burns through stored glucose to increase respiration, dilate pupils, increase heart rate etc.

21 Two Stress-Response Systems Likely activated at the same time, the primary and secondary response help to manage threat First response: NE/SAM Sympathetic nervous system Parasympathetic nervous system Burns through stored glucose to increase respiration, dilate pupils, increase heart rate etc. Second response: HPA Hypothalamic-pituitary-adrenal (HPA) axis Supports the first response by replenishing glucose stores and further suppressing long-term growth and restorative processes

22 HPA-Axis Response CRH/A VP CRH = corticotropin-releasing hormone AVP = argine vasopressin ACTH = adrenocorticotropic hormone

23 HPA-axis Cortisol Highly Conserved System HPA-axis shared with salmon at least 400 million years old

24 HPA-axis Cortisol Highly Conserved System HPA-axis shared with salmon at least 400 million years old Cortisol A potent steroid hormone that can cross the blood-brain barrier and the membranes of cells to exert wide-ranging effects Hydrocortisone cream, cortisone shots and steroid inhalants have clinical uses because they inhibit inflammation caused by the immune system

25 HPA-axis Cortisol Highly Conserved System HPA-axis shared with salmon at least 400 million years old Cortisol A potent steroid hormone that can cross the blood-brain barrier and the membranes of cells to exert wide-ranging effects Hydrocortisone cream, cortisone shots and steroid inhalants have clinical uses because they inhibit inflammation caused by the immune system Functions of Cortisol Mediates many bodily changes in response to stress & challenge Cortisol also has many other functions in the body e.g. Facilitates metabolism

26 Normal State Transitions & Metabolism

27 When is physiologic stress good vs. bad? When is it adaptive, helpful, necessary? When is it maladaptive, costly, and leading to physical and mental illness?

28 Stress as Allostasis & Allostatic Load Concept introduced by Sterling & Ewer, 1988; Developed and expanded by Bruce McEwen Reconceptualizes stress as an issue of balance

29 Stress as Allostasis & Allostatic Load Concept introduced by Sterling & Ewer, 1988; Developed and expanded by Bruce McEwen Reconceptualizes stress as an issue of balance Allostasis Maintaining homeostasis through change OR Adaptation

30 Stress as Allostasis & Allostatic Load Concept introduced by Sterling & Ewer, 1988; Developed and expanded by Bruce McEwen Reconceptualizes stress as an issue of balance Allostasis Maintaining homeostasis through change OR Adaptation O whe ou eed it, off whe ou do t Ideally, one would activate their stress systems infrequently, only for true threat situations, and they would quickly return to baseline once the threat was managed

31 Stress as Allostasis & Allostatic Load Concept introduced by Sterling & Ewer, 1988; Developed and expanded by Bruce McEwen Reconceptualizes stress as an issue of balance Allostasis Maintaining homeostasis through change OR Adaptation O whe ou eed it, off whe ou do t Ideally, one would activate their stress systems infrequently, only for true threat situations, and they would quickly return to baseline once the threat was managed Allostatic Load Wear and tear on stress systems over the life time Occurs when the systems are activated chronically

32 Healthy Stress Response vs. Maladaptive Response Types

33 Long-term Effects of Chronic Stress influences susceptibility to or progression of a number of diseases: cardiovascular disease (Smith & Ruiz, 2002) diabetes (Mooy, 2000) infectious illness (Cohen & Williamson, 1991)

34 Long-term Effects of Chronic Stress influences susceptibility to or progression of a number of diseases: cardiovascular disease (Smith & Ruiz, 2002) diabetes (Mooy, 2000) infectious illness (Cohen & Williamson, 1991) i creases the risk of risk : obesity (Brunner et al., 2007) decreases immune function (Segerstrom & Miller, 2004) Increased metabolic syndrome (Chandola, Brunner, Marmot, 2006)

35 Long-term Effects of Chronic Stress influences susceptibility to or progression of a number of diseases: cardiovascular disease (Smith & Ruiz, 2002) diabetes (Mooy, 2000) infectious illness (Cohen & Williamson, 1991) i creases the risk of risk : obesity (Brunner et al., 2007) decreases immune function (Segerstrom & Miller, 2004) Increased metabolic syndrome (Chandola, Brunner, Marmot, 2006) can impair cognitive functioning: memory (Lupien et al., 1998) attention (Liston, McEwen, & Casey, 2009)

36 Long-term Effects of Chronic Stress influences susceptibility to or progression of a number of diseases: cardiovascular disease (Smith & Ruiz, 2002) diabetes (Mooy, 2000) infectious illness (Cohen & Williamson, 1991) i creases the risk of risk : obesity (Brunner et al., 2007) decreases immune function (Segerstrom & Miller, 2004) Increased metabolic syndrome (Chandola, Brunner, Marmot, 2006) can impair cognitive functioning: memory (Lupien et al., 1998) attention (Liston, McEwen, & Casey, 2009) increases risk for mental health problems: depression (Siegrist, 2008) anxiety (Eisenberg, 2007)

37 Long-term Effects of Chronic Stress influences susceptibility to or progression of a number of diseases: cardiovascular disease (Smith & Ruiz, 2002) diabetes (Mooy, 2000) infectious illness (Cohen & Williamson, 1991) i creases the risk of risk : obesity (Brunner et al., 2007) decreases immune function (Segerstrom & Miller, 2004) Increased metabolic syndrome (Chandola, Brunner, Marmot, 2006) can impair cognitive functioning: memory (Lupien et al., 1998) attention (Liston, McEwen, & Casey, 2009) increases risk for mental health problems: depression (Siegrist, 2008) anxiety (Eisenberg, 2007) can accelerate aging: shorter telomere length, less telomerase activity (Epel et al., 2004)

38 Effects of stress depend on many factors the type of stressor the duration of the stress (acute vs. chronic) the unpredictability or uncontrollability of the stress the social environment of the stressed individual including caregiving in children and social support in adults Genetic/epigenetic risk factors

39 Risk Factors Effect o Life E pecta c Smoking 10 years 1 Obesity 6-7 years 2, 3 High blood pressure 5 years 4 Diabetes 7-8 years 5 1 Doll R, Peto R, Boreham J, utherla d I. Mortalit i relatio to s oki g: 5 ears o ser atio s o ale British do tors. BMJ 2004; 328: Haslam DW, James WP (2005). "Obesity". Lancet 366 (9492): Nedcom, A, Barendregt, JJ, Willekens, F et al. (January 2003). "Obesity in adulthood and its consequences for life expectancy: A life-table analysis" (PDF). Annals of Internal Medicine 138 (1): Franco OH, Peeters A, Bonneux L, de Laet C. Hypertension Aug;46(2): Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W. Arch Intern Med Jun 11;167(11):

40 Risk Factors Effect o Life E pecta c Smoking 10 years 1 Obesity 6-7 years 2, 3 High blood pressure 5 years 4 Diabetes 7-8 years 5 Early Life Stress 20 years 1 Doll R, Peto R, Boreham J, utherla d I. Mortalit i relatio to s oki g: 5 ears o ser atio s o ale British do tors. BMJ 2004; 328: Haslam DW, James WP (2005). "Obesity". Lancet 366 (9492): Nedcom, A, Barendregt, JJ, Willekens, F et al. (January 2003). "Obesity in adulthood and its consequences for life expectancy: A life-table analysis" (PDF). Annals of Internal Medicine 138 (1): Franco OH, Peeters A, Bonneux L, de Laet C. Hypertension Aug;46(2): Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W. Arch Intern Med Jun 11;167(11):

41 The life cycle model of stress From Lupien, S. J., McEwen, B.S., Gunnar, M. R., Heim, C. (2009). Effects of stress throughout the lifespan on the brain, behavior and cognition. Nature Reviews Neuroscience, 10,

42 Outline Understanding stress and its effects on the body What is your personal legacy of risk? Genetic and epigenetic Adverse childhood experiences Stress among caregivers Risk and resilience Stress Management tips!

43 How are Negative Life Events and their Consequences Perpetuated Generation to Generation? Socio-culturally

44 Epigenetically

45 Epigenetically We inherit our genes, or our DNA from our two biological parents, arranged in a novel configuration

46 Epigenetically We inherit our genes, or our DNA from our two biological parents, arranged in a novel configuration But DNA does not equal behavior, disease etc.

47 Epigenetically We inherit our genes, or our DNA from our two biological parents, arranged in a novel configuration But DNA does not equal behavior, disease etc. Genes must be copied and activated (or deactivated) in every cell of the body and across the lifespan If this as t true, ho ould heart ells differ fro rai ells et.?

48 Epigenetically We inherit our genes, or our DNA from our two biological parents, arranged in a novel configuration But DNA does not equal behavior, disease etc. Genes must be copied and activated (or deactivated) in every cell of the body and across the lifespan If this as t true, ho ould heart ells differ fro rai ells et.? A number of processes mark genes for activation or inactivation, collectively epigenetic processes (on top of the genome)

49 Epigenetically We inherit our genes, or our DNA from our two biological parents, arranged in a novel configuration But DNA does not equal behavior, disease etc. Genes must be copied and activated (or deactivated) in every cell of the body and across the lifespan If this as t true, ho ould heart ells differ fro rai ells et.? A number of processes mark genes for activation or inactivation, collectively epigenetic processes (on top of the genome) These markers are controlled/sensitive to illness, stress and toxin exposure, environmental supports etc. These markers CAN also be inherited across at least a few generations

50 Verbal Abuse, Threat of Physical Abuse While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household swear at you, insult you, put you down, or humiliate you? Never Once Twice Sometimes Often Very often 2. Did a parent or other adult in the household act in a way that made you afraid that you might be physically hurt? If often or very often for EITHER ITEM, enter 1, otherwise enter 0

51 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1

52 Physical Abuse While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household push, grab, slap or throw something at you? Never Once Twice Sometimes Often Very often 2. Did a parent or other adult in the household hit you so hard that you had marks or were injured? If often/very often for item 1, or EVER for item 2, enter 1, otherwise enter 0

53 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1

54 Sexual Abuse While you were growing up, during your first 18 years of life: 1. Did an adult or someone at least 5 years older than you touch or fondle you or have you touch their body in a sexual way? 2. Did an adult or someone at least 5 years older than you attempt to have oral, anal or vaginal intercourse with you? Yes No 3. Did an adult or someone at least 5 years older than you actually have oral, anal or vaginal intercourse with you? If yes for any of the above, enter 1, otherwise enter 0

55 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1

56 Lack of Supportive, Loving Environment While you were growing up, during your first 18 years of life: 1. You felt loved? 2. There was someone in your family who made you feel important or special? 3. People in your family looked out for each other? 4. People in your family felt close to each other? If never or rarely true for 1 AND 2 or never or rarely true for 3 AND 4, enter 1, otherwise enter 0

57 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1

58 Neglect While you were growing up, during your first 18 years of life:. You did t ha e e ough to eat? Never True Rarely True Sometimes True Often True Very often true 2. You had to wear dirty clothes? 3. You knew there was someone to take care of you and protect you? 4. Your parents were too drunk or high to take care of the family? Never True Rarely True Sometimes True Often True Very often true 5. There was someone to take you to the doctor if you needed it? If often/very often for 1 AND 2 AND never or rarely true for 3, OR Often/very often for 4, OR never or rarely for 5, enter 1, otherwise enter 0

59 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1 Neglect of child 1

60 Parents Divorced or Separated While you were growing up, during your first 18 years of life: 1. Were your parents ever separated or divorced? Yes No If yes, enter 1, otherwise enter 0

61 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1 Neglect of child 1 Parents ever separated or divorced 1

62 Mother/Stepmother Physically Abused While you were growing up, during your first 18 years of life: 1. Did someone push, slap, grab or throw something at your mother/stepmother? 2. Did someone kick, bite, hit with a fist or hit your mother/stepmother with something hard? 3. Repeatedly hit your mother/stepmother over at least a few minutes? 4. Threaten your mother/stepmother with a knife or gun or use a knife or gun to hurt her? If often/very often for 1, sometimes/often/very often for 2, OR ever for 3 or 4, enter 1, otherwise enter 0

63 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1 Neglect of child 1 Parents ever separated or divorced 1 Mother/stepmother physically abused 1

64 Household Member Substance Abuse While you were growing up, during your first 18 years of life: 1. Did you live with anyone who was a problem drinker or alcoholic? Yes No 2. Did you live with anyone who used street drugs? Yes No If yes to either, enter 1, otherwise enter 0

65 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1 Neglect of child 1 Parents ever separated or divorced 1 Mother/stepmother physically abused 1 Household member substance abuse 1

66 Household Member Mental Illness While you were growing up, during your first 18 years of life: 1. Was anyone in your household depressed or mentally ill? Yes No 2. Did anyone in your household attempt to commit suicide? Yes No If yes to either, enter 1, otherwise enter 0

67 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1 Neglect of child 1 Parents ever separated or divorced 1 Mother/stepmother physically abused 1 Household member substance abuse 1 Household member mental illness 1

68 Household Member Incarcerated While you were growing up, during your first 18 years of life: 1. Did anyone in your household go to prison? Yes No If yes, enter 1, otherwise enter 0

69 ACE Score Item type Score Verbal abuse, OR threat of physical abuse to child 1 Physical abuse of child 1 Sexual abuse of child 1 Lack of supportive, loving environment 1 Neglect of child 1 Parents ever separated or divorced 1 Mother/stepmother physically abused 1 Household member substance abuse 1 Household member mental illness 1 Household member incarcerated 1 TOTAL POSSIBLE 10

70 Adverse Childhood Experiences Study Collaboration between the CDC and Kaiser 17,000 Participants Compute an ACE score to calculate early life adversity 6 or more associated with a 20-year reduction in life span 4 or more with a number of serious health conditions For more information:

71 Outline Understanding stress and its effects on the body What is your personal legacy of risk? Genetic and epigenetic Adverse childhood experiences Stress among caregivers Risk and resilience Stress Management tips!

72 Accelerated Aging In Caregivers Kiecolt-Glaser et al, 2003 PNAS

73 Similar results from the MIDUS Study Caring for a biological or adoptive parent is associated with clinically assessed biological risk factors for allostatic load Inflammatory dysfunction Metabolic dysfunction Neuroendocrine dysfunction Kang & Marks, 2014, SAGE Open Medicine

74 Outline Understanding stress and its effects on the body What is your personal legacy of risk? Genetic and epigenetic Adverse childhood experiences Stress among caregivers Risk and resilience Stress Management tips!

75 Risk and Resilience Social and biological risk is not deterministic Some individuals with fewer risk factors may develop stress-related illness Some individuals with many risk factors may appear relatively unaffected

76 Risk and Resilience Social and biological risk is not deterministic Some individuals with fewer risk factors may develop stress-related illness Some individuals with many risk factors may appear relatively unaffected Risk factors a d resilie ce factors are ofte each others opposites Easy temperament/difficult temperament; high IQ/low IQ; maternal psychopathology/good maternal health

77 Risk and Resilience Social and biological risk is not deterministic Some individuals with fewer risk factors may develop stress-related illness Some individuals with many risk factors may appear relatively unaffected Risk factors a d resilie ce factors are ofte each others opposites Easy temperament/difficult temperament; high IQ/low IQ; maternal psychopathology/good maternal health Note that with sufficient strain to the system in the absence of support, no one is immune

78 Risk and Resilience Social and biological risk is not deterministic Some individuals with fewer risk factors may develop stress-related illness Some individuals with many risk factors may appear relatively unaffected Risk factors a d resilie ce factors are ofte each others opposites Easy temperament/difficult temperament; high IQ/low IQ; maternal psychopathology/good maternal health Note that with sufficient strain to the system in the absence of support, no one is immune Note that across decades of research, one of the most powerful resilience factors is one, consistent, supportive relationship

79 Outline Understanding stress and its effects on the body What is your personal legacy of risk? Genetic and epigenetic Adverse childhood experiences Stress among caregivers Risk and resilience Stress Management tips!

80 Stress Management Tips Reduce recurrent infections Sleep better Keep your glucose levels even Choose your audience Stay tuned for Building Your Bounce!

81 Reduce Recurrent Infections You work with children and families: exposure is a given Do you get sick for 1-3 days repeatedly, or when you are sick does it drag on? Are you using hygiene just to protect them, or also to protect yourself? Are ou follo i g gra d a s ad i e? Are you using broadband medications when sick? At the very first sign of illness, are you taking care of you?

82 Sleep Better: Sleep Hygiene 101 Trouble falling asleep? Create a bedtime ritual (even a short one) Make a list before bed, then put it aside Take a warm bath Natural light exposure in the afternoon Trouble staying asleep? Avoid alcohol at least 2 hours before bedtime Wean yourself off sleep aids Be sure ou are t ollapsi g i to sleep e haustio a o e (asleep i less than 15 minutes), then awaking to the troubles you left at bedtime Keep a consistent bed and wake time

83 Keep your Glucose Levels Even Glucose is what you use for energy If your levels skyrocket and plummet, your body has to recruit processes to handle the excess (or lack of) fuel Listen to how this makes you feel Instead, consider giving it an even supply: No u super ised ar oh drates No simple sugars Food with staying power, especially for breakfast choose a protein Less processed foods

84 Choose the Audience for your Life

85