title: Systematic review and meta-analysis of the impact of carer stress on subsequent institutionalisation of community-dwelling older people.
abstract: BACKGROUND
  In the caregiving literature there is a common assertion that a higher level of carer stress is a critical determinant of premature ending of homecare. However, this contention has not been systematically assessed. We therefore systematically reviewed and meta-analysed the prospective association between various forms of carer stress and subsequent institutionalisation of community-dwelling older people.
  
  
  METHODS
  Systematic literature search of prospective studies measuring carer stress at baseline and institutionalisation at follow-up. Given substantial interchangeability in the measurement of carer stress, we included a wide number of exposure measures, namely: carer stress, burden, depression, distress, anxiety, burnout, and strain. Institutionalisation included both acute and long-term care utilisation. The standardised mean difference between stressed and non-stressed carers was the primary measure of effect. We assessed study quality with the Crowe Critical Appraisal Tool (CCAT). Pre-planned sensitivity analysis included examination of estimates according to study size; decade published; study quality according to quartiles of CCAT scores; population; follow-up period; study design and impact of adjusted or unadjusted estimates.
  
  
  RESULTS
  The search yielded 6,963 articles. After exclusions, we analysed data from 54 datasets. The meta-analysis found that while carer stress has a significant effect on subsequent institutionalisation of care recipients, the overall effect size was negligible (SMD = 0 · 05, 95% CI = 0 · 04-0 · 07). Sensitivity analyses found that, the effect size was higher for measurements of stress than for other measures, though still relatively small (SMD = 0 · 23, 95% CI = 0 · 09-0 · 38). Thus, whether analysing the association between carer stress, burden, distress, or depression with either acute or long-term care, the effect size remains small to negligible. Concurrently, we found estimates reduce over time and were smaller with larger studies and those of higher quality, according to the CCAT scores.
  
  
  CONCLUSIONS
  Despite strong statements to the contrary, it appears that the effect of carer stress on subsequent care recipient institutionalisation is small to negligible. The current findings point to a biased literature, with significant small study effects. The results suggest a need to re-evaluate the degree to which carer stress predicts premature ending of home care. Concurrently, other factors may be more crucial in institutional placement than carer stress and should be investigated.
authors.affiliation: Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland.
authors.forename: Nora-Ann
authors.initials: NA
authors.lastname: Donnelly
authors.affiliation: Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland.
authors.forename: Anne
authors.initials: A
authors.lastname: Hickey
authors.affiliation: Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland.
authors.forename: Annette
authors.initials: A
authors.lastname: Burns
authors.affiliation: Mercer Library, Royal College of Surgeons in Ireland, Dublin, Ireland.
authors.forename: Paul
authors.initials: P
authors.lastname: Murphy
authors.affiliation: Department of Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland.
authors.forename: Frank
authors.initials: F
authors.lastname: Doyle
mesh_terms: D000368:Aged; D017028:Caregivers / Q000523:psychology*; D003153:Community Health Services; D006801:Humans; D007326:Institutionalization; D011446:Prospective Studies; D036301:Qualitative Research; D011788:Quality of Life; D013315:Stress, Psychological