Status of stroke patients: a community assessment

A five-year follow-up of stroke survivors: motorfunction and activities of daily living

At the University Hospital, Uppsala, a study was conducted to assess and follow the changes in motor activities, primary activities of daily living (ADL) and instrumental ADL over a five-year period. The functional level of 280 acute stroke patients was assessed over five years.

One year after the stroke 193 patients (68%) were alive, and after five years 113 patients (40%). Of the latter, 101 patients were assessed. During the first year after the stroke, a significant improvement was shown in all the assessed variables. However, most of the variables had deteriorated significantly between one and five years post-stroke. The activities that were best preserved were primary ADL and locomotion. The ability to perform active movements, maintain balance, walk and perform some household tasks and some psychosocial activities had declined. Five years post-stroke approximately one-quarter had substantial motor loss and one-third were moderately impaired. Three-quarters managed their primary ADL without or almost without help. Differences were found between men and women in instrumental ADL behaviour, the women showing more deterioration post-stroke. In spite of this most of the patients felt satisfied with their health and life situation.

Comparisons of social interaction and activities of daily living between long-term care facility and community-dwelling stroke patients

[Purpose] This study was conducted to compare the correlation between social interaction and activities of daily living (ADL) between community-dwelling and long-term care facility stroke patients. [Subjects and Methods] The Subjects were 65 chronic stroke patients (32 facility-residing, 33 community-dwelling). The Evaluation Social Interaction (ESI) tool was used to evaluate social interaction and the Assessment of Motor and Process Skills (AMPS) measure was used to evaluate ADL. [Results] Both social interaction and ADL were higher in community-dwelling than facility-residing stroke patients. There was a correlation between ESI and ADL for both motor and process skills among facility-residing patients, while only ADL process skills and ESI correlated among community-dwelling patients. In a partial correlation analysis using ADL motor and process skills as control variables, only process skills correlated with ESI. [Conclusion] For rehabilitation of stroke patients, an extended treatment process that combines ADL and social activities is likely to be required. Furthermore, treatment programs and institutional systems that can improve social interaction and promote health maintenance for community-dwelling and facility-residing chronic stroke patients are needed throughout the rehabilitation process.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations

BACKGROUND

Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations.

METHODS

Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model.

RESULTS

Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources.

CONCLUSION

Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

Changes in the status of hospitalized stroke patients since inception of the prospective payment system in 1983

OBJECTIVE

To describe epidemiologically the changes in acute-care delivery services for stroke victims since the inception of the 1983 prospective payment system (PPS).

DESIGN

A cross-sectional comparison of 2 acute-care hospitalized samples of stroke patients before and after implementation of PPS.

SETTING

Fifteen acute-care hospitals.

PARTICIPANTS

A total of 1992 stroke patients discharged from 15 acute care hospitals in 1995-1996 were compared with 1665 patients studied in the same geographic area in 1981-1982.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence rates, length of stay (LOS), discharge destinations, in-hospital transfers, and mortality.

RESULTS

Incidence rates between the 2 time periods remained similar (1.13-1.14/1000). Major changes between 1981-1982 and 1995-1996 included reengineering of hospitals to establish subacute units with an increased use of rehabilitation units, a 63% decrease in acute hospital LOS, a 44% increase in discharges to long-term care facilities, a 39% decrease in mortality, and a 5% decrease in discharge to home. Age (avg, 71y), gender, and living arrangements confounded discharge destinations. Significantly more men in 1995-1996 had strokes at younger ages, but overall 53% were women.

CONCLUSIONS

Institution of the PPS has dramatically influenced hospital LOS, location of treatment, and discharge destinations with no improvement in home discharges.

Epidemiologic determination of community-based nursing case management for stroke

Efforts to control costs, especially those resulting from the 1997 Balanced Budget Act, have resulted in profound opportunities for futuristic community-based nursing care. A retrospective chart review was conducted on 1,992 stroke patients discharged from 15 Cincinnati hospitals from July 1, 1995, to June 30, 1996. Determinants and descriptors of stroke distribution were identified. This study shows how nurses can plan cost-effective care while maintaining quality through an epidemiologic assessment of patient, family, and community needs.

The sequelae of hospitalization for ischemic stroke among older adults

OBJECTIVES

To estimate the independent effect of hospitalization for ischemic stroke on change in functional status, subsequent hospitalization, and mortality.

DESIGN

Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data were linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups.

SETTING

In-person and telephone interviews were conducted.

PARTICIPANTS

A total of 6071 noninstitutionalized respondents 70 years old or older at baseline.

MEASUREMENTS

Hospitalization for ischemic stroke was defined as having one or more episodes with primary discharge ICD9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Two reference groups were used: those who were hospitalized for something other than stroke, and those who were not hospitalized at all. The statistical methods employed were multivariable proportional hazards, logistic, and linear regression.

RESULTS

The adjusted hazards ratio for having a primary hospital discharge diagnosis of ischemic stroke on mortality was 7.57 (CI95% = 6.47 to 8.85) versus 3.67 (CI95% = 3.28 to 4.10) for having been hospitalized for something other than stroke (both compared with the reference category of those not hospitalized at all). The adjusted odds ratio for having any subsequent hospitalization associated with having a primary hospital discharge diagnosis of ischemic stroke (compared with having been hospitalized for something other than stroke) was not significantly elevated (AOR = 1.16; CI95% = .94 to 1.42). However, the percent increases in the subsequent number of hospital episodes, total charges, and total length of stay for those who were hospitalized for ischemic stroke relative to those hospitalized for something other than stroke were significant (P < .001), and ranged from 16.3 to 39.0%. Hospitalization for ischemic stroke was also related significantly to greater increases in the regression-adjusted mean number of instrumental activities of daily living and lower body function limitations at follow-up.

CONCLUSION

Hospitalization for ischemic stroke among older adults substantially increases the risk of subsequent mortality, the volume of hospital resource consumption, and greater functional decline, even when compared with hospitalization for something other than stroke. Therefore, greater attention to the prevention and management of ischemic stroke is needed.

Modeling case mix adjustment of stroke rehabilitation outcomes

Case mix adjustment models for long-term stroke rehabilitation outcomes should be developed (1) to facilitate equitable comparisons of outcomes across treatment settings, thereby reducing disincentives for treating complex cases, (2) to improve triage into the most appropriate level of rehabilitative care after discharge from acute care, and (3) to confirm that case mix factors are equated in treatment effectiveness studies and by random assignment across conditions in clinical trials. Case mix adjustment is necessary for valid quality improvement processes. A conceptual model of case mix adjustment of long-term rehabilitation outcomes is presented that (1) is diagnosis-specific, (2) includes demographic variables as important case mix factors, (3) encompasses triage into rehabilitation as well as treatment processes as aspects of quality of rehabilitative care, (4) contains outcomes measuring functional status as well as mortality and morbidity, and (5) keys timing of outcomes to onset of conditions requiring rehabilitation rather than discharge from rehabilitation. The number of potential interactions among case mix indicators requires a sophisticated analytic framework. Random factors in the model illustrate that case mix adjustment can never be perfect. Nevertheless, it is essential. A brief review of the stroke literature on prediction of long-term outcomes suggests that additional work is needed to specify relevant case mix indicators.

Stroke outcome in elderly people living alone

We prospectively followed 178 elderly people living alone prior to stroke who survived at least 30 days. At the time of hospital discharge and at months 2, 6 and 12 post-stroke one-third of survivors were living alone and half were living at home, either alone or with another person. Seventy-five per cent of survivors discharged to live alone were still living alone 6 months after stroke. Subjects discharged to live alone did not differ from other subjects with respect to age, gender or pre-stroke Barthel ADL score. The group discharged to live alone had less severe stroke deficits and higher ADL scores 1 week after stroke. This difference in ADL scores was maintained at hospital discharge and maximal recovery. Eleven variables were significant univariate predictors of discharge home to live alone. In multivariate models the strongest predictors of discharge home to live alone were high Barthel ADL score at day 7, high Mini-Mental State Score, high leg power and absence of homonymous hemianopia.

The Bradford community stroke trial: results at six months

OBJECTIVE

Comparison of day hospital attendance and home physiotherapy for stroke patients leaving hospital to determine which service produces greater functional and social improvement for the patient, reduces emotional stress for the care giver, and lessens the need for community support.

DESIGN

Stratified, randomised trial of stroke patients attending day hospital two days a week or receiving home treatment from a community physiotherapist. The six month assessment results are reported in this paper.

SUBJECTS

Patients over 60 years old resident within the Bradford metropolitan district discharged home after a new stroke with residual disability.

SETTING

Four day hospitals in two health authorities and domiciliary work undertaken by experienced community physiotherapists.

MAIN OUTCOME MEASURES

Barthel index, functional ambulatory categories, Motor Club assessment, Frenchay activities index, and Nottingham health profile were used. Carers' stress was indicated by the general health questionnaire. Treatment given and community care provided were recorded.

RESULTS

Of 124 patients recruited, 108 were available for reassessment at six months. Both treatment groups had significantly improved in functional abilities between discharge and six months. The improvements were significantly greater for patients treated at home (Mann-Whitney test; Barthel index, median difference 2 (95% confidence interval 0 to 3) p = 0.01; Motor Club assessment, median difference 2 (1 to 5), p = 0.01). The home treated patients received less treatment (median difference 16 (11 to 21) treatments, p less than 0.001). More than a third of patients in both groups showed depressed mood, and a quarter of care givers were emotionally distressed.

CONCLUSIONS

Home physiotherapy seems to be slightly more effective and more resource efficient than day hospital attendance and should be the preferred rehabilitation method for aftercare of stroke patients. New strategies are needed to address psychosocial function for both patients and care givers.

Social and family integration of hemiplegic elderly patients 1 year after stroke

We interviewed 120 elderly hemiplegic patients 1 year after their acute stroke to assess cognitive impairment using the Mini-Mental State Examination, functional autonomy using the Barthel Index, mood disorders using the Hamilton Rating Depression Scale, and social integration using the Social Functioning Exam. Of the 76 patients admitted to this study, eight (12.1% of those testable) had significant cognitive impairment, 41 (53.9%) were functionally self-sufficient, 27 (35.5%) showed depressive symptoms, and 44 (57.9%) had problems in social and family integration. We suggest that a complete rehabilitation program aimed at producing a good quality of life for elderly hemiplegic patients should take into account all these aspects of human existence.

Examining outcome measures in a clinical study of stroke

We investigated the relation between outcome and sample size for six selected stroke outcome measures to assist investigators in selecting end points for stroke studies. Data from a clinical trial of 167 stroke patients assessed shortly after admission to the hospital and 5 weeks later provided information on clinical, motor, and functional outcomes measured using a neurologic status scale, a stroke severity scale, the Fugl-Meyer Scale, the Barthel Index, and the activities of daily living and cognition subscales of the Level of Rehabilitation Scale. Data were examined using Pearson correlation coefficients and power analyses. All measures were significantly correlated. There was also substantial congruency between the subscales of a measure and its total score. The measures had variable efficiencies; the Barthel Index was the most efficient and therefore required the fewest subjects to identify a significant effect. These data suggest that careful consideration must be given to the choice of stroke outcome measures in terms of their numbers, interrelationships, and statistical properties, as these factors have important implications for the design, analysis, and conduct of clinical stroke studies.

Caregiver assessment of personal adjustment after stroke in a Veterans Administration Medical Center outpatient cohort

We evaluated 80 stroke patients to examine the contributions of caregiver anxiety, self-care ability, age, time since onset, marital and residential status, and need for health care services on personal adjustment as reported by caregivers. Mean age of the patients was 65.4 years, and the average time from stroke onset to evaluation was 415 days. Multiple regression analyses indicated that a significant amount of variance in patient adjustment was accounted for by caregiver anxiety (R2 = 0.28, p less than 0.05) and patient self-care ability (R2 = 0.13, p less than 0.05). Compared with community norms, stroke patients were reported to be more depressed, confused, and anxious and they demonstrated fewer household management skills. Stroke patients were not different from a normative sample on measures of interpersonal involvement or social activity. Caregivers had high levels of anxiety compared with norms. Our results may aid in developing methods for identifying stroke patients and caregivers at risk for suboptimal adjustment.

Destinations of stroke patients discharged from the Montreal area acute-care hospitals

The destinations of stroke patients after discharge from acute-care hospitals were studied to ascertain the current use of health care resources. The 1984-1985 acute-care hospital discharge listings for the province of Quebec were consulted to identify 3,045 adults of the Montreal area who were discharged, deceased or alive, with a primary or secondary diagnosis of stroke. The relation between the length of stay (i.e., the time to death or discharge to long-term care, rehabilitation, or home) and the explanatory variables (age, sex, neighborhood socioeconomic status, type of stroke, and university affiliation of the discharging hospital) was assessed using Cox's proportional hazards models. Older patients and those with hemorrhagic strokes had the highest risk of death. However, patients with hemorrhagic strokes were more likely to survive if admitted to a university teaching hospital. Older patients, those with nonhemorrhagic strokes, and those admitted to university teaching hospitals were more likely to be discharged to long-term care. A greater proportion of patients discharged to rehabilitation centers were young, lived in a high-socioeconomic-status neighborhood, and had suffered a nonhemorrhagic stroke. Patients had a significantly higher probability of going home if they were young, had had a nonhemorrhagic stroke, had been admitted to a university teaching hospital, or were male.

Outcome measurement in stroke rehabilitation research

The use of outcome measures in stroke rehabilitation research is examined in a sample of 50 representative articles. Research studies are found not adequately to reflect the aims of stroke rehabilitation expressed by leading practitioners in the field. In particular, evaluations of rehabilitation programmes tend to use physical and self-care measures to the exclusion of broader aims. Recent advances in health measurement are reviewed, and it is recommended that researchers in this area make greater use of measures of subjective evaluations of health status, family involvement in rehabilitation, patient satisfaction, and quality of life.