Who cares? - caring for the carers of stroke patients

Ethical issues relating to the inclusion of relatives as clients in the post-stroke rehabilitation process as perceived by patients, relatives and health professionals

OBJECTIVE

To document the ethical issues regarding the systematic inclusion of relatives as clients in the post-stroke rehabilitation process.

METHODS

A two-phase qualitative design consisting of in-depth interviews with relatives and stroke-clients (Phase 1) and three focus groups with relatives, stroke-clients and health professionals (Phase 2). Data was audio recorded. Transcribed interviews and focus groups content were rigorously analyzed by two team members.

RESULTS

The interview sample was composed of 25 relatives and of 16 individuals with a first stroke whereas the three focus group sample size varied from 5 to 7 participants. Four main themes emerged: (1) overemphasis of caregiving role with an unclear legitimacy of relative to also be a client; (2) communication as a key issue to foster respect and a family-centered approach; (3) availability and attitudes of health professionals as a facilitator or a barrier to a family-centered approach; and (4) constant presence of relatives as a protective factor or creating a perverse effect.

CONCLUSION/PRACTICE IMPLICATIONS

The needs of relatives are well known. The next step is to legitimize their right to receive services and to acknowledge the combined clinical and ethical value of including them post-stroke. Interdisciplinary health care approaches and communication skills should be addressed.

Recovery of functional status after stroke in a tri-ethnic population

OBJECTIVE

To examine recovery of functional status for white, black, and Hispanic patients who have had a stroke from the time of admission to inpatient medical rehabilitation to 12 months after discharge.

DESIGN

A longitudinal study that used information from the Stroke Recovery in Underserved Population database, a prospective observational study of persons with stroke who received inpatient medical rehabilitation services during 2005-2006.

SETTING

Eleven inpatient rehabilitation facilities located across diverse regions of the United States, including California, Florida, Iowa, Illinois, Kentucky, New Jersey, New York (2), Texas (2), and Washington, DC.

PARTICIPANTS

A total of 990 adults aged 55 years or older who had a stroke and were admitted to 1 of 11 inpatient medical rehabilitation facilities in the United States were interviewed at 4 time points, including admission to and discharge from an inpatient medical rehabilitation facility and 3 and 12 months after discharge.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status as measured by the Functional Independence Measure (FIM).

RESULTS

For the total sample, FIM ratings increased from admission to discharge and from discharge to 3-month follow-up, with little recovery occurring between 3 and 12 months. In random effects mixed models, at 3-month follow-up, both black and Hispanic patients had lower FIM ratings than did white patients. At 12-month follow-up, black and white patients were similar; however, Hispanic patients continued to have lower FIM ratings compare with white patients. Racial/ethnic group, age, length of stay, and medical comorbidities were significant predictors of total FIM ratings over the 4 time points.

CONCLUSIONS

Persons 55 years and older who have had a stroke, regardless of race/ethnicity, appear to benefit from inpatient medical rehabilitation. Most functional status gains occur during inpatient medical rehabilitation and continue in the first few months after discharge, with little change afterward.

An investigation of family carers' needs following stroke survivors' discharge from acute hospital care in Australia

PURPOSE

 To expand understanding of informal stroke care-giving, validated tools previously used in Hong Kong and in the U.K. were used with Australian stroke carers to assess their stroke-related knowledge, perceived needs, satisfaction with services received and sense of burden after stroke patients' discharge home from acute hospital care.

METHODS

 Record audit and telephone interviews with two cohorts of 32 carers recruited in Sydney and Brisbane 1 and 3 months post-hospital discharge, using validated scales and open questions in May-July 2006.

RESULTS

 Female carers, those with prior care-giving responsibility, and those interviewed at three compared to one month post-discharge reported greatest needs and burden from the care-giving role; needs alone significantly predicted burden. Getting information and being prepared for life after discharge were central concerns. Some felt this was accomplished, but inadequate information giving and communication mismatches were apparent.

CONCLUSIONS

 Service providers need to develop partnership working with stroke families and provide a network of services and inputs that cut across conventional boundaries between health and social care, public, private and voluntary organisations, with care plans that deliver what they delineate. Stroke care-givers have common issues across countries and healthcare systems; collaborative research-based service development is advocated.

Associations between positive emotion and recovery of functional status following stroke

OBJECTIVE

Accumulating evidence indicates the beneficial effects of positive emotion on health and general well-being in older age. Less evidence is available on whether positive emotion supports improvement in functional status after an acute medical event such as stroke. This study examined the association between positive emotion at discharge from inpatient medical rehabilitation and functional status 3 months later in persons with stroke.

METHODS

A longitudinal study using information from the Stroke Recovery in Underserved Patients database. The study included 823 persons aged 55 years or older with stroke and admitted to an inpatient medical rehabilitation facility. Information was collected during inpatient medical rehabilitation stay and approximately 3 months after discharge.

RESULTS

The mean age of the sample was 72.8 years (SD = 9.5), 51.5% were women and 53.8% were married. The sample was mostly non-Hispanic white (79.2%), followed by non-Hispanic black (15.0%) and Hispanic (5.8%). The average length of stay was 20.1 day (SD = 10.1). In multivariate regression analyses, discharge positive emotion score was significantly associated with higher overall functional status (b = 0.70, SE = 0.21, p = .001) as well as with higher motor (b = 0.37, SE = 0.17, p = .003) and cognitive (b = 0.30, SE = 0.05, p = .0001) status at 3-month follow-up after adjustment for relevant risk factors.

CONCLUSIONS

Our results indicate positive emotion is associated with gains in functional status after stroke. Findings have implications for stroke recovery programs and suggest the need to include measures of positive emotion inpatient assessments.

Changes in Participation Level after Spouse’s First Stroke and Relationship to Burden and Depressive Symptoms

BACKGROUND

No comprehensive data are available on the impact of stroke on the spouse's participation level. The purpose of this study was to document changes in participation level over time and explore associations between changes in participation level, burden and depressive symptoms for spouses of people who had had a first stroke.

METHODS

Participants were spouses recruited in the first 2 weeks after admission of individuals with a first stroke to acute care. Prestroke measures (T0) were collected at recruitment, simultaneously with the first measure (T1); further measures were collected 6 months after the stroke event (T2). Participation level was measured with the LIFE-H, perceived burden with the Caregiver Strain Index and depressive symptoms using the Beck Depression Inventory (BDI).

RESULTS

Mean age of participants (n = 54) was 69 years (SD 10.9) and the majority were female (75.9%). Changes in participation include small but significant increases at T1 for the nutrition (effect size, ES, 0.34) and responsibilities (ES 0.22) domains, and large significant persistent decreases at T2 compared to T0 were found for personal relationships (ES 0.83), employment (ES 0.63) and recreation (ES 0.93). Changes in these last three participation domains are associated with a higher Caregiver Strain Index score (p < 0.01) but not with the BDI.

CONCLUSIONS

Participation domains mostly affected for spouses after stroke were personal relationships, employment and recreation which could be addressed by clinicians in their provision of support.