The Barthel ADL index one year after stroke: comparison between relatives' and occupational therapist's scores

Stroke patients and long-term training: is it worthwhile? A randomized comparison of two different training strategies after rehabilitation

Objective : To find out if there were any differences in improvement and maintenance of motor function, activity of daily living and grip strength between patients with first-ever stroke receiving two different strategies of physical exercise during the first year after stroke.

Design : A longitudinal randomized controlled stratified trial.

Setting : Rehabilitation institutions, community, patients' homes and nursing homes.

Subjects : Seventy-five male and female first-time-ever stroke patients: 35 in an intensive exercise group and 40 in a regular exercise group.

Intervention : The intensive exercise group received physiotherapy with focus on intensive exercises in four periods during the first year after stroke. The regular exercise group patients were followed up according to their subjective needs during the corresponding year.

Main outcome measures : Motor Assessment Scale, Barthel Index of Activities of Daily Living, and grip strength.

Results : Both groups improved significantly up to six months when function stabilized. The groups did not differ significantly on any test occasions. The difference of improvement from admission to discharge was significant in favour of the intensive exercise group, in the Motor Assessment Scale total score (intensive exercise group 7.5; regular exercise group 1.7, P = 0.01), and in the Barthel Index of Activities of Daily Living total score (17.4 versus 8.9, P = 0.04).

Conclusion : Motor function, activities of daily living functions and grip strength improved initially and were maintained during the first year after stroke in all patients irrespective of exercise regime. This indicates the importance of motivation for regular exercise in the first year following stroke, achieved by regular check-ups.

Differences between patient and proxy reports in the assessment of disability after stroke

Objective : To determine whether the assessment of disability level including basic activities of daily living (ADL) and instrumental ADL varies between patients' and proxy respondents' reports, and to explore the factors influencing proxy agreement.

Design : Patient—proxy agreement study.

Setting : Hospital settings.

Subjects : Fifty-two stroke patients with mild or without cognitive impairments and their primary caregivers voluntarily participated in this study.

Main measures : The self-administered versions of the Barthel Index and Frenchay Activities Index were completed by the patients and their proxy respondents concurrently, yet separately, to assess the level of disability.

Results : The proxy agreement on total scores of the self-administered Barthel Index and self-administered Frenchay Activities Index demonstrated moderate to good agreement (self-administered Barthel Index: intraclass correlation coefficient (ICC) = 0.71; self-administered Frenchay Activities Index: ICC = 0.6). There were no significant differences between patient and proxy reports on self-administered Barthel Index and self-administered Frenchay Activities Index scores (paired

t = —0.22, P = 0.83; paired t = 0.88, P = 0.39, respectively). However, limits of agreement of patient and proxy reports on the self-administered Barthel Index and self-administered Frenchay Activities Index were notable. Stepwise regression analysis found no significant variables associated with proxy agreement.

Conclusions : These results indicate that it is appropriate for research purposes, but not appropriate for clinical usage, to use proxy reports to measure disability levels in patients with stroke. Furthermore, the two methods should not be used interchangeably to monitor patients because of the wide limits of agreement between patient and proxy reports on the self-administered Barthel Index and self-administered Frenchay Activities Index.

Quality of life in young adults with cerebral palsy

BACKGROUND

Little is known about the quality of life (QOL) of young adults with cerebral palsy.

OBJECTIVE/HYPOTHESIS

This cross-sectional analysis compares the QOL of a cohort of young Australian adults with CP with a cohort of able-bodied peers to explore the relationship between QOL and impairments, functioning, and social participation.

METHODS

Young adults identified from the Victorian Cerebral Palsy Register were invited to complete a survey about QOL, gross motor function, independence in self-care, and social participation. QOL was assessed with the Quality of Life Instrument for Young Adults (YAQOL). A general population sample of young North American adults, who had completed the YAQOL was selected for comparison.

RESULTS

Surveys and consent forms were completed by 335 young adults or their proxies, an overall participation rate of 63% of those located. The mean age of the study participants was 24.7 [s.d = 2.8] years; 51% were male and 49% female. Two hundred and seven (62%) of the 335 participants self-reported their QOL. When compared with the general population sample, self-reporting participants had similar QOL scores for the social relationship and environmental context domains (p > 0.05), while QOL scores were lower for the physical health, psychological well-being, and role function domains (p < 0.001). There was no association between psychological well-being and variables related to body structure and gross motor function in young adults with CP.

CONCLUSIONS

Contrary to the assumption that young adults with severe CP have low psychosocial well-being, it is apparent that these individuals can have good psychosocial well-being regardless of their disability.

Older adult stroke survivors discussing poststroke depressive symptoms with a healthcare provider: a preliminary analysis

PURPOSE

The purposes of this study were to examine the relationship between the poststroke depressive symptoms, older adult stroke survivors' perceptions of the depressive symptoms, and the congruence with an informal caregiver about the presence of depressive symptoms, and comfort talking to the health care provider with whether or not older stroke survivors discussed their depressive symptoms with a health care provider.

METHOD

A cross-sectional study where 44 caregiver/older adult stroke survivor dyads completed questionnaires including the Center for Epidemiologic Studies Depression Scale, Symptom Perception Questionnaire, and reporting of depressive symptoms to the health care provider via one time interview.

RESULTS

Thirty-seven percent (n = 16) of all older stroke survivors reported depressive symptoms to their health care provider. Of the stroke survivors who had high levels of depressive symptoms (CESD ≥ 16; n = 11), seven reported the depressive symptoms to their health care provider. Identifying the symptoms as possible depression and attributing the cause of the depressive symptoms to the stroke were related to stroke survivors reporting the depressive symptoms to a health care provider.

CONCLUSIONS

High functioning, older stroke survivors may benefit from strategies to help them identify when they experience depressive symptoms, in order to be able to play an active role in their recovery by appropriately discussing their symptoms with a health care provider.

Reliability of a short questionnaire for the diagnosis of severe disability in polypathological patients attended in hospital setting

BACKGROUND

A comprehensive evaluation of polypathological patients (PP) should always include a functional evaluation. For this purpose, a modified version of the Barthel Index (BI) is the most applied questionnaire, and it consists of a 10-variable scale. The aim of this study was to develop a screening and confirmation tool to diagnose high disability with the fewest number of dimensions of the BI as possible.

METHOD

This present cross-sectional observational multicentre study included PP attended in 36 Spanish hospitals that were divided into two geographical areas (Western and Eastern). The Western area was considered to be the derivation subgroup of PP, and the Eastern area was the validation subgroup. Complete disability for each item (value of 0) was assessed for the diagnosis of severe disability. Diagnostic validity indices (sensitivity, specificity, negative and positive predictive values [NPV and PPV, respectively], and negative and positive likelihood ratios [NLR and PLR, respectively]) were determined for the derivation subgroup. The dimensions with the best diagnostic validity indices were then used to evaluate the validation subgroup.

RESULTS

The analysis included 1521 PP, 753 PP from the Western area and 768 PP from the Eastern area. Needing complete help for bathing showed the highest NPV and lowest NLR in the derivation/validation subgroups (NPV 96.87/95.54, NLR 0.07/0.13). Being disabled for feeding alone showed high PPV and PLR values (PPV 97.97/95.65, PLR 109.25/49.62), as did disability for transfers (PPV 98.48/97.96, PLR 143.36/107.68). In addition, complete disability for feeding and transfers had the best PPV and PLR in both subgroups (PPV 100/100, PLR X/0).

CONCLUSIONS

A two-dimension mini-Barthel Index may represent a reliable diagnostic test for severe disability in PP.

The effect of a pre- and post-operative orthogeriatric service on cognitive function in patients with hip fracture. The protocol of the Oslo Orthogeriatrics Trial

BACKGROUND

Hip fractures mainly affect older people. It is associated with high morbidity and mortality, and in particular a high frequency of delirium. Incident delirium following hip fracture is associated with an increased risk of dementia in the following months, but it is still not firmly established whether this is an association or a causal relationship. Orthogeriatric units vary with respect to content and timing of the intervention. One main effect of orthogeriatric care may be the prevention of delirium, especially if preoperative and postoperative care are provided. Thus, the aim of Oslo Orthogeriatric Trial, is to assess whether combined preoperative and postoperative orthogeriatric care can reduce the incidence of delirium and improve cognition following hip fracture.

METHODS/DESIGN

Inclusion and randomisation will take place in the Emergency Department, as soon as possible after admission. All patients with proximal femur fractures are eligible, irrespective of age, pre-fracture function and accommodation, except if the fracture is caused by a high energy trauma or the patient is terminally ill. The intervention is pre-and post-operative orthogeriatric care delivered on a dedicated acute geriatric ward. The primary outcome measure is a composite endpoint combining the Clinical Dementia Rating Scale (CDR) and the 10 word memory task at four months after surgery. Secondary outcomes comprise incident delirium, length of stay, cognition, mobility, place of residence, activities of daily living and mortality, measured at 4 and 12 months after surgery. We have included 332 patients in the period 17th September 2009 to 5th January 2012.

DISCUSSION

Our choice of outcome measures and our emphasis of orthogeriatric care in the preoperative as well as the postoperative phase will enable us to provide new knowledge on the impact of orthogeriatric care on cognition.

TRIALS REGISTRATION

ClinicalTrials.gov NCT01009268.

Stroke survivor and informal caregiver perceptions of poststroke depressive symptoms

Poststroke depression is common but remains underdiagnosed and undertreated. One explanation for this is that depressive symptoms go unrecognized by stroke survivors and their family caregivers and thus go unreported to the stroke survivor's healthcare provider. Forty-four stroke survivor-informal caregiver dyads were interviewed using a depression knowledge scale, the Center for Epidemiologic Studies Depression Scale, and an adapted version of the Revised Illness Perception Questionnaire to determine their lay knowledge of depressive symptoms, recognition of poststroke depressive symptoms, and perception of the recognized symptoms. Caregivers and stroke survivors had moderate knowledge of depressive symptoms but had some misconceptions. The most commonly recognized poststroke depressive symptoms by stroke survivors were "feeling like everything was an effort," "restless sleep," "difficulty concentrating," and "talking less than usual." Caregivers identified that the stroke survivor was "feeling like everything was an effort," had "restless sleep," "felt sad," and "felt depressed." Three quarters of stroke survivors with high levels of depressive symptoms identified the cluster of symptoms as potentially being depression. Neuroscience nurses are in the unique position to educate stroke survivors and their caregivers about poststroke depressive symptoms, treatment options, and the importance of discussing depressive symptoms with their healthcare provider.

Confiabilidade de escalas de comprometimento neurológico em pacientes com acidente vascular cerebral

Escalas de comprometimento neurológico são utilizadas na avaliação de novos tratamentos, no acompanhamento da evolução clínica e em decisões terapêuticas. Estudamos a confiabilidade de três escalas: a Escala de Rankin (ER), o Índice de Barthel (IB) e a National Institute of Health Stroke Scale (NIHSS) versadas em português, em 51 indivíduos com acidente vascular cerebral, estimando a concordância entre resultados de diferentes examinadores. Utilizamos os coeficientes de concordância Kappa e Coeficiente de Correlação Intraclasse. A ER teve coeficientes moderados, substanciais ou excelentes. No IB estes foram substanciais ou excelentes nos totais e nos itens, assim como quando foi estratificado em agrupamentos prognósticos e funcionais. A NIHSS apresentou coeficientes excelentes nos totais, substanciais nos itens e moderados e excelentes nas estratificações em grupos de pontos e de itens afins. Estes resultados indicam que as versões em português da ER, o IB e a NIHSS apresentam adequada confiabilidade.

Critical Appraisal and Review of the Rankin Scale and Its Derivatives

BACKGROUND AND PURPOSE

Efforts to reduce stroke burden require accurate assessment of outcomes in order to compare treatments. The Rankin Scale and its derivatives, the Modified Rankin Scale and the Oxford Handicap Scale, taken together, are among the most common outcome measures that have been used in stroke research. The aim of this study was to perform a critical appraisal of the clinimetric properties of these scales. It was also planned to review the use of these scales in a selection of articles to illustrate concerns raised by the critical appraisal.

SUMMARY OF REVIEW

A literature search was performed using electronic databases to locate relevant articles about the reviewed scales. The scales were appraised using a structured format regarding the following properties: purpose, development, presentation, language, method of administration, content validity, face validity, feasibility, construct validity, reliability, responsiveness, and generalizability. There are concerns in each of the appraised areas regarding the clinimetric properties of these scales.

CONCLUSION

Further work is needed to improve the clinimetric properties of the reviewed scales to ensure that they are more useful tools in determining the outcome of stroke. Alternatively, a newer global outcome scale with improved clinimetric properties may be a better option for future stroke research.

[The Barthel Index in geriatrics. A context analysis for the Hamburg Classification Manual]

The Barthel Index (BI) is firmly established as an assessment instrument in geriatrics. It is a proven, clear and easy-to-use instrument for the recording of basic daily functions. However it is increasingly finding new applications beyond its original, clinically orientated use. It has been applied as a quality parameter, as an instrument for the management of service delivery provision and as an instrument to record treatment efforts relevant to care or costs. This study considers the basic suitability prerequisites of the Barthel Index for these applications.With the Hamburg Classification Manual for the BI, German geriatrics has made a contribution to the standardized operationalization of the items and to the standardized evaluation of aids. An evaluation was performed on a total of 5262 Barthel classifications at seven geriatric hospitals according to existing classification practice by comparison with 5483 classifications after introduction of the Hamburg Classification Manual. No significant differences were found in Barthel Index total scores either on admission or on discharge. With respect to further applications it is essential to be aware that the usability of the total score (including its changes over the course of time) is limited because of the ordinal scaling of the BI. Studies have been carried out which show how important this is, although they have so far received little attention. As a grading criterion the BI takes account not only of the "functional status" but also of the "extent of support effort". This can lead to positive changes in one focus -- especially with the use of aids -- without associated improvements in the other focus. Whether the BI in this form is meaningful for a specific application must be tested separately for each individual context. There is no justification for assuming that the BI has general validity irrespective of application. The results of a systematic literature survey on the testing quality criteria of the BI indicate an astonishingly generous approach to the question of the validity of the BI. Contrary to widespread opinion, cognitive-psychological components do influence the classification result of the BI. As an addition to the Hamburg Classification Manual we recommend that the extent of this influencing factor should also be more clearly operationalized and that "stimulation required" for the carrying out of an activity be included in the evaluation equivalent to the factor "supervision required" already introduced by Barthel and Mahoney. The BI has shown itself to be an efficient but nonetheless multidimensional global parameter in clinical practice, whose meaningfulness is on the level of the individual item and whose validity, particularly as total score and course parameter, needs to be proven for each new application. The Hamburg Classification Manual, as a standardized and consensus-based operationalization of the BI, provides an important basis for this.

The Families In Recovery From Stroke Trial (FIRST): primary study results

OBJECTIVE

Social support and family ties are strong predictors of functional recovery after stroke; however, development of successful psychosocial intervention programs has been difficult. This study examined whether a family-systems intervention designed to influence social support and self-efficacy affects functional outcome in older stroke patients.

METHODS

Two hundred ninety-one community-residing survivors of ischemic stroke or nontraumatic cerebral hemorrhage from eight acute-care hospitals and rehabilitation centers were randomized to either psychosocial intervention (PSI) or usual care (UC). PSI involved up to 16 sessions conducted in the home by a mental health worker. Functional recovery (measured by the Barthel Index [BI] at 6 months postrandomization, inability to assess functioning because of illness or death) was the primary end point.

RESULTS

Functional recovery did not differ between UC and PSI in intention-to-treat analyses. In adjusted logistic regression, the odds of being functionally independent at 6 months was 60% higher in the intervention group, but this difference was not statistically significant (p = .31). Subgroup analyses revealed that PSI may be more effective in subjects with better psychologic and cognitive functioning and who required less inpatient rehabilitation.

CONCLUSION

This study does not provide evidence for the efficacy of psychosocial intervention to improve functional recovery in stroke. Although PSI showed greater improvement than UC, the differences were not statistically significant.

Further evidence for the agreement between patients with stroke and their proxies on the Frenchay Activities Index

OBJECTIVE

To determine item, subscale and total score agreement on the Frenchay Activities Index (FAI) between stroke patients and proxies six months after discharge from rehabilitation.

DESIGN

Prospective study design.

SETTING/SUBJECTS

Fifty patient-proxy pairs, interviewed separately, in the patient's residence.

MAIN OUTCOME MEASURES

Modified FAI using 13 items. Individual FAI items, subscales and total score agreement as measured by weighted kappa and intraclass correlation coefficients (ICC).

RESULTS

Excellent agreement was found for the total FAI (ICC 0.87, 95% confidence interval (CI) 0.78-0.93), and domestic (ICC 0.85, 95% CI 0.73-0.91) and outdoor (ICC 0.87, 95% CI 0.78-0.95) subscales, with moderate agreement found for the work/leisure subscale (ICC 0.63, 95% CI 0.34-0.78). For the individual FAI items, good, moderate, fair and poor agreement was found for five, three, four and one item, respectively. The best agreement was for objective items of preparing meals, washing-up, washing clothes, shopping and driving. The poorest agreement was for participation in hobbies, social outings and heavy housework. Scoring biases associated with patient or proxy demographic characteristics were found. Female proxies, and those who were spouses, scored patients lower on domestic activities; male patients, and those who were younger, scored themselves higher on outdoor activities and higher patient FIM scores were positively correlated with higher FAI scores.

CONCLUSIONS

While total and subscale agreement on the FAI was high, individual item agreement varied. Proxy scores should be used with caution due to bias.

Quality of life for caregivers and stroke survivors in the immediate discharge period

Caregiver burnout leads to a decline in caregivers' quality of life and in the quality of care they can deliver. A sample of 22 stroke survivors and informal care givers from a 500-bed metropolitan teaching hospital were interviewed using a questionnaire. Pre- (at discharge) and post- (1 month later) test scores were tested using Wilcoxon rank tests. Associations between activities of daily living and quality of life were tested with Spearman's correlation coefficient. Over the month, caregivers' scores for relationships, social companionship, and daily emotional support decreased (but not significantly). Short hospital stays affected the recruitment for this study and contributed to problems for ward staff in implementing discharge plans. More innovative discharge planning is needed if caregivers' needs are to be met.

Comparison of patient and doctor responses to a total hip arthroplasty clinical evaluation questionnaire

BACKGROUND

Surgeons traditionally undertake a prospective evaluation of patients undergoing total hip arthroplasty in order to determine outcomes. The validity of doctor-derived data is questionable because of the potential for interobserver error, reporting bias, and differences between the perceptions of doctors and patients. Also, the use of doctor-derived data necessitates the use of costly outpatient services. Consequently, there are likely to be benefits associated with the use of patient-derived clinical evaluation data. However, few studies have focused on whether data obtained from the patient and doctor differ.

METHODS

The agreement between patient and doctor responses on a sixteen-item total hip arthroplasty clinical evaluation questionnaire completed at more than 2900 clinical assessments was determined. Data from repeated assessments performed preoperatively and postoperatively enabled stratified analyses that were used to examine reasons for disagreement and factors influencing agreement. Agreement was measured with use of the kappa coefficient.

RESULTS

For twelve of the sixteen items, the patient responses had acceptable agreement with the doctor responses. Some important differences between patient-derived and doctor-derived data were found. If the patient had other joint or health problems, had a revision total hip arthroplasty, or reported mild or moderate pain, there was a greater chance of reduced agreement on the pain items. Younger patients demonstrated better agreement with doctors than older patients did.

CONCLUSIONS

Patients' perceptions of symptoms and outcomes after total hip arthroplasty are relatively similar to those of their doctor. There is minimum risk of misinterpreting outcomes data by replacing doctor-completed questionnaires with patient-completed questionnaires in uncomplicated total hip arthroplasty cases. For patients with comorbid joint problems or other health problems, and for those reporting substantial pain, direct physician involvement in the evaluation of pain is recommended. The selective use of patient-completed questionnaires has the potential to substantially reduce the costs of outcomes evaluation programs by minimizing doctor input. Pending revision of some of the items, the use of this patient-completed questionnaire is advocated.

Prediction of long-term functional outcome after stroke rehabilitation

OBJECTIVE

To find patient characteristics in the early post stroke phase that could predict three years functional outcome.

DESIGN

Prospective study.

SETTING

In-hospital rehabilitation department (admission and discharge). Outpatient department one and three years post stroke.

SUBJECTS

One hundred and forty-two stroke patients (56% women), median age 75 years.

MAIN OUTCOME MEASURES

Barthel Index (BI) score; BI score change; accommodation status; Rankin scale score; and Frenchay Activities Index (FAI) score, all registered three years post stroke.

RESULTS

The percentages of patients still living at home after one and three years were 88% and 83%, respectively. Twenty per cent of the patients had deteriorated according to the BI after three years, mostly due to recurrent strokes (odds ratio (OR) 10.3; 95% confidence interval (CI) 3.0-35.5) and co-morbidity with other disabling disorders (OR 3.9; CI 1.1-13.5). Co-morbidity also emerged as an important risk factor for dependency according to BI score (OR 8.8; Cl 2.4-32.1) as well as for a poor FAI score (OR 4.9; CI 1.9-13.0). BI in the early phase was the strongest predictor for long-term functional outcome. Urinary incontinence emerged as a risk factor for nursing home placement after three years (OR 3.2; CI 0.9-11.3). Cognitive dysfunction was a risk factor for poor FAI scoring (OR 2.7; CI 1.0-7.0).

CONCLUSIONS

After stroke rehabilitation, concomitant chronic disabling disorders and recurrent strokes seem to play an important role regarding dependency, handicap and long-term functional decline.

Relationship between cognitive impairments and rated activity restrictions in stroke patients

OBJECTIVE

To investigate the relationship between cognitive impairments and rated activity restrictions.

DESIGN

Comparison of neuropsychological tests and activity questionnaires. Activity ratings were made by staff and stroke patients.

SETTING

Two neurological rehabilitation hospitals.

PARTICIPANTS

Eighty-seven stroke patients.

RESULTS

Moderately high correlations were found between cognitive test scores and activity ratings made by staff members. In contrast, correlations between ratings made by patients and cognitive tests were much lower. There was also little agreement between the staffs' ratings and the patients' own ratings. Multiple regression analyses indicate that cognitive impairments account for 28.9% of the variance in the activity rating made by the staff members. The coefficient of determination was slightly higher when age, time since onset of illness, and depression scores were included as predictors.

CONCLUSIONS

These findings provide partial support for a hierarchical structure of the "International Classification of Impairment, Activities and Participation" model of the World Health Organization.

Inter-rater reliability of the Barthel ADL index: how does a researcher compare to a nurse?

OBJECTIVES

To investigate whether a nonclinical research assistant, using standardized scoring criteria, can reliably administer the Barthel Activities of Daily Living (ADL) Index in a sample of elderly inpatients.

DESIGN

Paired comparison of nurse and nonclinical research assistant Barthel Index assessments.

SETTING

Acute hospital wards from two hospitals in a UK Healthcare Trust, with a catchment population of approximately 224,000 people.

METHODS

A consecutive sample of 94 elderly patients with a variety of medical problems.

MAIN OUTCOME MEASURES

Barthel ADL Index, Folstein Mini-Mental Status Examination.

RESULTS

Whilst the inter-rater reliability of the Barthel Index was within acceptable boundaries, two items out of ten had only fair agreement and low crude agreement (transfer and dressing) on Cohen's kappa scores.

CONCLUSIONS

Depending on the differences observed in any particular context, the Barthel Index can be applied with reasonable reliability by nonclinical staff applying the standardized scoring criteria. It should be noted, however, that the kappa coefficients between clinical and nonclinical assessors tend to be lower than those found when comparing two clinically trained assessors in previous research.

Disagreement in patient and carer assessment of functional abilities after stroke

BACKGROUND AND PURPOSE

The aims of this study were to describe differences between functional ability assessments made by stroke patients and their informal carers and to investigate the psychological associates of the difference in assessments.

METHODS

A prospective design was used, with repeated assessments of function, mood, and carer strain. Thirty hospital stroke patients and their main carer were interviewed 3 times: within 1 month of stroke, 1 month after discharge, and 6 months after discharge.

RESULTS

There were significant differences between patient and carer assessments at all 3 time points, with patient self-assessment less disabled than carer assessment (at least P<0.02). The disagreement in assessment was unrelated to patient or carer mood (P>0.05) but greater disagreement was associated with greater carer strain (P<0.05). The source of the disagreement in functional ability assessment remains unclear.

CONCLUSIONS

The method of assessment affects the rating of functional abilities after stroke. Carer strain is potentially increased when the patient or carer makes an unrealistic assessment of the patient's level of independence.

Functional status of elderly home care users: do subjects, informal and professional caregivers agree?

Professional or informal proxy respondents are frequently used in surveys when physical or mental health may compromise the ability to participate or the quality of responses. Functional status (Katz activities of daily living [ADL], Lawton instrumental activities of daily living [IADL]) was assessed in a sample of 420 chronically dependent elderly receiving home care. Separate in-person interviews were conducted with subjects, main informal caregivers and professionals coordinating home care. We found substantial agreement (Kappa) particularly between subjects and informal caregivers in all ADL except continence and in all IADL except housekeeping. High levels of agreement were also found for cognitively impaired subjects (Mini-Mental State Examination <24). Disagreement was characterized by more frequent reports of dependence from informal and professional caregivers. Our data suggest that proxy responses by informal caregivers conform with answers provided by subjects but produce slightly higher estimates of dependence and that cognitively impaired elderly living in the community will provide accurate information on their functional status in most cases.

Stroke unit versus general medical wards, II: neurological deficits and activities of daily living: a quasi-randomized controlled trial

BACKGROUND AND PURPOSE

The efficacy of stroke units has been extensively examined. It is unknown, however, whether the superiority of the stroke unit will remain after the increased focus on stroke treatment in general medicine. This study of patients admitted to the hospital early and with a short length of stay determines the effect and identifies certain important components of a stroke unit.

METHODS

Five hundred fifty patients aged 60 years or older with acute stroke were allocated by a quasi-randomized design to a stroke unit or a general medical ward based on date of birth in the month. Patients admitted within 24 hours of onset were enrolled. Outcomes after 7 months were death, proportion needing long-term care, and change in neurological and functional state assessed by the Scandinavian Stroke Scale and Barthel Index.

RESULTS

Seven months after admission there was a trend in favor of the stroke unit in all outcome measures, but no significant differences in clinical outcomes were found except for change in the Scandinavian Stroke Scale score. Recurrent stroke during hospitalization occurred more often in the general medical ward (P = .03). The stroke unit was significantly more aggressive in mobilization out of bed (P<.01) and use of parenteral fluid (P<.0001), aspirin (P<.0001), antipyretics (P<.0001), and antibiotics (P<.0001).

CONCLUSIONS

Our study confirms the benefit of the stroke unit, but the effects on the most reliable clinical outcomes were modest and insignificant. Treatment in this stroke unit hastened recovery. More aggressive rehabilitation and use of parenteral fluid, aspirin, antipyretics, and antibiotics appeared in the stroke unit.

Outcome after stroke rehabilitation in Hong Kong

OBJECTIVE

To determine the outcome of patients discharged to the community after stroke rehabilitation.

METHODS

One hundred and eighty-five consecutive patients discharged after stroke rehabilitation were enrolled for follow-up 12 months after discharge from a hospital in Hong Kong. A telephone interview to determine disability and place of residence was conducted. Disability was assessed by the Barthel Index and ratings of activities of daily living and mobility on a 4-point scale.

RESULTS

One hundred and thirty-one patients or their carers were contacted (70.1%). This comprised 19 patients (10.3%) who died and 112 patients or their carers (60.5%) who were interviewed. Fifty-four patients (29.2%) were lost to follow-up. Comparison of the patients contacted and those lost to follow-up did not detect membership bias. Median Barthel Index of the surviving patients who were contacted rose from 90.0 (interquartile range 78.75-100.0) at discharge to 100.0 (interquartile range 85.0-100.0) at 12 months. Ratings of activities of daily living and mobility were maintained, with significant improvement in toileting. After rehabilitation 77.3% of the patients were discharged home and there was no significant change in residence at 12 months. Elderly patients (> or = 70 years old) had higher rates of institutionalization after hospital discharge and more disability although they achieved similar gains in Barthel Index and had similar lengths of hospital stay compared to younger patients.

CONCLUSIONS

These results suggest that stroke patients were able to maintain their gains achieved during inpatient rehabilitation up to one year after discharge from hospital.

The Frenchay Activities Index in stroke patients: agreement between scores by patients and by relatives

The aim of the study was to compare stroke patients' own scorings of the Frenchay Activities Index with scorings based on interviews with their nearest relatives. Fifty-two patients and relatives were interviewed separately 1 year after the stroke. The mean sumscore based upon information from the patients was 29.0, and that based upon the relatives' replies was 27.7 (mean difference 1.4, 95% confidence interval (CI) -0.1 to 2.8). The Kendall tau B correlation between the two sumscores was 0.72 (95% CI 0.63 to 0.81). In half of the patients the two sumscores differed by four points or more, and in every fourth the two sumscores differed by six points or more. The weighted kappa for the single items varied between 0.36 and 0.89. No characteristics of patients or relatives were identified that were related to disagreement between the two scores.