Ann-Cathrin Jönsson

Determinants of Quality of Life in Stroke Survivors and Their Informal Caregivers

Background and Purpose— We examined longitudinal changes of quality of life (QOL) covering physical and mental factors in an unselected group of stroke patients and their informal caregivers. Our hypothesis was that informal caregivers would have better QOL than patients at both follow-ups, and that changes, if any, would be related to the patients’ status. Methods— QOL of 304 consecutive stroke patients and their 234 informal caregivers from the population-based Lund Stroke Register was assessed 4 months after stroke onset with the Short Form 36 (SF-36) questionnaire. SF-36 was repeated for both groups after 16 months together with Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS-20) for patients. Results— The patients’ mean QOL scores improved between 4 and 16 months after stroke in the socio-emotional and mental SF-36 domains and decreased in the domain physical function. Multivariate analyses showed that the patients’ most important determinants of QOL after 16 months were GDS-20 score, functional status, age, and gender. Informal caregivers had better QOL than patients except for the domain role emotional and the mental component summary. The caregivers’ most important determinants of QOL were their own age and the patients’ functional status. Conclusions— Our study highlights depressive symptoms in determining QOL of stroke patients. Despite self-perceived deterioration in physical function over time, several other components of QOL improved, suggesting internal adaptation to changes in their life situations. Informal caregivers of stroke patients may be under considerable strain as suggested by their lower emotional–mental scores.

Shoulder Pain After Stroke A Prospective Population-Based Study

Background and Purpose— Shoulder pain is a well-known complication after stroke, but data on prevalence, predictors, and outcome in unselected stroke populations are limited. Methods— During a 1-year period, 416 first-ever stroke patients were included in the population-based Lund Stroke Register. After 4 months, 327 patients were followed up and 1 year later, the surviving 305 patients were followed up again. General status (National Institutes of Health Stroke Scale score) was registered at stroke onset. Shoulder pain intensity (visual analog scale, score 0 to 30=no–mild and 40 to 100=moderate–severe pain); arm motor function; restricted dressing and/or ambulating; and functional status (Barthel Index) were registered at both follow ups. Results— Shoulder pain onset within 4 months after stroke was reported by 71 patients (22%). Among the 61 patients able to score the visual analog scale, 79% had moderate–severe pain. One year later, 8 of these 71 patients had died, 17 had no remaining pain, and 28 additional patients had developed shoulder pain since the first follow up. Lost or impaired arm motor function and high National Institutes of Health Stroke Scale score were predictors of shoulder pain. Shoulder pain restricted daily life often or constantly when dressing for 51%/31% and when ambulating for 29%/13% of the patients at 4 and 16 months, respectively. Conclusion— Almost one third of the 327 patients developed shoulder pain after stroke onset, a majority with moderate– severe pain. Shoulder pain restricts patients’ daily life after stroke. The increased risk of shoulder pain for patients with impaired arm motor function and/or low general status needs close attention in poststroke care.

Prevalence and intensity of pain after stroke: a population based study focusing on patients’ perspectives

Objective: To determine prevalence and intensity of pain after stroke, focusing on patients’ perspectives. Methods: During a one year period, 416 first-ever stroke patients were included in the population based Lund Stroke Register. After 4 and 16 months (median), 297 patients (98% of survivors) were followed up. Worst pain intensity during the previous 48 hours was assessed on a visual analogue scale (VAS), range 0 to 100: a score of 0 to 30 was defined as no or mild pain; 40 to 100 as moderate to severe pain. NIH stroke scale (NIHSS) score and HbA1c were assessed at baseline. At 16 months, screening for depression was done using the geriatric depression scale (GDS-20), and cognition with the mini-mental state examination (MMSE). Predictors of pain were determined by multivariate analyses. Results: Moderate to severe pain was reported by 96 patients (32%) after four months (VAS median = 60). Predictors of pain were younger age (p = 0.01), female sex (p = 0.006), higher NIHSS score (p<0.001), and raised HbA1c (p = 0.001) at stroke onset. At 16 months, only 62 patients (21%) had moderate to severe pain, but pain intensity was more severe (median VAS score = 70; p<0.016). Higher pain intensity correlated with female sex, worse GDS-20 score, better MMSE score, and raised HbA1c. Pain was persistent in 47%, disturbed sleep in 58%, and required rest for relief in 40% of patients. Conclusions: Although prevalence of pain after stroke decreased with time, after 16 months 21% had moderate to severe pain. Late pain after stroke was on average more severe, and profoundly affected the patients’ wellbeing.

Stroke Incidence and Survival in the Beginning of the 21st Century in Southern Sweden Comparisons With the Late 20th Century and Projections Into the Future

Background and Purpose— We report trends of stroke incidence and survival up to year 2001/2002 in Lund-Orup, Sweden, and projections of future stroke incidence in Sweden. Methods— Lund Stroke Register, a prospective population-based study, included all first-ever stroke patients, between March 1, 2001 and February 28, 2002, in the Lund-Orup health care district. Institution-based studies for 1983 to 1985 and 1993 to 1995 were used for comparison. We calculated age-standardized incidence and Cox proportional hazards analysis of survival (stroke subtype, sex, age group, and study period in the analysis). Minimum follow-up was 46 months. Based on our register’s stroke incidence and the official Swedish population projection, a projection for future stroke incidence on a national basis was calculated. Results— We included 456 patients with first-ever stroke in 2001/2002. The age-standardized incidence (to the European population) was 144 per 100 000 person-years (95%CI 130 to 158) in 2001/2002, 158 (95%CI 149 to 168) in 1993 to 1995, and 134 (95%CI 126 to 143) in 1983 to 1985. Cox proportional hazard analysis indicated decreased risk of death after stroke in 2001/2002 (hazard ratio 0.80; 95%CI 0.67 to 0.94) compared with 1993 to 1995. Up to year 2050, the annual number of new stroke patients in Sweden may increase by 59% based solely on demographic changes. Conclusions— Despite possible underestimation of stroke incidence during the previous institution-based studies, the increased stroke incidence between 1983 to 1985 and 1993 to 1995 did not continue in 2001/2002. The long-term survival after stroke continues to improve. As the elderly population is growing in Sweden, stable incidence and increasing survival will result in a rapidly increasing prevalence of stroke patients in Sweden.

Weight Loss After Stroke A Population-Based Study From the Lund Stroke Register

Background and Purpose— Data on the prevalence and indicators of weight loss in population-based groups of stroke survivors are scarce. We aimed to find the predictors and indicators of weight loss >3 kg as a possible marker of malnutrition after stroke. Methods— We registered weight at baseline, after 4 months, and 1 year later in 305 survivors from a population-based cohort of first-ever stroke patients. Characteristics of the patients were registered at baseline and follow-ups, including glycosylated hemoglobin at baseline and follow-up II, eating difficulties at both follow-ups, and screening for depression at follow-up II. We used univariate and multivariate analyses to find baseline predictors and follow-up indicators related to weight loss >3 kg from baseline. Results— Among the 305 patients, 60% were male, the mean age was 72.5 years, and mean body mass index was 25.8 kg/m2. The main stroke types were cerebral infarction (89%), intracerebral hemorrhage (7%), and subarachnoid hemorrhage (4%). Weight loss >3 kg was found in 74 (24%) patients (mean, −6.6 kg) after 4 months and in 79 patients (26%; mean, −8.3 kg) 1 year later. Severe stroke and elevated glycosylated hemoglobin levels were baseline predictors of weight loss >3 kg. Indicators associated with short-term weight loss (at follow-up I) were eating difficulties, low prealbumin value, and dependence (Barthel Index), whereas indicators associated with long-term weight loss (follow-up II) were eating difficulties, hemorrhagic stroke, and low prealbumin value. Conclusions— Weight loss >3 kg after stroke indicates the need for closer observation regarding nutritional status. Monitoring of body weight may be useful, particularly among patients with severe stroke, eating difficulties, low prealbumin values, and impaired glucose metabolism.

Lund Stroke Register: hospitalization pattern and yield of different screening methods for first-ever stroke

Objectives –  To explore case ascertainment, hospitalization, characteristics of both hospitalized and non‐hospitalized patients in a population‐based group of stroke patients.

Ischaemic stroke in hypertensive patients is associated with variations in the PDE4D genome region

Previous Icelandic studies reported that single nucleotide polymorphisms (SNPs) in the phosphodiesterase 4D (PDE4D) region and the 5-lipoxygenase activating protein ALOX5AP were associated with ischaemic stroke, whereas other studies reported ambiguous findings. We examined 932 ischaemic stroke patients from a Swedish population-based stroke register, and 396 control subjects. We assessed possible associations between ischaemic stroke and nine preselected SNPs in the chromosome regions of the PDE4D gene, including rs12188950 (SNP45) and rs3887175 (SNP39); the ALOX5AP gene, including rs17222814 (SG13S25) and the promoter region of the MHC class II transactivator, MHC2TA. The T allele of SNP45 showed negative association with ischaemic stroke (odds ratio, OR=0.72; 95% confidence interval (CI): 0.58–0.91; P=0.0055). Among hypertensive subjects, this influence of the T allele of SNP45, and the T allele of SNP39, were more pronounced (with OR=0.52; 95% CI: 0.37–0.73; P=0.0001 and OR=0.57; 95% CI: 0.41–0.79; P=0.0007, respectively). These SNPs also interacted with hypertension with a relative excess risk due to interaction of −1.66 (P=0.0002) for SNP45 and −1.65 (P=0.0005) for SNP39. The P-values remained significant after correction for multiple testing. Among nonhypertensives, the A allele of SG13S25 indicated increased stroke risk (OR=1.82; 95% CI: 1.21–2.74; P=0.0039; not significant after Bonferroni correction). SNP45 was associated with ischaemic stroke even when controlling for hypertension, diabetes, heart disease and smoking. Our meta-analysis of 13 studies (including ours) showed no overall influence of SNP45 on ischaemic stroke. However, the 13 studies may differ because of nonrandom causes, as suggested by the heterogeneity test (P=0.042). This might support previously undetected mechanisms causing fluctuating ischaemic stroke risk.

Prevalence of Stroke and Vascular Risk Factors among First-Degree Relatives of Stroke Patients and Control Subjects

Background: Genetic and environmental factors may be of importance for stroke risk. We assessed the prevalence of stroke and vascular risk factors among first-degree relatives and spouses of stroke patients and control subjects. Methods: As a part of the Lund Stroke Register study, we asked 925 consecutive patients with first-ever stroke and 286 control subjects to complete a questionnaire about all their first-degree relatives and spouses. The questionnaires addressed whether these relatives had been affected by stroke or TIA, hypertension, heart disease, diabetes mellitus, and if they were smokers. Results: A total of 606 patients and 261 control subjects returned the questionnaire, providing information on 4,972 first-degree relatives and 738 spouses. The prevalence of stroke or TIA was 12.3% among first-degree relatives of patients and 7.5% among first-degree relatives of control subjects (OR 1.74, 95% CI 1.36–2.22). Corresponding results for hypertension were 21.0 and 16.7% (OR 1.33, 95% CI 1.10–1.60). The prevalences of heart disease, diabetes mellitus and smoking did not differ significantly between first-degree relatives of patients and control subjects. Spouses of patients and control subjects had similar prevalences of stroke or TIA and vascular risk factors. Conclusions: The prevalences of stroke or TIA and hypertension are higher among first-degree relatives of stroke patients than among first-degree relatives of control subjects. This, and the lack of differences between spouses of patients and control subjects, indicates that an increased risk of stroke may in part be explained by heritability of hypertension.

Functional Status and Patient-Reported Outcome 10 Years After Stroke: The Lund Stroke Register

Background and Purpose— Long-term studies of outcome after stroke are scarce. Our aim was to study functional status and patient-reported outcome 10 years after a first-ever stroke. Methods— Ten-year follow-up was conducted among the survivors from a population-based group of 416 patients included in the Lund Stroke Register, Sweden, between March 1, 2001, and February 28, 2002. The Barthel index was used to assess the functional status and the modified Rankin Scale to assess the degree of disability. The EQ-5D scale was used for survivors’ self-reports about health outcome and the specific Short-Form 36 (SF-36) question for rating their overall health. The patients also reported their frequency of physical activity. Results— Among 145 survivors 10 years after stroke (median age, 78 years), 59% were men, 90% lived in their ordinary housing, 73% were assessed as independent, and 71% had no or slight disability. The need of assistance with mobility and self-care was reported by 14% and with usual activities by 22%. Moderate pain was reported by 39%, and 4% had a high degree of pain. Moderate anxiety/depression was reported by 28% and high degree only by 1%. Overall health status was reported in positive terms by more than two thirds of the survivors. Almost half the cohort reported the same frequency of physical activity (≥4× weekly) as before stroke onset. Conclusions— This study indicates that 10-year stroke survivors in Sweden are mostly independent in daily activities and report good overall health and frequent physical activity, although half of them are ≥78 years.

Secondary Prevention and Health Promotion after Stroke: Can It Be Enhanced?

The aim was to study if health outcome and secondary prevention were satisfactory 1 year after stroke and if nurse-led interventions 3 months after stroke could have impact. Design was a randomized controlled open trial in a 1-year population. Primary outcome was health status 1 year after stroke. One month after stroke, survivors were randomized into intervention group (IG) with follow-up by a specialist nurse (SN) after 3 months (n = 232), and control group (CG) with standard care (n = 227), all to be followed up 1 year after stroke. At the first follow-up, patients graded their health, replied to the EuroQol-5 Dimensions (EQ-5D) health outcome questions, health problems were assessed, and supportive counseling was provided in the IG. Health problems requiring medical interventions were primarily referred to a general practitioner (GP). One year after stroke, 391 survivors were followed up. Systolic blood pressure (BP) had decreased in IG (n = 194) from median 140 to 135 (P = .05), but about half were above the limit 139 in both groups. A larger proportion (22%) had systolic BP >155 in the CG (n = 197) than in the IG (14%; P = .05). In the IG, 62% needed referrals compared with the 75% in the CG (P = .009). Forty percent in the IG and 52.5% in the CG (P = .04) reported anxiety/depression. In the IG, 75% and 67% in the CG rated their general health as fairly good or very good (P = .05). Although nurse-led interventions could have some effect, the results were not optimal. A more powerful strategy could be closer collaboration between the SN and a stroke clinician, before referring to primary care.