Rosemarie B. King

Quality of Life After Stroke

BACKGROUND AND PURPOSE The purposes of this study were to examine overall and domain-specific quality of life in long-term stroke survivors and to identify variables that predict quality of life after stroke. METHODS The study used a cross-sectional, descriptive correlational design. Subjects were 86 stroke survivors who were interviewed 1 to 3 years after stroke. Quality of life was measured with the use of an instrument that assesses satisfaction and importance for four domains (health and functioning, socioeconomic, family, and psychological-spiritual). Independent variables were age, social class, aphasia, functional status, motor impairment, depression, comorbidity, and perceived social support. Multiple regression analysis was used to predict quality of life. RESULTS Thirty percent of subjects scored in the depressed range. The mean overall quality of life score was relatively high and was comparable to that of a normative population. Quality of life was highest for the family domain and lowest for health and functioning. Depression, perceived social support, and functional status predicted quality of life (adjusted R2 = .38) and contributed to prediction of domain quality of life. Social support and three additional variables, social class, age, and cardiovascular disease, predicted socioeconomic quality of life. CONCLUSIONS The identification of depression, social support, and functional status as predictors of quality of life suggests the need to assist stroke survivors in coping and in maintaining and strengthening their support systems.

Evidence for Stroke Family Caregiver and Dyad Interventions: A Statement for Healthcare Professionals From the American Heart Association and American Stroke Association

Stroke is a leading cause of severe, long-term disability. Most stroke survivors are cared for in the home by a family caregiver. Caregiver stress is a leading cause of stroke survivor institutionalization, which results in significant costs to the healthcare system. Stroke family caregiver and dyad intervention studies have reported a variety of outcomes. A critical analysis of 17 caregiver intervention studies and 15 caregiver/stroke survivor dyad intervention studies was conducted to provide evidence-based recommendations for the implementation and future design of stroke family caregiver and dyad interventions.

Risk adjustment of ischemic stroke outcomes for comparing hospital performance a statement for healthcare professionals from the american heart association/american stroke association

Background and Purpose— Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research. Methods and Results— This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care. Conclusions— There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.

Analysis of problem types and difficulty among older stroke caregivers

Abstract Stroke onset causes disruption of family roles as caregiving tasks are assumed. The current study presents a qualitative and quantitative analysis of the problems of 123 older, spousal stroke caregivers. Problems were coded into 14 categories; frequencies of occurrence and difficulty were also analyzed. Differences in problem difficulties were examined by race, gender, years caregiving, and care receiver’s functional level, depression, burden, and loneliness. Noncompliance was the least frequent but most difficult problem type. Lack of social involvement was the most frequent problem type and the most difficult for the more depressed, burdened, and lonely caregivers. This increase in problem specificity and detail of analysis has provided direction for clinical application in counseling the spouses of stroke survivors on how to manage the stress of their new life role.

Stroke Caregivers: Pressing Problems Reported during the First Months of Caregiving

The major purpose of this study was to identify the types and frequency of caregiving problems and associated stress and coping effectiveness. Secondary purposes were (a) to examine changes in problem frequency, stress, and coping effectiveness over time and (b) to identify relationships between problem stress and personal, illness, coping, and well-being variables. A stress and coping model guided the study. Fifty-eight caregivers participated during the first 4 months of caregiving. Caregiver and stroke survivor demographic and well-being data were collected during acute rehabilitation. Three problem-related themes emerged: interpersonal disruptions, sustaining the self and the family, and stroke survivor functioning. Although problems sustaining the self and the family were most frequent, interpersonal disruption problems were rated most stressful and lowest in coping effectiveness. A component of emotional distress, either anxiety or depression, was related significantly (p < .05) to the stress level of each problem theme. Counseling on problem-solving strategies may improve caregiver well-being.

Problem-solving early intervention: a pilot study of stroke caregivers.

&NA; Caregivers (CGs) of stroke survivors assume their role suddenly and with little preparation. Negative emotions are common, persist over time, and are related to other negative outcomes. This pilot study, guided by a coping model, examined the efficacy and durability of a caregiver problem‐solving intervention (CPSI) on CG and stroke survivor outcomes. Additional aims included assessment of feasibility issues and reliability and sensitivity of the study measures. The nonrandom sample of 15 stroke CGs was matched on depression and demographics with a comparison group. The CPSI started during acute rehabilitation and continued through 2 months after discharge. Parametric and nonparametric tests were used to assess achievement of the aims. CG depression, anxiety, preparedness, and survivor motor function improved significantly in the intervention group over time. Burden, life changes, and taking care of CGs own needs did not change significantly. CPSI group CG depression significantly improved compared with the matched group. The improvement in outcomes for the CPSI group supports further testing of the intervention with a large sample.

Preventive skin care beliefs of people with spinal cord injury.

&NA; Although health beliefs have been correlated with self‐care adherence in other chronic conditions, little is known about skin care beliefs after spinal cord injury (SCI). The purpose of this qualitative study was to identify the skin care beliefs of individuals with SCI. The conceptual framework was the Health Belief Model (HBM), which proposes that adherence to a health regimen is motivated by beliefs about susceptibility, severity, barriers, benefits, and self‐efficacy. Purposive sampling was used to recruit 22 people with SCI. Content analysis of data collected using semistructured questions was used to identify domains of skin care beliefs, including HBM components. Themes that emerged about skin care beliefs included taking vigilant care, taking charge, maintaining health, and passing up care. Although most participants believed they were susceptible to pressure ulcers and preventive care was important, paradoxical statements about beliefs and preventive behaviors were common. These incongruent responses may reflect ambivalence about competing priorities or the efficacy of preventive practices. Further research is needed to understand this phenomenon. Increased understanding of skin care beliefs will assist in developing tailored teaching programs for people with SCI.

A problem-solving early intervention for stroke caregivers: one year follow-up.

Purpose: The study purposes were to assess the efficacy of a caregiver problem‐solving intervention (CPSI) on stroke caregiver physical and psychosocial adaptation compared with a wait‐list control (WLC) treatment, and to assess the mediation effects of coping on outcomes. Methods: A stress and coping model guided the study design. Outcomes were depression, anxiety, preparedness, life changes, and family functioning. CPSI started during acute rehabilitation and continued 3 months postdischarge. Data were collected at baseline (T1), postintervention (T2), and 6 (T3) and 12 months postdischarge (T4). Results: Of 255 caregivers, 75% were depressed at baseline. Repeated measures ANOVA of study completers (n = 121) indicated improved T2 depression, life change, and health (ps < .04) favoring the CPSI group. Improvements faded by 6 months. Although no group differences in outcomes were found in the intention‐to‐treat analysis, growth curve modeling indicated a difference in depression rate of change, favoring the CPSI (p = .04). Perceived health, threat appraisal and rational problem‐solving were significant mediators (ps < .05). Conclusions: Findings provide direction for future interventions to promote and sustain healthy caregiver adaptation.

Patterns of Relationships Between Background Characteristics, Coping, and Stroke Caregiver Outcomes

Abstract Purpose: Little is known about mediators of stroke caregiver outcomes or patterns of relationships of outcome predictors. We examined relationships between the variable sets of caregiver and stroke survivor characteristics, coping (proposed mediators), and caregiver outcomes. Methods: We assessed 253 dyads prior to discharge from acute rehabilitation. Outcomes were depression, anxiety, preparedness, life change, and family functioning. Coping included problem solving, caregiver appraisal, and unmet resource needs. Multivariate canonical correlation analyses were computed between the sets of variables to identify unique patterns of relationships. Results: Six patterns of significant relationships were found (R =.30 to .84, Ps <.01 to .02). The strongest relationship was that between greater threat appraisal and negative life change, greater anxiety, and lower caregiving preparedness (P < .01). Caregiver characteristics (nonwhite, spousal caregivers) were related significantly to several outcomes (positive life change, lower anxiety, and less healthy family functioning) (R = .43, P <.01) and remained significant after controlling for the effect of mediators (R = .32, P < .02). Conclusion: Findings suggest various patterns of relationships that provide guidance for individualizing early caregiver intervention. Clinicians can build on caregivers’ strengths while identifying threats to adaptation to tailor interventions that promote healthy outcomes.

The use of writing groups to facilitate adaptation after stroke.

Abstract Purpose: This is a report on a pilot study of small writing groups to assist in long-term adaptation after stroke onset. Method: 26 stroke survivors participated in a small group experience to write a short essay to be published about their recovery. The sample consisted of middle-aged, well-educated participants who were several years post stroke and were self-selected by interest and experience in writing. The sample was evenly divided between men and women, and minority racial groups were adequately represented. Essays were published on a website and clustered in themes about coping with recovery and personal growth/changes in self-concept. Results: The group experience was well received by participants. Objective measures showed a trend toward improvement in positive identity and no significant change in depression or well-being. Significant differences found between subgroups (improved vs. declined; aphasia vs. no aphasia) are discussed. Anecdotal observations of the group process and implications for practice and further research are provided.