Vera P. Schepers

Is Fatigue an Independent Factor Associated with Activities of Daily Living, Instrumental Activities of Daily Living and Health-Related Quality of Life in Chronic Stroke?

Background: To determine the longitudinal association of poststroke fatigue with activities of daily living (ADL), instrumental ADL (IADL) and perceived health-related quality of life (HRQoL) and to establish whether this relationship is confounded by other determinants. Methods: A prospective cohort study of stroke patients consecutively admitted for inpatient rehabilitation was conducted. ADL, IADL and HRQoL were assessed in 223 patients at 6, 12 and 36 months after stroke. Fatigue was determined by the Fatigue Severity Scale. Random coefficient analysis was used to analyze the impact of fatigue on ADL, IADL and HRQoL. The association between fatigue and outcome was corrected for potential confounders, i.e. age, gender, comorbidity, executive function, severity of paresis and depression. The covariate was considered to be a confounder if the regression coefficient of fatigue on outcome changed by >15%. Results: Fatigue was significantly related to IADL and HRQoL but not to ADL. The relation between fatigue and IADL was confounded by depression and motor impairment. Depression biased the relation between fatigue and HRQoL, but fatigue remained independently related to HRQoL. Conclusions: Fatigue is longitudinally spuriously associated with IADL and independently with HRQoL. These findings suggest that in examining the impact of poststroke fatigue on outcome, one should control for confounders such as depression.

Spouses' quality of life 1 year after stroke: Prediction at the start of clinical rehabilitation

Background and Purpose: The purpose of this prospective study was to identify early predictors of spouses’ quality of life at 1 year after stroke. Methods: At the start of clinical rehabilitation patient and caregiver characteristics, psychological factors, harmony in the relationship and social support were assessed. One year after stroke, caregiver burden (Caregiver Strain Index), life satisfaction (Life Satisfaction Checklist) and depressive symptoms (Goldberg Depression Scale) were assessed in 187 participants. Multiple regression analyses were performed. Results: About 80% of the spouses reported low quality of life on one or more of the measures; 52% reported depressive symptoms, 54% significant strain and only 50% was satisfied with life as a whole. The regression analysis identified ‘passive coping strategy of the caregiver’ as the most important predictor. ADL dependency was the only baseline patient characteristic significantly related to burden and life satisfaction, but explained just 0–4% of the variance. Conclusions: A large proportion of caregivers perceive impaired quality of life 1 year after stroke. Caregivers at risk should be identified at the start of rehabilitation by means of coping measurement instruments or selected anamneses on coping.

Comparing contents of functional outcome measures in stroke rehabilitation using the International Classification of Functioning, Disability and Health

Purpose. To examine the content of outcome measures that are frequently used in stroke rehabilitation and focus on activities and participation, by linking them to the International Classification of Functioning, Disability and Health (ICF). Method. Constructs of the following instruments were linked to the ICF: Barthel Index, Berg Balance Scale, Chedoke McMaster Stroke Assessment Scale, Euroqol-5D, Functional Independence Measure, Frenchay Activities Index, Nottingham Health Profile, Rankin Scale, Rivermead Motor Assessment, Rivermead Mobility Index, Stroke Adapted Sickness Impact Profile 30, Medical Outcomes Study Short Form 36, Stroke Impact Scale, Stroke Specific Quality of Life Scale and Timed Up and Go test. Results. It proved possible to link most constructs to the ICF. Most constructs fitted into the activities and participation component, with mobility being the category most frequently covered in the instruments. Although instruments were selected on the basis of their focus on activities and participation, 27% of the constructs addressed categories of body functions. Approximately 10% of the constructs could not be linked. Conclusions. The ICF is a useful tool to examine and compare contents of instruments in stroke rehabilitation. This content comparison should enable clinicians and researchers to choose the measure that best matches the area of their interest.

PREDICTING MOBILITY OUTCOME ONE YEAR AFTER STROKE: A PROSPECTIVE COHORT STUDY

OBJECTIVE To develop a prognostic model to predict mobility outcome one year post-stroke. DESIGN Prospective cohort study in patients with a first-ever stroke admitted for inpatient rehabilitation. PATIENTS A total of 217 patients with stroke (mean age 58 years) following inpatient rehabilitation in 4 rehabilitation centres across the Netherlands. METHODS Mobility was measured using the Rivermead Mobility Index at one year poststroke. Included independent variables were: patient and stroke characteristics, functional status, urinary incontinence, sitting balance, motor and cognitive function. Univariate and multivariate linear regression analyses were performed in a model-developing set (n=174) and the model was validated in cross-validation set (n=43). RESULTS Total Rivermead Mobility Index score at one year post-stroke was predicted by functional status, sitting balance, time between stroke onset and measurement, and age. The derived model predicted 48% of the variance, while validation in the cross-validation set resulted in an adjusted R(2) of 0.47. CONCLUSION The present prospective study shows that outcome of mobility one year after stroke can be predicted validly by including functional status, sitting balance, moment of admission to the rehabilitation centre after stroke onset and age.

Predicting Functional Outcome after Stroke: The Influence of Neglect on Basic Activities in Daily Living

One prominent deficit resulting from stroke is visuo-spatial neglect, which has been associated with slower and more attenuated recovery patterns of sensory-motor impairment as well as limitations in activities of daily living (ADL). The aim of the current study was to further specify the relationship between neglect and recovery of different domains of ADL. One hundred eighty four patients were assessed with the Functional Independence Measure in the first week of inpatient rehabilitation, and again at 6, 12, and 36 months post-stroke. On average, neglect patients scored significantly lower on Self-care, Transfers, and Locomotion compared to non-neglect patients, but these differences became smaller with progress of time. Overall, no differences between groups were found for Sphincter control and Cognition. Patients with more severe neglect scored significantly lower on Self-care and Transfers compared to patients with mild neglect. During rehabilitation, it would be of importance to test for independence in ADL domains in neglect in order to define realistic treatment goals. The current findings could be taken into account in early multidisciplinary intervention planning in the sub-acute phase, to optimize regaining ADL.

Responsiveness of functional health status measures frequently used in stroke research

Purpose. To compare the responsiveness of several functional health status measures frequently used in stroke research, namely the Barthel Index (BI), Functional Independence Measure (FIM), Frenchay Activities Index (FAI) and Stroke-Adapted Sickness Impact Profile 30 (SA-SIP 30). Method. Patients with a first-ever supratentorial stroke admitted for inpatient rehabilitation were included. Complete datasets for 163 patients were available for analysis. Floor/ceiling effects and responsiveness, quantified by effect sizes, were studied for the periods between rehabilitation admission and six months post stroke (subacute phase) and between six and 12 months post stroke (chronic phase). Results. Effect sizes in the subacute phase were similar and were classified as large for the BI, FIM total and FIM motor score. The FIM cognitive score showed a considerable ceiling effect and had the smallest effect size in the subacute phase. In the chronic phase, the FAI and SA-SIP 30 detected the most changes and had moderate effect sizes. Conclusions. BI, FIM total and FIM motor score, FAI and SA-SIP 30 were responsive measures. We recommend the use of the BI in the subacute phase and the use of the FAI and SA-SIP 30 in the chronic phase, especially for the stroke rehabilitation population.

Social activity contributes independently to life satisfaction three years post stroke

Objective: To determine social activity and life satisfaction three years post stroke and to investigate the contribution of social activity to life satisfaction controlled for the influence of demographic, physical and cognitive disabilities and social support. Design: Cross-sectional study. Subjects: One hundred and sixty-five patients with a stroke. Main measures: The Life Satisfaction questionnaire (LiSat-9), the Social Support List – Interaction (SSL-12-I), the Barthel Index, the Mini-Mental State Examination (MMSE) and the Frenchay Activities Index. Results: In total, 165 stroke patients participated, of whom 112 (67.9%) reported that they were satisfied with life as a whole. Socially inactive patients were significantly less often satisfied (50%, n = 26) than socially moderately (74.4%, n = 64) and socially highly active (81.5%, n = 22) patients. Lowest satisfaction ratings were found for sexual life (40.6%, n = 58). The socially inactive group was most satisfied with their partner relationship (85.1%, n = 40), the moderately and highly socially active group with their self-care ability (87.2%, n = 75 and 96.3%, n = 26, respectively). ADL and social activity were moderately correlated with life satisfaction. Social activity was found to explain an additional variance of the LiSat-9 total score (6.9%) and overall life satisfaction item (5.2%) after controlling for demographic variables, social support, ADL and cognitive functioning. Conclusions: Three years post stroke, many patients report ongoing dissatisfaction with various life domains. Social activity was related to life satisfaction.

Screening for poststroke depression using the patient health questionnaire.

Background:Although poststroke depression has a significant impact on a patient’s ability to recover after stroke, it is generally not recognized. Structured screening can help nurses identify symptoms of depression in stroke patients. In clinical practice, the utility of an instrument is as importantas its validity and reliability. Objective:To investigate the reliability, validity, and clinical utility of the nine-item and two-item patient health questionnaires (PHQ-9 and PHQ-2, respectively) in stroke patients in a clinical nursing setting. The results of these questionnaires will be compared against those from the Geriatric Depression Scale. Methods:The PHQ-9 was administered by 43 ward nurses in 55 patients with an intracerebral hemorrhage or ischemic infarction who were able to communicate adequately. The interrater reliability, test–retest reliability and internal consistency, concurrent validity, diagnostic accuracy, and clinical utility were evaluated. Results:The interrater reliability (intraclass correlation [ICC] = 0.98, 95% CI [0.96, 0.99]), test–retest reliability (&rgr;Sp = 0.75, p < .001), and internal consistency (Cronbach’s &agr; = 0.79) of the PHQ-9 were good. The concurrent validity was moderate for the PHQ-9, with a Pearson’s correlation of .7 (p < .001) and acceptable for the PHQ-2 with a Pearson’s correlation of .8 (p < .01). The optimum cutoff point of the PHQ-9 for major depression was 10 (sensitivity, 100%; specificity,86%; positive predicted value, 50%; and negative predicted value, 100%). For the PHQ-2, the optimum cutoff point was 2 (sensitivity, 100%; specificity, 77%; positive predicted value, 38%; and negative predicted value, 100%). Discussion:The PHQ is a brief and easy-to-use instrument for nursing practice. It shows good reliability, validity, and clinical utility when used in stroke patients who are able to communicate adequately.

Life satisfaction of couples 3 years after stroke

Purpose: To compare the life satisfaction of stroke patients to that of their spouses, and to examine spouses’ variables as determinants of the patients’ life satisfaction. Method: Patients with a first-ever stroke who were admitted to an inpatient rehabilitation centre and their spouses were included (n = 78 couples). Measurements took place 3 years after the stroke. Life satisfaction was measured using the Life Satisfaction Questionnaire (LiSat-9). Results: More spouses (50%) than patients (28%) were dissatisfied with their life as a whole. Spouses were also more likely to be dissatisfied with all other domains of life satisfaction than patients. The associations between the life satisfaction of patients and of spouses were weak (Cramer’s V 0.00–0.43). In the backward linear regression analysis both patients’ participation in social activities and spouses’ life satisfaction were significantly related to patients’ life satisfaction. A total of 17.8% of the variance of patients’ life satisfaction could be explained by the model. Conclusions: Both spouse and patient in a couple experience decreased life satisfaction in the chronic phase after stroke, spouses even more so than patients. The life satisfaction of stroke patients was significantly related to spouses’ life satisfaction. Family-centred care should be an important part of the rehabilitation process. Implications for Rehabilitation Both spouse and patient in a couple experience decreased life satisfaction in the chronic phase after stroke. The life satisfaction of stroke patients was significantly related to spouses’ life satisfaction. Family-centred care, in which the spouse is closely involved, should be an important part of the rehabilitation process.

Respite Care After Acquired Brain Injury: The Well-Being of Caregivers and Patients

OBJECTIVE To investigate satisfaction with respite care, the well-being of informal caregivers and patients with acquired brain injury (ABI) who receive respite care by day-care activity centers, and factors related to caregiver well-being. DESIGN Cross-sectional cohort study. SETTING Adult day-care activity centers. PARTICIPANTS A sample of caregivers and patients (N=108) with ABI (mean of 8y since injury) enrolled in 1 of 7 day-care activity centers. The sample consisted predominantly (70%) of stroke patients. INTERVENTION Respite care by adult day-care activity centers. MAIN OUTCOME MEASURES Well-being was defined in terms of life satisfaction (Life Satisfaction Questionnaire [LiSat-9]), emotional functioning (Hospital Anxiety and Depression Scale [HADS]), and caregiver burden (Caregiver Strain Index [CSI]). Factors related to well-being were personal, injury related, and psychological. RESULTS Satisfaction with day-care activity center care was high for caregivers (7.8) and patients (8.1). Caregiver satisfaction with care was unrelated to caregiver well-being. Most caregivers (61%) showed low life satisfaction and high subjective burden (69%), and 33% of caregivers and 42% of the patients reported depressive symptoms. Caregiver well-being was positively correlated with a high sense of mastery of caregivers and patients and low passive coping of the patient (LiSat-9 R(2)=.32; HADS R(2)=.55; CSI R(2)=.35). CONCLUSIONS This study emphasizes the need for care for both caregivers and patients in the chronic phase after ABI. Although respite care is highly appreciated, it is not sufficient for caregivers to attain a healthy level of well-being. Results indicate that caregiver well-being might improve by targeting passive coping and mastery skills of caregivers and patients. Continuous support for both caregivers and patients is needed.