Psychological Burden in Stroke Survivors and Caregivers Dyads at the Rehabilitation Center of Kinshasa (Democratic Republic of Congo): A Cross-Sectional Study

IntroductionStroke is a major cause of burden which can lead to anxiety and depressive disorders in stroke patients and their caregivers. This study aimed to assess the burden of depression and anxiety and covariates as well as its association with functional disability level among stroke survivors and caregivers dyads.MethodsThis cross-sectional study assessed for anxiety and depressive symptoms, and perceived burden among survivors of stroke and their caregivers in the rehabilitation center of Kinshasa; using the Hospital Anxiety and Depression Scale to identify participants with anxiety and depression; the Zarit Burden Inventory to assess the burden of depression and anxiety; and the modified Rankin scale used to assess functional outcome or level of disability.ResultsEight in ten caregivers of stroke survivors perceived the burden, which took more expression of depression than anxiety, whereas three in ten stroke survivors had a burden expressed by symptoms consistent with depressive and anxiety disorders. Being married increases the risk of perceiving the burden among stroke survivors. We found a positive association between high level of burden and depression and anxiety among caretakers of stroke survivors. Moreover, our findings did not reveal a statistical association between the burden and level of dependence evaluated based on the severity of disability.ConclusionsThe psychological burden is higher among caregivers than stroke survivors. Specialized programs targeted the psychological distress, its association with anxiety and depressive symptoms; and the functional disability level of stroke survivors should be integrated into the rehabilitation center of patients with disabled illnesses. Our findings warrant further studies to test the impact of reducing psychological burden on functional disability.     

Neurological outcome and quality of life after stroke due to vertebral artery dissection

BACKGROUND: Vertebral artery dissection is a well-recognized cause of posterior circulation stroke for which there is relatively little information on long-term outcomes. Quality of life (QOL) is an important patient-centred outcome measure. METHODS: Stroke due to vertebral artery dissection was conservatively defined by neuroimaging documentation. Thirty sequential cases were identified based on a retrospective database and chart review with prospective follow-up. Surviving patients completed the Short Form-36 (SF-36) and the Stroke-Specific Quality of Life (SSQOL) scales and were subsequently examined neurologically and scored on the National Institutes of Health Stroke Scale (NIHSS). Comparisons were made between outcome on the stroke scale and QOL scales and between outcome on the SF-36 and the Canadian population. RESULTS: There was discordance between outcomes recorded on a standard stroke scale and QOL measures with more patients scoring poorly on QOL measures. QOL was low in one third of the survivors. Overall QOL was significantly lower than the general population. CONCLUSIONS: Stroke due to vertebral artery dissection results in poorer outcomes on patient-centred QOL measures than on a standard stroke scale.     

The measure of stroke environment (MOSE): development and validation of the MOSE in post-stroke populations with and without aphasia

Objectives. The purpose of this paper is to present the development and psychometric properties of a new environmental measure that identifies barriers and facilitators in receptivity, physical environment and communication for post-stroke populations, including survivors with aphasia.

Methods. The Measure of Stroke Environment (MOSE) was developed using information from semi-structured interviews and three pilot studies. Reliability and validity were assessed in 43 post-stroke participants.

Results. The MOSE contains 47 items across 33 questions in three domains (receptivity, physical environment, communication). Internal consistency reliability was high (.83 to .85) across each domain and over the entire assessment (.91). Convergent validity showed moderate correlation with the Stroke Impact Scale (.33 to .37), the National Institute of Health Stroke Scale (-.31 to -.46) and the Boston Diagnostic Aphasia Examination (.55 to .61). Persons with aphasia had significantly lower scores on the communication domain. Stroke survivors with (26% overall difficulty) and without aphasia (31% overall difficulty) continue to experience difficulty ≥ 2 years post-stroke.

Discussion. The MOSE offers a brief, reliable and valid assessment of environmental barriers and facilitators to participation for post-stroke survivors reintegrating into their communities. Stroke survivors with very mild deficits continue to experience barriers from the environment many years post-stroke. These barriers are not typically identified during the rehabilitation process but persist post-reintegration.

Conclusion. The MOSE is able to determine how frequently a stroke survivor faces challenges in their environment and how that impacts his or her participation.     

Pre‐stroke use of beta‐blockers does not affect ischaemic stroke severity and outcome

Background and purpose: It is unclear whether pre‐stroke beta‐blockers use may influence stroke outcome. This study evaluates the independent effect of pre‐stroke use of beta‐blockers on ischaemic stroke severity and 3 months functional outcome. Methods: Pre‐stroke use of beta‐blockers was investigated in 1375 ischaemic stroke patients who had been included in two placebo‐controlled trials with lubeluzole. Stroke severity was assessed by either the National Institute of Health Stroke Scale (NIHSS) or the European Stroke Scale (ESS). A modified Rankin scale (mRS) score of >3 at 3 months was used as measure for the poor functional outcome. Results: Two hundred and sixty four patients were on beta‐blockers prior to stroke onset, and 105 patients continued treatment after their stroke. Pretreatment with beta‐blockers did not influence baseline stroke severity. There was no difference in stroke severity between nonusers and those on either a selective beta₁‐blocker or a non‐selective beta‐blocker. The likelihood of a poor outcome at 3 months was not influenced by pre‐stroke beta‐blocker use or beta‐blocker use before and continued after stroke onset. Conclusions: Pre‐stroke use of beta‐blockers does not appear to influence stroke severity and functional outcome at 3 months.     

Optimizing stroke systems of care by enhancing transitions across care environments

Stroke affects many aspects of the lives of stroke survivors and their family caregivers. Supporting long-term recovery and rehabilitation are necessary to help stroke survivors adapt to living with the effects of stroke and to help family members adapt to the caregiving role. During recovery and rehabilitation, many elements of the health care continuum are utilized, including emergency response, acute care, inpatient and outpatient rehabilitation, and community and long-term care. With the advent of thrombolytic therapy and the benefits of stroke units, stroke survival and outcomes are improving. As a result, the current emphasis of stroke system improvement is to implement stroke units throughout the developed world. To enhance the patient centeredness of stroke care delivery, an important next phase of stroke system improvement will center on the experiences of stroke survivors and their family caregivers as they move through diverse care environments. The objective of this article was to conduct a scoping review of the literature on stroke transitions to identify the current areas of research emphasis. This article highlights stroke survivors' and family caregivers' experiences with transitions across care environment and some potential strategies to improve those transitions.     

Open label tissue plasminogen activator for stroke: The oregon experience.

Background: Tissue plasminogen activator (t-PA) is the first effective treatment for stroke. This study sought to explore the outcome of patients treated with t-PA in the community after approval of its use in the treatment of stroke in June, 1996. Methods: All patients with acute stroke within the 6-hospital Oregon Stroke Center network were screened for potential t-PA treatment. Baseline and 24-hour outcome assessments were performed with the use of the National Institutes of Health Stroke Scale (NIHSS) and computed tomography (CT); 3-month outcome was evaluated by using the Modified Rankin scale. Results: Thirty-three patients who met the criteria for t-PA therapy were treated within 3 hours of symptom onset. All but 2 strokes were in the anterior circulation; 48.5% were cardioembolic. The NIHSS scores at 24 hours after administration of t-PA (mean, 14.7) showed modest gains from baseline NIHSS scores (mean, 16.6). Twelve patients (36%) had minimal or no deficits at 3 months. Three patients (9%), all of whom had baseline NIHSS scores of 20 or more, had symptomatic intracranial hemorrhages, 2 of which were fatal (6%). Conclusion: This study shows the feasibility of treating acute stroke with t-PA in the community. The percentage of fully recovered patients at 3 months mirrored those in the National Institute of Neurologic Disorders and Stroke (NINDS) trial.     

Verbal indicators of depression in conversations with stroke survivors

TOPIC: This secondary analysis study examined patients' comments at 1 and 6 months poststroke when they had scores of > or = 16 on the Center for Epidemiologic Studies-Depression Scale. Stroke survivors' depressive comments were matched with items of two well-established depression instruments. METHODS: A qualitative study using content analysis to analyze the data (N = 7). FINDINGS: Verbal indicators of depression were evident in patients' comments, and depressive themes were identified. Depression instrument items were congruent with minor themes, except for spirituality. CONCLUSIONS: The analysis provides guidance for assessment of stroke survivor depression. It provides direction for designing interventions to decrease depression after stroke.     

Caring for stroke survivors: experiences of family caregivers in Sri Lanka – a qualitative study

Background: Stroke is a life-changing event for both stroke survivors and their family caregivers. After receiving acute care at the hospital, family members are expected to take care of stroke survivors at home and to continue treatment and rehabilitation. The new role of “informal caregiver” is a challenge that creates many difficulties for family caregivers that are not explicit in the Sri Lankan context.

Objectives: This study aimed at exploring family caregivers’ experiences of providing informal care for dependent stroke survivors.

Methods: The sample was chosen by purposive sampling with a maximum variation by age, ethnicity, religion, educational level, relationship, and monthly income. Ten informal family caregivers to stroke survivors with hemiplegia who had been treated at the National Hospital of Sri Lanka participated in in-depth interviews analyzed using conventional content analysis.

Results: Qualitative content analysis of data resulted in an overriding theme, “Caring with love, against all odds,” along with four categories, “Life alterations,” “Lack of resources,” “Compassionate care,” and “Coping strategies.” Although the increased workload, restricted social life, physical problems, and knowledge and financial deficits were challenging for the family caregivers, self-strength and supportive social networks helped them to compassionately care for their stroke survivor.

Conclusions: The phenomenon of family caregivers providing informal care for stroke survivors was explicated as compassionate care, notwithstanding numerous difficulties. The findings motivate further research and strategies to minimize family caregivers’ burden and facilitate the positive aspects of caregiving to promote the health and well-being of both stroke survivors and their families.     

Evidence for accelerated vascular aging in bipolar disorder

ObjectivesLittle is known about the effect of lifetime history of depression on ischemic stroke outcomes. This study compared a measure of current symptoms of depression at the time of the stroke and a measure of lifetime history of depression for their ability to predict quality of life and functioning at 3 and 12 months after stroke.MethodsA cohort of 460 ischemic stroke patients from the 2005 Greater Cincinnati/North Kentucky Stroke Study was assessed within 2 weeks of the stroke, including the 10-item Center for Epidemiological Studies Depression Scale (CESD) for current symptoms of depression. Lifetime history of depression was also assessed by a 2-question measure at 3 and 12 months after stroke. Two outcome measures, Stroke Specific Quality of Life (SSQOL) and the modified Rankin Scale (mRS) to assess functional status, were also collected at 3 and 12 months.ResultsOf the 322 survivors included in the analysis, 52.2% reported depression on at least one measure. Both current symptoms and lifetime history of depression predicted poor functional outcomes and poor quality of life at 3 and 12 months, after adjustment for age, race, sex, prior stroke, baseline functional status, and stroke severity. The combination of depression measures was a better predictor of poor outcomes than either measure alone.ConclusionDepression by either measure was a frequent, substantial, and independent predictor of poor outcomes at 3 and 12 months after stroke. Stroke outcomes studies should further examine the predictive value of assessing both depressive symptoms at the time of the stroke and lifetime history of depression.     

Depressive symptoms in patients admitted to a semi-intensive stroke unit

Aim of this study was to evaluate depressive symptoms in a semi-intensive Stroke Unit (SI-SU) by a scale specifically devised to assess depression in patients with stroke and to identify the symptoms better contributing to the early detection of post stroke depression (PSD). Fifty-four patients admitted to a SI-SU because of suffering from single, first-ever hemispheric stroke were enrolled. Depressive symptoms were assessed by the Post Stroke Depression Rating Scale (PSDRS). All patients were also evaluated by the National Institute of Health Stroke Scale (NIHSS), the modified Rankin scale, the Mini-Mental State Examination (MMSE) and the Frontal Assessment Battery (FAB). The PSDRS detected depressive symptoms in twenty-two patients (40%). The PSDRS scores were not influenced by severity of stroke, functional outcome, site of lesion and type of stroke. Three psychopathological factors were identified inside the PSDRS: "reactivity", "melancholic" and "apathetic", with significant inverse correlations with cognitive measures found only with the "apathetic" factor Less than one-half items of the PSDRS were able to identify overt depressive symptoms. Depressive symptoms are a frequent and early complication in patients referred to a SI-SU with the PSDRS being a suitable tool to detect depressive symptoms in acute phases of stroke.     

Insomnia and health-related quality of life in stroke

Abstract

Background:

Insomnia is a common complaint in stroke survivors. Insomnia after stroke is correlated with physical disability, dementia, anxiety, depression, and fatigue. However, the influence of insomnia following stroke on health-related quality of life (HRQoL) has not been investigated.

Objectives:

The current study aimed to examine the effect of insomnia on HRQoL in stroke survivors 3 months after their index stroke over and above confounding variables.

Method:

Three hundred and thirty-six patients were recruited from the acute stroke unit in a regional hospital in Hong Kong. Insomnia was ascertained by a single item on a locally validated, seven-item insomnia questionnaire. HRQoL was measured by the total score and the 12 domain scores of the Stroke Specific Quality of Life (SSQoL) scale. Demographic and clinical characteristics were obtained using the following scales: National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS).

Results:

Forty-four percent of stroke survivors reported experiencing insomnia in the past month; they were more likely to be female and to have a higher GDS score. The insomnia group had significantly lower overall SSQoL, energy and thinking scores after adjusting for sex, BI, and GDS scores.

Conclusion:

The findings show that stroke survivors who experienced insomnia had a reduced overall HRQoL and were impaired in the energy and thinking domains of HRQoL. Early screening for sleep disturbance would be beneficial to prevent later development of post-stroke insomnia. Pharmacological and non-pharmacological interventions are suggested to improve HRQoL in stroke patients with insomnia.     

Caregiver experiences of social support following stroke

ObjectivesInformal caregivers need to support their loved ones while performing caregiving responsibilities. A phenomenological qualitative study was done to understand the role of social support accessible for stroke caregivers.Materials and methodsThe respondents were enrolled from different organizations or support groups who were conducting activities specifically for stroke victims and/or their caregivers. Data collection was concluded after 10 participants were interviewed as no new major themes were discovered. Hence, saturation of data was obtained with a sample of 10 respondents.ResultsTwo themes were identified from the interviews: “Response to Stroke” and “Stress and Coping”. Categories in theme one “Response to Stroke” were “Work Life Balance”, “Reaction of Other People or Family to Stroke”, and “Expectations and Responsibility from Caregivers”. Categories in theme two “Stress and Coping” were “Impact of Stroke on Abilities of Victim”, “Stressors and Concerns for the Caregivers”, “Strategies used by Caregivers to Cope with Stress”, and “Role of Support Group and Social Support to Stroke Caregiver and Care Recipient”.ConclusionsStroke can lead to stress that can alter the responsibilities of caregivers of stroke victims. The role of social support and support groups was found to be critical for family caregivers to cope with caregiving issues.     

Development of a stroke-specific quality of life scale.

BACKGROUND AND PURPOSE: Clinical stroke trials are increasingly measuring patient-centered outcomes such as functional status and health-related quality of life (HRQOL). No stroke-specific HRQOL measure is currently available. This study presents the initial development of a valid, reliable, and responsive stroke-specific quality of life (SS-QOL) measure, for use in stroke trials. METHODS: Domains and items for the SS-QOL were developed from patient interviews. The SS-QOL, Short Form 36, Beck Depression Inventory, National Institutes of Health Stroke Scale, and Barthel Index were administered to patients 1 and 3 months after ischemic stroke. Items were eliminated with the use of standard psychometric criteria. Construct validity was assessed by comparing domain scores with similar domains of established measures. Domain responsiveness was assessed with standardized effect sizes. RESULTS: All 12 domains of the SS-QOL were unidimensional. In the final 49-item scale, all domains demonstrated excellent internal reliability (Cronbach's alpha values for each domain >/=0.73). Most domains were moderately correlated with similar domains of established outcome measures (r2 range, 0.3 to 0.5). Most domains were responsive to change (standardized effect sizes >0.4). One- and 3-month SS-QOL scores were associated with patients' self-report of HRQOL compared with before their stroke (P<0.001). CONCLUSIONS: The SS-QOL measures HRQOL, its primary underlying construct, in stroke patients. Preliminary results regarding the reliability, validity, and responsiveness of the SS-QOL are encouraging. Further studies in diverse stroke populations are needed.     

Validation of the Caregivers’ Satisfaction with Stroke Care Questionnaire: C-SASC hospital scale

To date, researchers have lacked a validated instrument to measure stroke caregivers’ satisfaction with hospital care. We adjusted a validated patient version of satisfaction with hospital care for stroke caregivers and tested the 11-item caregivers’ satisfaction with hospital care (C-SASC hospital scale) on caregivers of stroke patients admitted to nine stroke service facilities in the Netherlands. Stroke patients were identified through the stroke service facilities; caregivers were identified through the patients. We collected admission demographic data from the caregivers and gave them the C-SASC hospital scale. We tested the instrument by means of structural equation modeling and examined its validity and reliability. After the elimination of three items, the confirmatory factor analyses revealed good indices of fit with the resulting eight-item C-SASC hospital scale. Cronbach’s α was high (0.85) and correlations with general satisfaction items with hospital care ranged from 0.594 to 0.594 (convergent validity). No significant relations were found with health and quality of life (divergent validity). Such results indicate strong construct validity. We conclude that the C-SASC hospital scale is a promising instrument for measuring stroke caregivers’ satisfaction with hospital stroke care.     

Japan stroke scales and its application for stroke]

There are many stroke scales currently available for estimating the severity and outcome of stroke. However, none of the stroke scales have been able to objectively quantify the severity of stroke. The Japan Stroke Society formed a subcommittee to task force the development of an innovative, quantifiable stroke scale. Conjoint analysis was utilized to compile this data. Finally, they developed a novel, and quantifiable Japan Stroke for the acute phase of stroke (JSS) (Stroke 32: 1800-1807, 2001). In addition to standard JSS, the Japan Stroke Scale Motor Function and Japan Stroke scale--Higher Cortical Function were finalized. These stroke scales are all parametric stroke scales. We utilize the stroke scales to monitor stroke patients, to start clinical pathway on patients with lacunas infarction after deciding whether severity of stroke is suitable for the clinical pathway by JSS. We use the JSS for the clinical studies of stroke patients. Furthermore, the JSS was utilized in the phase 2 trial of a new treatment in stroke patients which had significant statistical power. The scales were also introduced to the stroke databank. Therefore, these scales are useful to monitoring the neurological damage of stroke patients in the acute and chronic phase and to estimating the severity of stroke symptoms and predicting stroke outcome in clinical studies. They also have a potential to prove the efficacy of treatments through parametric analysis.     

Development and Validation of the Stroke Knowledge Test

Abstract

Purpose: The purpose of this study was to develop a measure of stroke knowledge (the Stroke Knowledge Test [SKT]) using a systematic test construction process and to investigate the psychometric properties of this test. There are relatively few published measures of stroke knowledge, and, of those that exist, relatively little is documented about test construction or psychometric properties. Such tests are important for evaluation of stroke education programs. Method: Test construction involved systematic generation of pilot test items, expert review of pilot items, and calculation of pilot item properties. After final item selection, two experiments were conducted to determine if the SKT was sensitive to varying levels of stroke knowledge and to estimate the reliability of the test. Results: The final version of the test included 20 items with good content coverage, acceptable item properties, and positive expert review ratings. Results from psychometric investigations suggest that SKT has relatively good reliability (internal consistency and test-retest reliability) and construct validity (i.e., SKT scores significantly increased after stroke education [cf. nonstroke education], and community-dwelling older adults who had a relative with stroke [and more prior exposure to stroke information] scored higher on the SKT than those without a stroke relative). Conclusion: Findings provide preliminary support for the SKT as a valid and reliable tool for assessing stroke knowledge. The SKT may be used to identify individual information needs of stroke survivors and their caregivers or as a tool to evaluate group- or community-based stroke education programs.     

The longitudinal and dyadic effects of mutuality on perceived stress for stroke survivors and their spousal caregivers

Objective: Functional impairment resulting from a stroke frequently requires the care of a family caregiver, often the spouse. This change in the relationship can be stressful for the couple. Thus, this study examined the longitudinal, dyadic relationship between caregivers’ and stroke survivors’ mutuality and caregivers’ and stroke survivors’ perceived stress.

Method: This secondary data analysis of 159 stroke survivors and their spousal caregivers utilized a cross-lagged, mixed models analysis with the actor–partner interdependence model to examine the dyadic relationship between mutuality and perceived stress over the first year post-discharge from inpatient rehabilitation.

Results: Caregivers’ mutuality showed an actor effect (β?=??3.82, p?β?=?0.13, p?=?0.047). Caregivers’ perceived stress did not show a partner effect and did not significantly affect stroke survivors’ perceived stress.

Conclusion: These findings highlight the interpersonal nature of stress in the context of caregiving for a spouse. Caregivers are especially influenced by perceived stress in the spousal relationship. Couples should be encouraged to focus on positive aspects of the caregiving relationship to mitigate stress.