PSYCHOGERIATRICS PSYCHOGERIATRICS2016; 2015;16: ••:185–190 ••–••

doi:10.1111/psyg.12137 doi:10.1111/psyg.12137

ORIGINAL ARTICLE

Longitudinal functional changes, depression, and health-related quality of life among stroke survivors living at home after inpatient rehabilitation Hitoshi MUTAI,1,2 Tomomi FURUKAWA,2 Kosuke NAKANISHI3 and Tokiji HANIHARA1

1

School of Health Sciences, Shinshu University School of Medicine, Matsumoto, 2Department of Rehabilitation, Azumino Red Cross Hospital, Azumino, and 3Department of Occupational Therapy, Faculty of Health Science, Health Science University, Fujikawaguchiko, Japan Correspondence: Mr Hitoshi Mutai OTR PhD, School of Health Sciences, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan. Email: [email protected] Received 2 December 2014; revision received 9 March 2015; accepted 11 May 2015.

Key words: activities of daily living, depression, health-related quality of life, instrumental activities of daily living, stroke.

Abstract Aim: This study investigated changes in functional status in home-dwelling stroke survivors 1–3 years after inpatient rehabilitation. It also examined the factors associated with longitudinal functional changes and health-related quality of life. Methods: Survey evaluations were conducted at the homes of 27 stroke survivors. The Functional Independence Measure (FIM), Short Form 36, Frenchay Activities Index, and Hamilton Depression Rating Scale were used to assess functional status, quality of life, social activity, and depression symptoms, respectively. Results: From the time of discharge to follow-up (mean: 2.1 1 0.6 years), total FIM and motor FIM scores were mildly improved, and cognitive FIM score was significantly improved. On the Short Form 36, physical functioning, general health, and vitality scores were lower than norm-based scores. Multiple regression analyses showed a positive association between change in motor FIM score and Frenchay Activities Index score and a negative association between change in cognitive FIM score and elapsed time after discharge. With regard to health-related quality of life, motor FIM score was associated with the physical component summary, whereas age and Hamilton Depression Rating Scale score were associated with the mental component summary. Conclusion: Social participation was associated with long-term improvement in activities of daily living, indicating that interventions targeting social function are important for maintaining and further improving activities of daily living in stroke survivors. Health-related quality of life was correlated with activities of daily living and depression; therefore, interventions targeting these parameters are important in improving the quality of life of stroke survivors.

INTRODUCTION Stroke is the most prevalent cause of disability in the elderly.1,2 Because stroke is the major cause of the need for in-home nursing care in elderly individuals,2 methods to support the daily lives of home-dwelling stroke survivors have become a significant social issue in Japan. Rehabilitation plays an important role in improving physical impairments and disabilities, as well as in achieving social reintegration in stroke sur© © 2015 2015 The The Authors Authors Psychogeriatrics Psychogeriatrics © © 2015 2015 Japanese Japanese Psychogeriatric Psychogeriatric Society Society

vivors suffering post-stroke sequelae. In Japan, convalescent rehabilitation wards play a central role in rehabilitation during the subacute phase of stroke, and their intensive multidisciplinary approach has been reported to improve physical impairments and activities of daily living (ADL) in stroke survivors and to promote their return home.3 In our previous cross-sectional studies, we have shown that social inactivity and depression symptoms

1851

H. H. Mutai Mutai etet al. al.

remain highly prevalent in home-dwelling stroke survivors after discharge from a convalescent rehabilitation ward.4 Maintaining and improving ADL acquired through inpatient rehabilitation is important for stroke survivors to be able to continue living at home. However, only a few prospective studies have investigated longitudinal functional changes in stroke survivors after inpatient rehabilitation. Whiting et al. reported that Functional Independence Measure (FIM) scores increased slightly during the 1-year follow-up after discharge but decreased after 5 years in elderly stroke patients.5 This study examined the longitudinal changes in functional status after inpatient rehabilitation in selected stroke survivors using the FIM, a validated measure of ADL. In addition, this study examined the health-related quality of life (HR-QOL) of the survivors and determined the association between quality of life (QOL) and functional impairment, social participation, and depression symptoms.

METHODS Subjects Subjects (n = 27; mean age: 69.4 1 9.9 years; 19 men and 8 women) were recruited from 151 consecutive stroke patients (mean age: 72.7 1 10.4 years; 83 men and 68 women) discharged from the convalescent rehabilitation ward at Azumino Red Cross Hospital between August 2006 and August 2008. A letter was sent to the subjects to explain the aims of this study and to obtain permission for a researcher to visit their home. The diagnosis of stroke was confirmed by clinical and radiologic findings. Subjects with severe confusion, unstable medical complications, or other acute diseases that could impede active rehabilitation were excluded. Assessment The follow-up assessment was performed 1–3 years after discharge. A certified occupational therapist conducted face-to-face interviews at the subjects’ homes. For subjects who had difficulty answering the survey questions, a family member responded instead. The scales employed in this study were the FIM for ADL, Frenchay Activities Index (FAI) for social activities, Short Form 36 (SF-36) for HR-QOL, and Hamilton Depression Rating Scale (HDRS) for depression symptoms.

186 2

The FIM measures physical and cognitive disabilities. Thirteen items comprise the motor subscale (motor FIM) and five items comprise the cognitive subscale (cognitive FIM). The FIM items are scored on a 7-point ordinal scale based on the amount of assistance required. The minimum FIM score is 18, which indicates a low level of functioning; the maximum score is 126, which indicates a very high level of functioning.6,7 The degree of functional change was assessed by determining the change in the FIM score from discharge to follow-up. Social activities status was assessed by the FAI, which is based on the frequency of performing 15 activities (e.g. preparing meals, gardening). Scores range from 15 to 60, with higher scores indicating higher levels of activity.8 The SF-36 is the most popular questionnaire for measuring HR-QOL. It measures eight domains of physical and emotional functioning: (i) physical functioning (PF); (ii) physical role; (iii) bodily pain; (iv) general health perceptions (GH); (v) vitality; (vi) social role functioning; (vii) emotional role functioning; and (viii) mental health. Each domain score was calculated by norm-based scoring. The national standard value and standard deviation are 50 points and 10 points, respectively. Higher scores indicate higher levels of HR-QOL. The eight domain scores of the SF-36 can be summarized in two main scores: the physical component summary (PCS) and mental component summary (MCS).9 The HDRS is one of the most widely used clinicianadministered assessments of depression symptoms.10 It contains 21 items pertaining to symptoms of depression experienced over the past week. The cutoff point for the presence of depression is a score ≥9.11 The following demographic characteristics were also obtained: age, sex, living situation (with spouse only or with another family member), premorbid dependence (modified Rankin Scale >2),12 and paralysis (normal, slight, moderate, or severe). In addition, history of stroke, stroke type, and FIM score at discharge were obtained from the subjects’ medical records. Statistical analysis All statistical analyses were performed using SPSS software for Windows, version 18.0 (SPSS Inc., Chicago, IL, USA). The Wilcoxon signed-rank test was © © 2015 2015 The The Authors Authors Psychogeriatrics Psychogeriatrics © © 2015 2015 Japanese Japanese Psychogeriatric Psychogeriatric Society Society

Factors associated associated with with QOL Factors QOL after after stroke stroke

used to compare the medians of quantitative variables between two groups. Multivariable stepwise regression analysis was used to determine factors associated with changes in the FIM score, SF-36, and MCS. In all analyses, a P-value 8

Mean 1 SD Male/female First ever stroke/recurrent Ischaemic/haemorrhagic Alone/with spouse/with family Mean 1 SD

n = 27 69.4 1 9.9 19/8 20/7 15/12 0/11/16 2.1 1 0.6

Dependent/independent

3/24

Normal, slight/moderate, severe Mean 1 SD Mean 1 SD

21/6 28.4 1 9.4 27.3 1 22.6 54.1 1 4.9 52.3 1 12.3 46.3 1 9.6 49.8 1 7.5 51.7 1 11.5 53.4 1 6.5 50.5 1 9.5 43.9 1 9.5 52.8 1 8.9

Mean 1 SD Prevalence of depression

4.4 1 5.5 18.5%

FAI, Frenchay Activities Index; HDRS, Hamilton Depression Rating Scale; mRS, modified Rankin Scale; SF-36, Short Form 36.

© © 2015 2015 The The Authors Authors Psychogeriatrics Psychogeriatrics © © 2015 2015 Japanese Japanese Psychogeriatric Psychogeriatric Society Society

age was 69.4 1 9.9 years, and 29.6% of the subjects were women. The mean elapsed time from discharge was 2.1 1 0.6 years. Regarding history of stroke, 74.1% of subjects had had only one stroke episode, and 55.6% of subjects had had an ischaemic stroke. Premorbid ADL status revealed that 11.1% of subjects were dependent. Moderate or severe paralysis was present in 22.2% of subjects. The mean FAI score was 28.4 1 9.4. The norm-based scoring of the SF-36 subscales and summary scores was as follows: PF, 27.3 1 22.6; physical role functioning, 54.1 1 4.9; bodily pain, 52.3 1 12.3; GH, 46.3 1 9.6; vitality, 49.8 1 7.5; social role functioning, 51.7 1 11.5; emotional role functioning, 53.4 1 6.5; mental health, 50.5 1 9.5; PCS, 43.9 1 9.5; and MCS, 52.8 1 8.9. The mean HDRS score was 4.4 1 5.5. Five subjects had an HDRS score >8. Therefore, the estimated prevalence of depression was 18.5%. Regarding changes in ADL from discharge to follow-up, mean motor, cognitive, and total FIM scores improved from 78.4 1 12.3 to 79.3 1 14.5, 29.6 1 5.5 to 32.5 1 3.7, and 108.0 1 16.1 to 111.9 1 16.8, respectively. The mean cognitive FIM score was significantly higher at discharge than at follow-up (Table 2). A stepwise multivariate linear regression analysis was performed to determine variables associated with change in FIM score and SF-36 domain scores (Tables 3,4). The independent variables included age, sex, living situation, elapsed time after discharge, premorbid dependence, paralysis, history of stroke event, stroke type, FAI, and HDRS. Change in total FIM score was associated with elapsed time after discharge (β coefficient = −0.413, P = 0.021) and FAI score (β coefficient = 0.365, P = 0.039). The change in motor FIM score was associated with FAI score, and change in cognitive FIM score was associated with elapsed time after discharge. The PCS was associated with motor FIM score (β coefficient = 0.663, P = 0.003), whereas the MCS was associated with age

Table 2 Comparison at time of discharge and follow-up of the FIM FIM

At discharge

At follow-up

Change in FIM

P-value

Motor Cognitive Total

78.4 1 12.3 29.6 1 5.5 108.0 1 16.1

79.3 1 14.5 32.5 1 3.7 111.9 1 16.8

0.9 1 12.5 2.9 1 4.7 3.8 1 15.4

0.221 0.014 0.076

Change in FIM = FIM at follow-up − FIM at discharge. FIM, Functional Independence Measure.

1873

H. H. Mutai Mutai etet al. al. Table 3 Multivariable stepwise regression analysis for the change in the FIM FIM variable Motor FAI Cognitive Length from discharge Total Length from discharge FAI

β

P-value

HDRS domains

β

P-value

0.435

0.018

Middle insomnia Feeling of guilt Retardation

0.046 0.003 0.014

−0.525

−0.285 −0.441 −0.369

0.005

−0.413 0.365

0.021 0.039

Change in FIM = FIM at follow up − FIM at discharge. FAI, Frenchay Activities Index; FIM, Functional Independence Measure.

Table 4 Multivariate stepwise regression analysis for the SF-36 domains, PCS, and MCS SF-36 variable Physical functioning Motor FIM FAI HDRS Physical role functioning – Bodily pain HDRS General health perception Age Motor FIM HDRS Vitality Family member Cognitive FIM Social role functioning HDRS Emotional role functioning – Mental health HDRS PCS Motor FIM MCS Age HDRS

β

P-value

0.578 0.312 −0.226

Longitudinal functional changes, depression, and health-related quality of life among stroke survivors living at home after inpatient rehabilitation.

This study investigated changes in functional status in home-dwelling stroke survivors 1-3 years after inpatient rehabilitation. It also examined the ...
882KB Sizes 0 Downloads 7 Views