Nonphysical Problems Common After Stroke

March 29, 2018

A new study highlights some of the more common nonphysical problems experienced by patients after they have an ischemic stroke, with some surprising findings.

The study, which examined patient-reported information collected systematically at the Cleveland Clinic cerebrovascular clinic from 2015 to 2017, found that after physical function, the domains most affected in patients with ischemic stroke were satisfaction with social roles (eg, the ability to do domestic tasks, go out and socialize, and go to work) and executive function.

"While we would all expect physical function to be impacted by stroke, satisfaction with social roles and executive function are not as well appreciated as being common problems after stroke. We actually found that these were much more common than anxiety and depression, which was quite surprising," lead author, Irene L. Katzan, MD, Cleveland Clinic, Ohio, told Medscape Medical News.

"Even if patients don't have an obvious physical disability after a stroke — so on the surface they appear normal — they often suffer from these less obvious issues which can have a large effect on quality of life. While they may be able to get to the grocery store, they may have problems organizing a list or paying for their goods or they may feel too fatigued to go out at all," she said.    

"While many centers will systematically screen for depression after stroke, I don't think we routinely think about satisfaction with social roles and executive function as common problems for stroke patients," Katzan added. "Our results suggest that we should.  While there is no quick fix for these problems, we can provide suggestions on how to cope better maybe, in programs aimed at integrating people back into society again."

The study was published online in Neurology on March 28.

Katzan explained that while it is well known that stroke affects lives in many different ways, usually patients are assessed by using limited scores that don't take account of multiple factors occurring together and how they interact with each other.

"The main scale used to assess stroke patients — the modified Rankin Scale (mRS) — is quite a crude scale with only seven different categories and is heavily weighted towards mobility. It doesn't differentiate the impact of things like sleep, cognition, anxiety, and depression on day-to-day life."   

For the current study, the researchers analyzed information from 1195 stroke patients by using the Patient-Reported Outcomes Measurement Information System (PROMIS), which captures patient responses for physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance. Scores are calibrated to the US general population, which aids in the clinical interpretation of results.

Additional information on executive function was derived from response to the Neuro-QoL executive function scale.

The most affected domains were physical function (T score, 58.8), satisfaction with social roles (T score, 55.4), and executive function (T score, 53.4).

PROMIS scores for all domains except depression and sleep disturbance were worse than in the general population. However, patients with an mRS score of 0 (no symptoms) were not worse than the general population on any of the eight domains measured.

Disability, lower income, and female sex were associated with worse scores in multiple domains. Age was associated with worse physical function but lower anxiety, depression, and sleep disturbance.

Patient-reported health worsened with increasing levels of disability in all domains, although to varying degrees.

A graded response of worsening physical function, worsening executive function, and worsening satisfaction with social roles was correlated with the mRS and the National Institutes of Health Stroke Scale. While fatigue, depression, pain, and anxiety had modest correlations and sleep disturbance had only a slight correlation with disability, scores remained relatively stable in patients with disability levels ranging from mild to severe (mRS score, 2 to 5).

"Our findings that domains of health are differentially affected with increasing levels of disability support the value of assessing individual domains of health in stroke patients, regardless of stroke severity," the researchers say. 

"The results of this study, which represents one of the largest analyses of patient-reported outcomes after stroke collected as part of routine care, improve our understanding of the well-being of patients with ischemic stroke compared to the general population and bring attention to the importance of social roles and executive function for stroke survivors," they conclude.

In an accompanying editorial, Mary G George, MD, Centers for Disease Control and Prevention, Atlanta, Georgia, and Xingquan Zhao, MD, Beijing Institute for Brain Disorders, China, say the study "sheds light on understanding how survivors of ischemic stroke differ from the general population across multiple health domains that can be useful in improving the clinician's understanding of patients' challenges and needs, as well as addressing outcomes that matter most to patients."

The study had no targeted funding. Katzan, George, and Zhao have disclosed no relevant financial relationships. Disclosures for coauthors appear in the paper.

Neurology. Published online March 28, 2018. Abstract, Editorial

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