Short-Term Changes in and Predictors of Participation of Older Adults After Stroke Following Acute Care or Rehabilitation Johanne Desrosiers, PhD, Louise Demers, PhD, Line Robichaud, PhD, Claude Vincent, PhD, Sylvie Belleville, PhD, Bernadette Ska, PhD, and the BRAD Group Background. Stroke can lead to restrictions in participation in daily activities and social roles. Although considered an important rehabilitation outcome, little is known about participation after stroke and its predictors, and about the differences associated with the types of services provided following stroke. Objective. The aims of this study were 1) to follow and compare changes in participation of older adults discharged home after stroke from acute care or postacute rehabilitation, and 2) to identify the best predictors of participation after stroke from physical, cognitive, perceptual, and psychological ability measures taken shortly after discharge. Methods. Level of participation in daily activities and social roles of 197 older adults who had a stroke was evaluated at 2 to 3 weeks (T1), 3 months (T2), and 6 months (T3) after being discharged home from acute care (n = 86) or rehabilitation (n = 111). Physical, cognitive, perceptual, and psychological abilities were assessed at T1. Results. A significant increase in participation was found over time for both groups, mainly in the first 3 months. The best predictors of participation differed between the groups and between the daily activities and social roles domains. Walking and From the Research Center on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke (JD); Department of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke (JD); Research Centre, University Institute of Geriatrics of Montreal, Montréal (LD); School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal (LD); Department of Rehabilitation, Université Laval, Quebec City (LR, CV); Center for Interdisciplinary Research in Rehabilitation and Social Integration, Québec City (CV); Department of Psychology, Faculty of Arts and Sciences, Université de Montréal (SB); and School of Speech Therapy and Audiology, Faculty of Medicine, Université de Montréal (BS), Quebec, Canada. The BRAD Group is composed of Gina Bravo, Philippe Landreville, Louisette Mercier, Nicole Paquet, Hélène Payette, Constant Rainville, Jacqueline Rousseau, Lise R. Talbot, and René Verreault, in addition to the authors of this article. Address correspondence to Johanne Desrosiers, OT, PhD, Research Centre on Aging, 1036 Belvédère sud, Sherbrooke, Québec, Canada J1H 4C4. E-mail:
[email protected]. Desrosiers J, Demers L, Robichaud L, Vincent C, Belleville S, Ska B; the BRAD Group. Short-term changes in and predictors of participation of older adults after stroke following acute care or rehabilitation. Neurorehabil Neural Repair 2008;22:288-297. DOI: 10.1177/1545968307307116
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acceptance of the stroke or fewer depressive symptoms were the best predictors of the level of participation after stroke. Conclusions. Participation was not optimal at discharge because it continued to increase after the return home. The importance of psychological factors in participation after stroke is undeniable. Many predictors are amenable to interventions. Key Words: Stroke rehabilitation—Neurological score—Cognitive functions—Affect (depressive symptoms).
troke is a major cause of disabilities leading to restrictions in participation in daily activities and social roles,1 especially in older adults. Since the publication of the International Classification of Functioning, Disability and Health (ICF) at the beginning of 2000,2 the concept of participation has become a subject of interest because it goes beyond disabilities and considers individuals in their environment. In the early 1990s, Fougeyrollas and his team3 made an important contribution to the advancement of knowledge about the concept of participation by developing the Disability Creation Process (DCP) model. In this model, participation is defined as the accomplishment of a person in his/her daily activities and social roles, resulting from the interaction between personal factors (such as abilities) and environmental factors acting as facilitators or obstacles.3 Similarly, in the ICF,2 participation is defined as the person’s involvement in a life situation. After a brief hospital stay after stroke, many older adults return to their own environment quickly, despite various impairments and disabilities, and often without having had any rehabilitation to reduce or compensate for them.4 In Canada, only about 10% to 15% of people with stroke receive inpatient rehabilitation services.5 The rest, whose physical deficits are not so serious or whose sequelae are not properly identified, return to their own environment frequently without rehabilitation services. Deficits that are not always correctly identified include perceptual, cognitive, and mood disorders that may result in serious participation restrictions.6
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Copyright © 2008 The American Society of Neurorehabilitation
Changes in and Predictors of Participation
So far, little is known about short-term changes in participation after stroke of people who returned home directly after discharge from an acute care hospital or who participated in a rehabilitation program before being discharged home. Two longitudinal studies on long-term changes in participation after stroke were found in the literature.7,8 They both found a decline in participation over time (up to 4 years after stroke). However, little is known about the process by which participation evolves soon after discharge. Short-term improvement is critical because this is the period when patients remain in contact with the health care system and can thus still benefit from support to promote participation over the long term. This may also provide important information regarding the factors that promote participation. For example and contrary to a longterm decline in participation, an increase in participation is expected in the first few months following a stroke because people need time to resume previous activities and roles as well as initiate new ones. To our knowledge, only two short-term studies have explored changes in participation over time.9,10 In the study by Rochette and colleagues,10 only people with mild stroke were included, whereas the study by Jette and colleagues9 was carried out exclusively with people admitted to an inpatient rehabilitation unit, which limits the ability to generalize their findings to the wider stroke population. We know little about the personal factors (abilities) that may explain differences in participation of people who had a stroke. Short-term and long-term predictors of participation after stroke were previously studied with individuals hospitalized in one inpatient rehabilitation unit,11,12 which limits the external validity of these studies. Also, Cardol and colleagues13 studied the explanatory factors of restriction in participation in adults who had chronic disabled conditions such as stroke. The crosssectional design of this study made it impossible to predict the level of participation. Recently, Jette and colleagues9 also studied factors predicting restriction in participation of people with different types of disability in an inpatient rehabilitation program. No previous studies have compared predictors of participation after stroke according to the last level of services (acute care hospital vs inpatient rehabilitation or day hospital) received before returning home. It was expected that people discharged directly home after stroke would have different physical abilities among other characteristics from people transferred to rehabilitation, which justifies considering them separately. The objectives of this study were 1) to follow and compare changes in participation of people with a recent stroke who returned home after discharge from an acute care hospital versus an inpatient rehabilitation unit or geriatric day hospital, and 2) to identify the best predictors of their participation in daily activities and social roles among physical, cognitive, and psychological abilities. Neurorehabilitation and Neural Repair 22(3); 2008
METHODS Participants This study was conducted in 3 regions of the province of Quebec, Canada: Montreal (metropolitan area), Eastern Townships, and Chaudière-Appalaches (both urban and rural areas) in the context of a larger study on the rehabilitation needs of people who had a stroke and lived at home. In each region, the participants were selected upon discharge from 1 of 3 health services: acute care hospital (ACH), inpatient rehabilitation unit (IRU), or geriatric day hospital (GDH). After verifying eligibility, a research assistant met with the potential participants to explain the research aims and procedure and request their participation. If they agreed, an appointment was made for the first assessment at the patient’s home. To be included in the study, subjects had to 1) be 65 years of age or older, 2) have had at least one stroke according to WHO criteria,14 3) be at the end of treatment at an ACH, IRU, or GDH at the time of recruitment, and 4) return to live at home. Individuals who presented severe cognitive disorders (based on clinical judgment: inability to follow a simple discussion and lack of awareness of their potential involvement in the study) were excluded. The research protocol was approved by the Research Ethics Committee of the 8 institutions involved.
Data Collection Procedure The subjects’ participation level (dependent variable) was evaluated on three occasions: 1) time 1 (T1), between the 18th and 24th day following discharge from an ACH, IRU or GDH; 2) time 2 (T2), 3 months after discharge; and 3) time 3 (T3), 6 months after discharge. The delay between discharge and the first measure (T1) was deliberately chosen to give participants time to recover from returning home. T2 corresponds to the initial phase of adapting to their new situation; at T3, most patients should have had the time or opportunity to resume their usual daily activities and social roles. The subjects’ physical, cognitive and psychosocial abilities (independent variables) were measured at T1. Sociodemographic and clinical characteristics (see Table 1) were also collected. To estimate the severity of the stroke, the Canadian Neurological Scale (CNS)15 was used 24 hours after the stroke, at discharge from an acute care hospital and at T1. The CSN gives a score ranging from 1.5 to 11.5, where a higher score indicates a less severe stroke. It is composed of two sections: cognition (/5) (alertness, orientation, and communication) and motor function (/6.5) (face, arm, and leg). Comorbidity was estimated with the Charlson Index.16 289
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Table 1. Sociodemographic and Clinical Characteristics of Participants at T1 Acute Care Group (n = 86)
Rehabilitation Group (n = 111)
Continuous Variables
Mean (SD)
Mean (SD)
P Valuea
Age (years) Time since stroke (days) Schooling (years) Falls in the last 3 months Comorbiditites (number) Neurological score (/11.5) 24 hours after stroke Discharge T1
77.2 (7.1) 33.7 (14.0) 7.7 (3.5) 0.45 (.96) 2.0 (1.6)
76.7 (7.0) 134.3 (81.9) 8.1 (4.1) 0.54 (.90) 2.4 (2.4)
.56
