…it’s not just a minor stroke… APSS Telehealth Presentation Teri Green, RN PhD Calgary Stroke Program Faculty of Nursing/University of Calgary June 2008.

…it’s not just a minor stroke…

APSS Telehealth PresentationTeri Green, RN PhD

Calgary Stroke ProgramFaculty of Nursing/University of Calgary

June 2008

An Examination of Male Patient, Wife-Caregiver, and Marital Dyad Outcomes Over

a Three-Month Period Following Minor Stroke

BACKGROUND

• 50,000 Canadians have a stroke annually; minor stroke or transient ischemic attacks account of 82% of all cerebrovascular disease

• Having a stroke creates a need for short and long-term adjustments for the patient as well as the family

• Minor stroke patients are discharged from acute care

shortly after their stroke event • There is little empirical evidence available regarding:

(a) the effect of minor stroke on patient’s abilities to return to their previous roles and functions; and (b) how this seemingly minor event influences the marital dyad in the immediate post-discharge

period

RESEARCH QUESTIONSPrimary Question

• What are the changes in patient functional status, patient and wife-caregiver health related quality of life (HRQOL) and depression, wife-caregiver strain, and marital dyad functioning between hospital discharge and 3-months following the stroke event?

Secondary Questions• What are the associations between patient functional status, patient and wife-caregiver HRQOL and depression; caregiver strain; and marital dyad functioning over a 3-month period following stroke? • What are the predictors of marital function at 3-months following a minor stroke?

Tertiary Question• What do minor stroke patients and wife-caregivers identify as factors affecting their HRQOL and/or caregiver strain over 3-months following discharge?

RESEARCH METHODS

• Prospective pilot study of 38 male stroke patients and their wife-caregivers

• Demographic and clinical information obtained from the health record and in-person interviews at time of discharge

• Questionnaires administered, using standardized measures, at discharge and one month intervals over a period of 3-months post-stroke using:

• SS-QOL• SF-12v2• BDI-II• FADGFS• BCOS (1-,2-,&3-months)

Inclusion/Exclusion Criteria

Inclusion

• Male patient with a wife-caregiver

• Minor stroke (NIHSS<4, mRS<2, BI>65)

• d/c home within 7 days• MMSE ≥ 24• Able to provide informed

consent• Able to read/speak

English

Exclusion

• No identified spousal caregiver

• Moderate/severe stroke• Extended hospital stay• MMSE < 24• Unable to provide

informed consent• Unable to read/speak

English

DATA ANALYSES• Patients and wife-caregivers characterized using

descriptive statistics

• Correlation analyses to examine relationships between biophysical and psychosocial measures

• Repeated measures ANOVA & MANOVA to examine changes over time

• Logistic regression analysis to determine predictors of marital function at 3-months

• Conventional content analysis of responses to open-ended questions from the Stroke-Specific Quality of Life Scale and the Bakas Caregiver Outcomes Scale administered at 1-, 2-, and 3-months post-discharge

Demographic CharacteristicsPatient Wife-caregiver

Age mean (SD) 63.9 years (12.0)

(range 39-83)

58.5 years (11.7)(range 33-75)

Caucasian n (%) 38 (100) 36 (96)

MMSE mean (SD) 29.5 (1.71) 29.5 (1.49)

Employment Status n(%)

NoYes

Retired

3 (8)25 (66)10 (26)

8 (21)21 (55)9 (24)

Education Level n (%)≤ high school

High School graduatePost-secondary

7(18)13 (34)18 (47)

3 (8)8(21)

27 (71)

Stroke Characteristics

• Stroke Type: ischemic 36 (95%), hemorrhagic 2 (5%)

• Lesion Side: right 21 (55%), left 17 (45%)

• Location: supratentorial 27 (63%), brainstem 4 (11%), unknown 7 (18%)

Stroke Severity & Functional Outcomes

Paired t-test

Discharge X (SD)

3-monthsX (SD)

t(df) p

NIHSS(0-42)

2.0 (1.70) 1.1 (2.38)

1.87 (37)

0.076

mRS(o-6)

1.4 (0.95) 1.0 (0.75)

2.34 (37)

0.025*

BI(0-100)

93.2 (12.44)

98.6 (8.13)

-2.22 (37)

0.033*

SIS-16(16-80)

74.0 (8.26) 74.6 (7.05)

-3.91 (37)

0.698

Changes in Psychosocial Measures between Discharge and 3-months

Post-dischargeANOVA

DischargeX (SD)

3-monthsX (SD) F (df) p

SS-QOL (1-5) 4.08 (.504) 4.17 (.479) 1.06 (3) 0.311

SF-12 (0-100)Physical

Mental Health

51.07 (9.45)49.20 (9.95)

51.02 10.09)51.10 10.64)

0.039 (3)1.69 (3)

0.9890.186

BCOS (15-105)1 and 3-mo

57.13 (8.70) 57.80 (8.70) 0.201 (2) 0.819

Changes in Depression and Marital Function between

Discharge and 3-months Post-discharge

Discharge

X (SD)

3-months

X (SD)

MANOVA

t(df) p

BDI-II (0-63)Patient

Wife-caregiver

6.18 (6.70)7.21 (5.73)

6.0 (6.64)6.39 (3.50)

2.67(3) 0.063

FADGFS (1-4)Patient

Wife-caregiver

1.58 (.503)1.73 (.471)

2.0 (.428)1.83 (.519)

3.75 (3) 0.025*

Patient and Wife-caregiver Mean BDI-II Scores Over Time

Three months post-discharge

(p=0.904)

Two month post-discharge (p=0.610)

One month post-discharge (p=0.018)

Discharge (p=0.456)

8.0

7.5

7.0

6.5

6.0

5.5

5.0

5.97

5.21

5.42

7.21

7.26

6.66

7.53

6.18

Patients

Wife-ca

regive

rs

Patient and Wife-caregiver Mean FADGFS Scores Over

Time

Three months post-discharge

(p=0.551)

Two months post-discharge (p=0.278)

One month post-discharge (p=0.000)

Discharge (p=0.001)

1.9

1.8

1.7

1.6

1.821.821.82

1.73

1.88

1.891.92

1.58

Patients

Wife-caregivers

Associations Between Outcome Variables

Patient: • HRQOL & depression

• r=-.577, p<0.001 (discharge)• r=-.662, p<0.001 (1-month post-discharge)• r=-.495, p=0.002 (2-months post-discharge) • r=-.758, p<0.001 (3-months post-discharge)

• Depression & wife-caregiver’s perception of marital function

• r=.442, p=0.005 (discharge)• r=.376, p=0.020 (2-months) • r=.610, p<0.001 (3-months)

Associations Between Outcome Variables

Wife-caregiver:• Depression & wife-caregiver’s perception of

marital function • r =.362, p=0.026 (discharge)• r=.538, p<0.001 (1-month)• r=.334, p=0.040 (2-months)• r=.578, p<0.001 (3-months)

• Wife-caregiver’s perception of marital function and caregiver strain

• r=-.517, p<0.001 (1-month)• r=-.742, p<0.001 (2-months)• r=-.620, p<0.001 (3-months)

Predictors of Marital Function at

3-monthsOR 95% CI p

mRS . 270 .081 - .902 0.033*

SS-QOL .032 .001 - .987 0.049*

SF-12 physical

1.257 1.035 – 1.526

0.021*

BCOS .739 .543 – 1.005

0.054

Qualitative Data

• Transitional framework* “Passage from one life condition or status to another “

o processo timeo perception

• **Content analysis

*Chick & Meleis (1986). Transitions: A Nursing Concern

Hsieh & Shannon (2005)

Content Analysis

• Overarching Themes– Being vulnerable– Realization of the new self and changing

relationships

• Subthemes• Masculine image• Hyper-vigilance• Loss

Being Vulnerable

• Uncertainty– Fear of recurrent stroke – vulnerable to

the disease

• Frustration over recovery process• Lack of assurance about the future

- health status- work and financial situations- lifestyle

Being Vulnerable

• Gossiped about• Stigmatized• Isolated & abandoned• Insecure• Financial/work stability challenged• Mood changes and stress

Realization

• Increasing awareness and insight• Apprehension about ability to put

their lives back together - Continuity of the family- Maintenance of relationships

• Adaptation– Acceptance and denial– Incorporation of physical deficits– Ongoing challenges of emotional and

cognitive changes– Stabilization – changing priorities– Recognition of need for continuous

adaptation

Key Threads

• Masculinity: imposed limitations, life-changes

• Hyper-vigilance: protective monitoring, control

• Loss: physical, emotional, social

Masculinity

• “I was surprised by the long term effects of the stroke…not prepared for the loss of energy and changes in mood, thinking and personality.”

• “The stroke has made me useless. I can’t do the things for my family like protect them. If an intruder came in I couldn’t even defend my family. I wouldn’t even have the strength to fight off a child.”

Masculinity

• “The largest challenge has been the feelings of depression that have been part of life since the stroke. It’s a struggle to accept that I am not the person I used to be, that I can’t contribute like I used to, it seems like I’m not worthwhile as I was before.”

• “…I am feeling blue and I cry at the drop of a hat…fear and anxiety are new to me.”

Hyper-vigilance • “always watching”

• “Since I am his wife and I am the one closest to him, the only one who can really take care of him, I really do feel this as a responsibility and yet it is so different to have him here in my space…”

• “…my husband would kill me if he knew that I check on him in the night to see if he is still breathing.”

• “My husband accuses me of babying him, but my over-protectiveness is an automatic reaction because I am afraid to let him go.”

Loss

• “I am feeling the burden of having to make many life decisions because my husband doesn’t want to make any decisions himself.”

• “I feel trapped by my husband and sometimes I would like to run away…I have to spend all my time with him and this has negatively impacted my relationship with friends and family.”

• “I am feeling overwhelmed…the whole family system is disrupted.”

Loss

• “…marital relationship is tense and negative with arguments over everything.”

• “I am not the same person that I was before.”

• “I always pride myself in being healthy and athletic, now I feel so weak. Physically I am going soft.”

Participant’s Personal Reflections

• “There is more to life than tangibles, and I have learned to count my blessings.”

• “I realize how devastating the stroke could have been…I am humbled by everything and I am most grateful.”

• “…more reflective and more aware of what is important…”

• “I am entering a transitional period, where I will have to learn to get over my past perceptions of self-image. Perhaps it is time to focus on other things…Previously I had a dichotomy between my physical and emotional needs. The stroke has highlighted the need to develop all aspects of myself in order to have a better quality of life. It has taught me the importance of moderation and balance.”

CONCLUSIONS…it’s not just a minor stroke…

• Patients experienced significant improvement in functional status over time however overall psychosocial status did not improve from time of discharge

• Though patients perceived a deterioration in marital function over time, wife-caregiver scores did not change significantly (on any of the psychosocial measures)

Conclusions

• Qualitatively, patients and wife-caregivers reported difficulty returning to previous life roles (including family, work, and social roles) over the 3-month period

• The lack of complete functional recovery over time created a disconnect between the hope and the reality of having a ‘minor’ event

Thank You!

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