INTRODUCTION
Stroke is one of the main causes of adult disability and has been the top four leading causes of death in developing countries. It is expected that the prevalence of stroke would be doubled in the next decade, corresponding to the increase in life expectancy and in lifestyle related illnesses namely hypertension, hyperlipidaemia and obesity. In Malaysia alone, stroke ranked as the fifth highest cause of death in 2009 with a mortality rate of Malaysia8.43 per 100 000 population (MOH 2009).
Management of stroke is through a multidisciplinary approach incorporating acute stroke units, seamless transfer of care from hospital to home, structured rehabilitation and comprehensive long term care to address post stroke complications and also management of secondary risk factors (NICE 2008; Yong & Foster 2007; Langhorne et al. 2011). It is acknowledged that approximately two thirds of stroke survivors would survive the acute episode of stroke but many of these survivors may be living with various degrees of disabilities and dependent for the rest of their life (Internet Stroke Center 2013). Fragmented community services post transfer of care was identified as one of the barriers for optimum recovery; together with other issues related to the elderly population such as exposure to the risk of falls, dementia and safety (Young 2001).
Over the last two decades, stroke rehabilitation has been acknowledged as an integral part of stroke recovery, with specific restorative and repetitive learning processes tailored to individual disabilities; this is the key to improving the survivor’s physical function in performing activities of daily living and mobility over time (Langhorne et al. 2011). Nonetheless, the degree of recovery depends on several factors, namely the patient’s age, functional independence, support system and premorbid condition (Langhorne et al. 2009; Jorgensen et al. 1995; Musicco et al. 2003). Cardiovascular risk factors, notably diabetes, were also identified to influence the recurrence and rate of recovery. For example, a study done by Hamidon and Raymond found that diabetes is an independent risk factor influencing post stroke complications, which may result in poorer outcome after strokes as these patients tend to be more prone to infection and already had pre existing end organ damages secondary to diabetes (Hamidon & Raymond 2003).
The management of these risk factors requires long term commitment by medical personnel extending beyond in-hospital care. Guidelines have advocated the need of structured transfer of care from hospital to primary care as an important element for long term care and control (Langhorne et al. 2005). This study looked at early functional recovery and its associated factors in post ischemic stroke patients after they have been discharged from a tertiary hospital back to the community. It is hoped that the findings of this trial can be used to initiate a better transfer of care plan from the hospital to the community doctors by incorporating multidisciplinary team collaboration between in hospital physicians, primary care doctors, rehabilitation personnel and other support team members.
METHODOLOGY
This study was approved by the Medical Research and Ethics Committee of the Universiti Kebangsaan Malaysia (UKM).
DESIGN
A prospective study looking at 37 newly diagnosed stroke patients admitted to Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from December 2010 to June 2011 with a primary diagnosis of stroke based on the WHO definition of stroke (Hatano 1976). Those who were comatose or somnolent and had substantial physical and cognitive impairment as a result of previous neurological and mental illness were excluded from the study. Each patient was seen at admission. Those who consented were assessed in terms of their functional status using the Modified Barthel Index (MBI) at baseline and at three months.
The MBI was developed by Shah et al. (1989) derived from the original 1965 Barthel’s Index by Mahony and Barthel, a 10-question self reported questionnaire that measures physical disability based on ability to perform basic activities of daily living (ADL) (Mahoney & Barthel 1965). It is the most common instrument used to measure functional disability in stroke rehabilitation studies (Sangha et al. 2005). A score of less than 50 was taken as “dependent“ since subjects below this score were unlikely to be able to perform any basic activities of daily living (ADL) such as showering and mobilising without being assisted. The demographic and clinical information of the stroke patients were also assessed at baseline.
All stroke patients in this study were followed up as standard care for any stroke patient admitted to the hospital. At three months post stroke, patients were reassessed for functional status using the MBI and also for depression using the Patient Health Questionnaire 9-item depression scale (PHQ-9). This 9-item self-administered questionnaire was developed by Spitzer (Spitzer et al. 1999). It is based on the 9 DSM-IV symptoms of depression, which facilitates its use as a depression diagnostic tool as well as a screening instrument. It has been validated for use in primary care and stroke patients (Dietrich et al. 2003).
Other outcomes such as mortality and placement post hospital discharge, were also collected. Those who were not contactable physically at the respective outpatient clinics were interviewed by phone. A defaulter was labelled for patients who failed to be contacted through the clinic appointments and by phone.
STATISTICAL ANALYSIS
Data was analysed using the Statistical Package for the Social Sciences (SPSS) version 13. Descriptive statistics were used to described demographic and clinical profiles. Functional recovery comparing baseline and three months MBI scores were analysed using the Wilcoxon signed Rank Test. Bivariate association between the demographic and clinical profiles were analysed using the Student’s T Test and ANOVA. A p-value of less than 0.05 and confidence interval of 95% were considered as statistically significant.
RESULT AND ANALYSIS
A total of 46 ischaemic stroke patients were recruited during the 6-month study period. At the end of the three months observational period, seven patients (15.2%) had died and two patients (4.3%) were lost to follow up. A total of 37 patients (84.7%) were still alive and continued in the study. A significant proportion of the patients were living at home (69.6%) with their family members, 6.5% readmitted to hospitals for various reasons and 4.3% were living in nursing homes. The demographic and clinical profiles are as presented in Table 1 and Table 2 respectively.
Looking into the clinical profile of the stroke patients, 30.4% of the subjects had recurrent strokes and 6.5% had had TIA in the past. Hypertension (89.1%) was the commonest risk factor for stroke patients in this study followed by dyslipidaemia (65.2%) and diabetes mellitus (63.0%).
The functional status of the patients at the end of the three months observational period demonstrated a significant improvement in terms of the MBI score (Table 3). The PHQ-9 score, which was also assessed at the end of the observed period demonstrated that 21.6% of patients had some form of depression.
Bivariate analysis of functional recovery and PHQ-9 demonstrated that lower functional recovery was significantly found among depressed patients (p<0.026). Among other variables, only patients with recurrent stroke were found to have had lower functional recovery (p<0.05).
DISCUSSION
This was a prospective study that observed the functional outcome of 37 post stroke patients after being discharged from a tertiary hospital care in Malaysia. At baseline 78.4% of patients were found to be dependent and 21.6% were independent. At three months post stroke, only 18.9% of the patients were still dependent with functional recovery from baseline to three months noted to be significant (p<0.01) with a mean difference in Barthel’s Index of 45.2 (SD 27.0). These findings showed that the speed and extent of recovery are important in planning the care and the need for rehabilitation during the recovery period.
Local studies looking at functional outcomes showed that the number of stroke patients who were still dependent on their carer within the three to six months follow up varied from 18.9% to 40% which is comparable to the present findings (Jaya et al. 2002; Rameezan & Zaliha 2005).
However, most outcome studies on stroke varied in their methodology and used different tools to access function and used different cut off points to define dependency level. Therefore, it was not possible to compare outcomes between these studies. In spite of this, this study also demonstrated that a significant number of stroke survivors were still dependent on their carers well after they have been discharged from hospital; thus the need for good outpatient medical support network for a structured and continued medical care.
Our stroke patients were mainly elderly with multiple risk factors with a mean age of 67.2±11 years old. This is expected as most strokes occur in the elderly and is comparable to other studies conducted in Asian and Western countries (Venketasubramanian 1999; Rothwell et al. 2004). With the increasing life span of the world’s population, the mean age for stroke is expected to rise unless effective health promotion and risk prevention efforts are made in the community, especially by the primary health care services (Krishnamoorthy 2007).
The top five risk factors identified in this study were all modifiable risk factors through better lifestyle choices and better preventive measures from the health care system in the community. Similarly, hypertension was identified to be the most common risk factor for stroke locally and despite the high prevalence of hypertension in the world, the level of awareness, treatment and control of hypertension in the community remain low especially in developing countries including Malaysia (Internet Stroke Center 2013; Jaya et al. 2002; Rampal et al. 2008). Dyslipidaemia and diabetes were the second and third commonest risk factors for stroke in this study. These two lifestyle diseases are also among the top risk factors associated with stroke in the East Asian region including Australia (Burke & Venketasubramanian 2006; Ong & Raymond 2002). These three risk factors are sufficient for the diagnosis of metabolic syndrome, which is strongly associated with higher cardiovascular consequences and was also found to have more negative outcomes from stroke (Hamidon & Raymond 2003; Oh et al. 2013). Despite this, our study did not find any significant association of these factors with functional recovery after stroke.
One third or 30.4% of the subjects recruited in this study had a previous stroke and another 28.3% had ischemic heart disease in the past, which may suggest the lack of attention given to secondary prevention strategies. Previous studies had shown that, patients with previous stroke had slower functional recovery when compared to patients with a first ever stroke as many of them suffered some form of residual disability hampering the recovery process (Kwakkel et al. 1996; Hankey et al. 2002; Jorgensen et al. 1997). This study did not directly assess the association between functional recovery and number of stroke due to the small sample size (Kwakkel et al. 1996).
Nearly 21.6% of the patients were found to have depression at three months. This is not uncommon, as post stroke depression (PSD) has been reported to occur in approximately 10% to 50% of all stroke patients after a few months post stroke (Glamcevski & Pierson 2005; Sulaiman et al. 2002). Local studies reported that the prevalence of depression ranges from 36% at one to two months to 66% at three to six months post stroke (Glamcevski & Pierson 2005; Sulaiman et al. 2002). PSD has been associated with increased mortality, disability, length of hospital stay and reduced health-related quality of life (Townend et al. 2007). Similarly, our study also found that patients with depression at three months had a significantly lower functional recovery from their stroke with a mean difference of 22.79 (SD=2.88, 42.69) in the PHQ-9 score when compared to the non depressed stroke patients. Depression is a very debilitating mental problem that may result in social isolation causing patients to be unable to perform certain activities that can affect the rehabilitation process and hinder recovery.
Depression not only delays functional recovery, but on the other hand, those with delayed functional recovery may also succumb to depression (Glamcevski & Pierson 2005; Townend et al. 2007). Nevertheless, Townend et al. (2007) reported that depression may also occur even with the improvement of functional status (Townend et al. 2007). It was suggested that rather than the rate of recovery, the initial impact of disability brought by the stroke insult could pre determine the onset of depression. Despite the detrimental effect of depression, PSD is often under-recognised and under-treated in the community even within non-stroke patients (MOH 2006). This may stem from the social stigma associated with the condition or failure to recognise the depressive symptoms as significant by the sufferers or by the treating primary care doctors (Lotfi et al. 2010).
For primary care physicians, this study demonstrates the need to be aware of the caveats of managing stroke patients after being discharged to the community. These include mandatory screening for cardiovascular risk factors and depression, documentation of functional status and provision of rehabilitation. The management should be coordinated between hospital and primary care services. The coordination of care is important, as management of stroke care post discharge is complex, involving managing risk factors, preventing recurrent stroke and further rehabilitation. It is also prudent to reintegrate them back to the community (Aziz et al. 2008). Hence, there is a need for the local health system to plan a coordinated transfer of care pathway to ensure continuous medical treatment and support given not only to the patients but also their carers and family.
Therefore, information from this study can be used to improve this transitional process and also community stroke management especially during the rehabilitation stages. It is hoped that by identifying the prevalence of the risk factors of stroke and factors associated with its functional recovery, primary and secondary prevention strategies of stroke can be enhanced. This is vital in the effort to restructure the medical care organisation and support network for stroke patients beyond acute in hospital care to the community.
ACKNOWLEDGMENT
The authors acknowledge Universiti Kebangsaan Malaysia for providing the fundamental research grant and center for data collection.