Return to work predictors of stroke survivors and their spousal caregivers.

BACKGROUND: Return to work is an issue of concern for stroke survivors and their spouses. Ramifications may include loss of income and self-efficacy. OBJECTIVE: This study describes the return to work patterns of stroke survivors and their spousal caregivers post stroke. METHODS: One hundred fifty-nine dyads were examined for their return to work patterns at baseline (post hospital discharge) and then at 3 month intervals for one year. Relationships were determined between work and gender, age, ethnicity, education, type of insurance, type of stroke, location of stroke, motor and cognitive functional status, depression, mutuality, and life satisfaction. RESULTS: Low levels of return to work by stroke survivors (7.5%) and a small decrease in the amount of working caregivers (from 45.3% to 40.35%) were found one year post baseline. Variables that predicted return to work changed over the five data points except for younger age for the caregiver, which was consistently significant across all data points. Three case scenarios representative of working patterns are offered. CONCLUSIONS: Further research is needed regarding the return to work needs of stroke survivors and their spousal caregivers, particularly what role the occupational therapist may play in facilitating that process.

Improving adherence in African American women with uncontrolled hypertension.

BACKGROUND AND OBJECTIVES: African American women are disproportionately affected with hypertension (HTN). The aim of this randomized controlled trial was to evaluate the effectiveness of a 6-week culturally tailored educational intervention for 60 African American women with HTN. METHODS: Sixty African American women, 29 to 86 years old (mean ± SD, 57.98 ± 12.37 years), with primary HTN were recruited from 4 rural locations and randomized to intervention (n = 30) and control (n = 30) groups to determine the effectiveness of the intervention on knowledge, attitudes, beliefs, social support, adherence to an HTN regimen, and blood pressure control. Culturally tailored educational classes were provided for 90 minutes once a week for 6 weeks. The control group received usual care. RESULTS: A significant favorable overall main effect (time) was found for systolic blood pressure (F3,174 = 11.104, P = .000) and diastolic blood pressure (F3,174 = 4.781, P = .003) for both groups. Also for diastolic blood pressure, older age was a significant covariate (F1,56 = 6.798, P = .012). Older participants tended to have increased diastolic blood pressures. There were no significant differences between groups on knowledge, adherence, or attitudes. CONCLUSION: The culturally tailored program used the African American church as a basis for recruitment and implementation of the program that retained all participants over a 6-month period. African American women living in rural Texas who participated in a 6-week intervention program demonstrated a significant decrease in blood pressure over a 6-month period regardless of whether they were in the intervention or control group. In general, they had a relatively good knowledge of HTN and reported an average level of adherence. Future studies using a culturally tailored program with a larger sample size are warranted to decrease the high level of HTN-related complications in African American women.

Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial.

PURPOSE: This randomized trial compared 6- and 12-month outcomes of a home-based psychoeducational program to mailed information provided to 159 survivors of stroke (SS) and their spousal caregivers (CG). METHODS: SS (age 50+) and CG were recruited as dyads post-discharge from inpatient rehabilitation. All dyads received mailed information for 12 months. Dyads randomized to the home-based group received an average of 36.7 h of psychoeducation over 6 months. Health status, depression, stress, burden, coping, support, mutuality and function were obtained on all dyads. Repeated measures analysis with linear mixed models was used to compare the groups for change over time in the outcome variables. RESULTS: Both groups demonstrated less depression and stress over time. Compared to the mailed information group, SS in the home-based group demonstrated significantly improved self-reported health and cognitive function; CG demonstrated significantly improved self-reported health and coping strategies. Mutuality and social support decreased in both groups. CONCLUSIONS: The home-based intervention was effective in improving self-reported health, coping skills in CG and cognitive functioning in SS. However, the finding that dyads in both groups demonstrated decreased depression and stress suggests that providing repeated doses of relevant, personalized information by mail may result in positive changes. IMPLICATIONS FOR REHABILITATION: A stroke affects both the stroke survivor and the spousal caregiver, so nurses and therapists should use multicomponent strategies to provide education, support, counseling and linkages to community resources to ease the transition from hospital to home. Stroke may have a negative impact on the dyad's relationship with each other and also on the availability of support people in their lives during the 12 months after hospital discharge. Comprehensive stroke programs should encourage dyads to attend support groups and to seek individual and group counseling, as needed. Establishing an ongoing relationship with stroke survivors and their spouses and providing relevant and engaging information by mail can reduce stress and depression over 12 months post-discharge at a minimal cost. Nurses and therapists should consider home visits post-discharge to reinforce education and skills taught in the hospital, increase self-reported health in stroke survivors and spousal CG, increase coping skills and to link the couple to community resources.

Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation.

PURPOSE: To identify the incidence of adverse events (AE) that occurred in stroke survivors during the first year following discharge from inpatient rehabilitation and to determine the type and patterns of AE. METHODS: Data were collected for 12 months on events resulting in admissions to the emergency department, hospital, long-term care facility, or death. Descriptive statistics were used to depict the patterns of AE and univariate comparisons were made of the differences between survivors who did or did not experience one or more AE. RESULTS: Of the 159 participants, 50% reported a total of 163 AE. Most AE (82.2%) were unexpected and the majority occurred during the first 6 months; 12 recurrent strokes and 6 transient ischemic attacks occcurred. CONCLUSIONS: Education on prevention and treatment of common AE is important prior to discharge. Anticipatory guidance may help survivors and caregivers modify their lifestyle and prevent common AE.

Long-term health-related quality of life of stroke survivors and their spousal caregivers.

Because treatment for stroke has improved, individuals are living longer with the effects of a stroke. The resulting long-term impairment can affect both stroke survivors' and their caregivers' health-related quality of life (HRQOL). Few studies have examined the HRQOL of stroke survivors and their caregivers greater than 2 years poststroke. The stroke survivors and their spousal caregivers (n = 30 dyads) who had previously completed a 12-month study after discharge from inpatient rehabilitation were assessed at 3-5 years poststroke. The HRQOL and related outcomes were measured for stroke survivors and caregivers. Data from baseline to 12 months were used in conjunction with data from this study. Linear mixed models were used to analyze the change in repeated measures over time. Multiple linear regression was used to analyze the relationship of generic HRQOL to related psychosocial outcomes. The stroke survivors were an average of 4.68 years poststroke. The mean age for stroke survivors and caregivers was 70.8 and 64.9 years, respectively. Most stroke survivors were men (80%) and non-Hispanic White (70%). Among stroke survivors, depression decreased from baseline to 12 months (p = .04) but increased from 12 months to the end of follow-up (p = .003). The caregivers' depression decreased from baseline to all time points (p = .015). Stroke-specific HRQOL showed statistically significant (p < .03) decreases between 12 months and end of follow-up. Increased number of illnesses and older age were associated with caregivers' lower physical HRQOL score (p = .004). Higher depression was associated with lower mental HRQOL score for both caregivers and stroke survivors (p = .003 and p = .011, respectively). Both stroke survivors and caregivers continue to experience negative stroke-related health outcomes for many years after the initial stroke; some of these outcomes even worsen over time. These findings illustrate the need for ongoing psychological and medical evaluation for both long-term stroke survivors and caregivers. Development and testing of targeted behavioral interventions are also warranted.

The longitudinal and dyadic effects of mutuality on perceived stress for stroke survivors and their spousal caregivers.

OBJECTIVE: Functional impairment resulting from a stroke frequently requires the care of a family caregiver, often the spouse. This change in the relationship can be stressful for the couple. Thus, this study examined the longitudinal, dyadic relationship between caregivers' and stroke survivors' mutuality and caregivers' and stroke survivors' perceived stress. METHOD: This secondary data analysis of 159 stroke survivors and their spousal caregivers utilized a cross-lagged, mixed models analysis with the actor-partner interdependence model to examine the dyadic relationship between mutuality and perceived stress over the first year post-discharge from inpatient rehabilitation. RESULTS: Caregivers' mutuality showed an actor effect (ß = -3.82, p < 0.0001) but not a partner effect. Thus, caregivers' mutuality influenced one's own perceived stress but not the stroke survivors' perceived stress. Stroke survivors' perceived stress showed a partner effect and affected caregivers' perceived stress (ß = 0.13, p = 0.047). Caregivers' perceived stress did not show a partner effect and did not significantly affect stroke survivors' perceived stress. CONCLUSION: These findings highlight the interpersonal nature of stress in the context of caregiving for a spouse. Caregivers are especially influenced by perceived stress in the spousal relationship. Couples should be encouraged to focus on positive aspects of the caregiving relationship to mitigate stress.

Examining the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors.

BACKGROUND AND PURPOSE: There is a growing consensus among healthcare researchers that, within the field of family caregiving, cost-effectiveness research is needed to determine which programs have the greatest benefit for family members. This study examines the cost per caregiver of an intervention designed to improve the quality of life of spousal caregivers of stroke survivors. METHOD: Cost data from the CAReS study were analyzed to determine the cost of the intervention per caregiver. RESULTS: The cost of the intervention per caregiver was $2,500 at the 2009 median wage estimate. It was $1,700 at the 2009 10 percentile wage estimate and $3,500 at the 2009 90 percentile wage estimate. CONCLUSIONS: This study provides a prototype cost analysis from which researchers can build. In future analyses, costs should be tracked at a participant level so uncertainty can be calculated using the bias-corrected percentile bootstrapping method and plotted to calculate cost-effectiveness acceptability curves, enabling cost-effectiveness comparisons between interventions.

Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment.

BACKGROUND: Stroke survivors often have impairments that make it difficult for them to function safely in their home environment. PURPOSE: The purpose of this study is to identify occupational performance barriers in the home and describe the subsequent recommendations offered to stroke survivors and their caregivers. METHODS: An occupational therapist administered a home safety tool to assess stroke survivors' home environments, determine home safety problems, and provide recommendations. FINDINGS: Among 76 stroke survivors, the greatest problems were indentified in the categories of bathroom, mobility, and communication. Two case studies illustrate the use of the home safety tool with this population. IMPLICATIONS: The home safety tool is helpful in determining the safety needs of stroke survivors living at home. We recommend the use of the home safety tool for occupational therapists assessing the safety of the home environment.

Cost associated with stroke: outpatient rehabilitative services and medication.

PURPOSE: This study aimed to capture direct costs of outpatient rehabilitative stroke care and medications for a 1-year period after discharge from inpatient rehabilitation. METHODS: Outpatient rehabilitative services and medication costs for 1 year, during the time period of 2001 to 2005, were calculated for 54 first-time stroke survivors. Costs for services were based on Medicare reimbursement rates. Medicaid reimbursement rates and average wholesale price were used to estimate medication costs. RESULTS: Of the 54 stroke survivors, 40 (74.1%) were categorized as independent, 12 (22.2%) had modified dependence, and 2 (3.7%) were dependent at the time of discharge from inpatient rehabilitation. Average cost for outpatient stroke rehabilitation services and medications the first year post inpatient rehabilitation discharge was $17,081. The corresponding average yearly cost of medication was $5,392, while the average cost of yearly rehabilitation service utilization was $11,689. Cost attributed to medication remained relatively constant throughout the groups. Outpatient rehabilitation service utilization constituted a large portion of cost within each group: 69.7% (dependent), 72.5% (modified dependence), and 66.7% (independent). CONCLUSIONS: Stroke survivors continue to incur significant costs associated with their stroke for the first 12 months following discharge from an inpatient rehabilitation setting. Changing public policies affect the cost and availability of care. This study provides a snapshot of outpatient medication and therapy costs prior to the enactment of major changes in federal legislation and serves as a baseline for future studies.

Spiritual practices in self-management of diabetes in African Americans.

In this qualitative study, African Americans described 3 orientations about spiritual practices and diabetes self-management: Spiritual practice as effort toward self-management; spiritual practice and self-management as effort toward healing; and spiritual practice as effort toward healing. Spiritual practices may influence diabetes self-management in African Americans and be a resource in care.

Improving glycaemic control self-efficacy and glycaemic control behaviour in Chinese patients with type 2 diabetes mellitus: randomised controlled trial.

AIMS AND OBJECTIVES: To examine the effect of a hospital-based clinic intervention on glycaemic control self-efficacy and glycaemic control behaviour of Chinese patients with type 2 diabetes mellitus (DM). BACKGROUND: Self-efficacy expectations are related to self-management of diabetes and, in conjunction with environmental support, are better predictors of behaviour than are knowledge and skills. Enhancing self-efficacy in patients with DM has been shown to have a positive effect on behavioural change and positively influence long-term glycaemic control. DESIGN: A randomised controlled trial study consisting of two-group pretest-post-test. METHODS: One hundred and fifty-seven patients with type 2 DM were randomly divided into two groups: (1) the experimental group (77 patients) receiving one-month hospital-based clinic intervention and (2) the control group (80 patients) receiving usual care. Data collection instruments used in this study were Diabetes Management Self-Efficacy Scale and Summary of Diabetes Self-Care Activities Measure. Outcomes were determined by changes in glycaemic control self-efficacy and glycaemic control behaviour of patients with type 2 DM. RESULTS: The findings revealed that the experimental group showed statistically significant improvement in glycaemic control self-efficacy and glycaemic control behaviour immediately and four months after the intervention (F = 26.888, df = 1, 155, p < 0.05 and F = 18.619, df = 1, 155, p < 0.05, respectively). CONCLUSIONS: One-month hospital-based clinic intervention could be useful in improving glycaemic control self-efficacy and glycaemic control behaviour. RELEVANCE TO CLINICAL PRACTICE: Nurses can learn and use the sources of self-efficacy to enhance patients' self-efficacy on their glycaemic control in clinical care. The health education is most important in nursing care and should be considered while organising the hospital-based clinic intervention.

Systematic review of current executive function measures in adults with and without cognitive impairments.

BACKGROUND: Executive function pertains to higher cognitive processes historically linked to frontal lobes. Several measures are available to screen for executive function; however, no gold standard exists. The difficulty in assessing executive function is the existence of its many subsets. OBJECTIVES: To evaluate the psychometric properties of executive function measures and determine the most effective measure(s) through a systematic review of the literature. SEARCH STRATEGY: The search strategy utilised a comprehensive literature review of articles written in the English language published from January 2003 to September 2009. The following electronic databases were searched: SCOPUS, PUBMED, Medline Ovid, PsychArticles and CINAHL Plus. Initial key words used were 'executive function', 'measures', 'reliability' and 'validity' followed by the addition of 'traumatic brain injury'. The initial search elicited 226 articles, of which 28 were retrieved. After further exclusion 19 were included in the review. RESULTS: Eight measures underwent factor analysis and 18 underwent various forms of reliability and/or validity testing. Factor analysis showed different aspects of executive functions. According to preset evaluation criteria, only the Test of Practical Judgment performed all of the recommended reliability and validity testing. REVIEWER'S CONCLUSION: Of the recently developed measures, several show promise for future use yet further validity and reliability testing is warranted. Future tool development should measure all subsets of executive function rather than only a few and include the recommended components of reliability and validity testing.

Younger residents in nursing homes.

Younger residents in nursing facilities represent a growing but little recognized population. This study examined a group of younger residents, describing issues identified by residents and facility staff and identifying strategies that might improve their quality of life. In this study, the majority of younger residents were men with significant physical and mental health deficits, who spent most of their time alone or watching television. Residents wanted a greater variety of relevant recreational activities and more meaningful relationships with family, staff, and other residents. Staff believed nursing facilities were not designed for younger residents, resulting in unmet psychosocial and recreational needs.

Stress experienced by stroke survivors and spousal caregivers during the first year after discharge from inpatient rehabilitation.

PURPOSE: This study describes levels of stress in stroke survivors and spousal caregivers and identifies predictors of stress in couples during their first year at home. METHOD: The Perceived Stress Scale (PSS) was administered to 159 stroke survivors and caregivers at discharge and at 3, 6, 9, and 12 months. Other variables tested included stroke survivor function (FIM), health status, mutuality, stroke impact (SIS), caregiver coping (F-COPES), support (MOS Social Support Survey), and preparedness. Repeated measures analyses of PSS scores were conducted with linear mixed models for stroke survivors and caregivers. RESULTS: PSS scores for stroke survivors and caregivers were positively correlated (p<.01). Scores decreased significantly over the year, but caregivers had higher scores initially and decreased less. Stroke survivor function was a significant predictor of stress for both survivors and caregivers. Preparation was the most powerful predictor of stress in caregivers, whereas mutuality was the strongest predictor for stroke survivors. Good health, social support, and coping were associated with less stress. CONCLUSIONS: Stress is increased by poor function and mediated by internal and external buffers including health, the dyadic relationship, coping ability, and social support. More research using a dyadic research approach is needed to better understand stress within couples.

Predictors of life satisfaction in stroke survivors and spousal caregivers after inpatient rehabilitation.

A global measure of life satisfaction has become increasingly important as an adjunctive outcome of healthcare interventions for people with disabilities, including those caused by stroke. Life satisfaction of stroke survivors mayaffectcaregivingspouses, as well. The purpose of this study was to identify, among many physical and psychosocial variables, specific variables that were associated with life satisfaction at 12 months after discharge from inpatient rehabilitation, and variables that were predictive of life satisfaction 1 year later (at 24 months). Between 12 and 24 months, life satisfaction decreased for stroke survivors, while it increased for caregiving spouses. The relationship between the couple (mutuality) was the only variable that was a significant predictor of life satisfaction for both stroke survivors and their spouses.

Predictors of resuming therapy within four weeks after discharge from inpatient rehabilitation.

PURPOSE: To identify the percentage of persons with stroke resuming therapy within 4 weeks of inpatient rehabilitation discharge, to compare the characteristics of those who did and did not resume therapy, and to determine the predictors of resuming physical (PT), occupational (OT), and speech (ST) therapy. METHOD: Sociodemographic, stroke-related, and therapy data for persons with stroke (N = 131) were abstracted from inpatient rehabilitation charts. FIM, Stroke Impact Scale, Geriatric Depression Scale, and data on therapy received after discharge were also collected. RESULTS: Logistic regression models demonstrated that minorities were less likely to resume PT (odds ratio [OR] = 0.30) and OT (OR = 0.25). Survivors with neglect/visual-field cut/spatial-perceptual loss were 2-3 times more likely to resume PT, OT, and ST. Survivors with higher scores on the SIS Physical domain subscale were less likely to resume PT (OR = 0.98) and OT (OR = 0.97). Men were 3.3 times more likely to have OT than women. Those with comprehensive health insurance were 11.2 times more likely to receive ST. CONCLUSIONS: The benefits of outpatient therapy are not universally available to all persons with stroke. Further research needs to explore the factors that hinder the prompt resumption of therapy for minority and female persons with stroke and to test appropriate interventions.

Who Is caring for the caregiver? Promoting spousal caregiver's health.

Older adults are at high risk for developing chronic illnesses; those older than 85 are also the most rapidly growing segment of the US population. The majority of care for older adults with disabilities is provided in the community by family caregivers, as well as spouses if they are available. Although there has been significant research on the effect of caregiving on spousal health, few studies have addressed the health promotion needs of spousal caregivers. More research is needed to study health-promoting behaviors in the context of the social and physical environments in which spousal caregivers live and work.

Predictors of functional independence and stress level of stroke survivors at discharge from inpatient rehabilitation.

BACKGROUND AND RESEARCH OBJECTIVE: Stroke is the primary cause of long-term disability among older adults. This study identifies predictors of functional independence and perceived stress for stroke survivors discharged home from inpatient rehabilitation with a spousal caregiver. SUBJECTS AND METHODS: Stroke survivors (N = 97) were interviewed immediately after discharge to obtain scores on the National Institutes of Health Stroke Scale, Functional Independence Measure (FIM), Stroke Impact Scale, Geriatric Depression Scale-15, Perceived Stress Scale, and Perceived Health Status. Demographic and stroke-related data were abstracted from their inpatient rehabilitation charts. Descriptive and regression analyses determined the relationships among variables and the models that best predicted functional independence and perceived stress. RESULTS: Stroke survivors perceived a 50% recovery in their function upon discharge from inpatient rehabilitation. National Institutes of Health Stroke Scale, age, socioeconomic status, and number of complications predicted 63% of the variance of the total FIM score (F6,88 = 24.64; P < .0001). Total FIM, depression, and Stroke Impact Scale Emotion subscale predicted 45% of the Perceived Stress Scale score (F6,88 = 12.04; P < .0001). CONCLUSIONS: Variables that predict the stroke survivors' recovery are complex as the severity of the stroke combines with demographic and economic variables and depression to predict functional independence and perceived stress. These factors need to be considered when preparing a discharge plan for stroke survivors who are discharged home from rehabilitation.

Evidence-based educational guidelines for stroke survivors after discharge home.

Stroke survivors today are discharged home from the hospital more quickly than in the past because of shifting economic realities. Survivors continue to experience significant impairments after discharge and families may be poorly prepared for the full extent of caregiving responsibilities. This article describes 39 comprehensive educational guidelines that have been tested with 72 stroke survivors and families during 1,150 home visits throughout the first 6 months after discharge from inpatient rehabilitation. Two case studies illustrate use of the guidelines with stroke survivors and their families.

Improving foot self-care behaviors with Pies Sanos.

Participants who received Pies Sanos, a 15-min intervention designed to improve diabetes self-efficacy and foot self-care behaviors in adult patients with type 2 diabetes who lived in a predominantly Mexican American community, performed more-complete foot self-care 1 month later in their homes. Recruited when they presented for nonurgent care to the emergency department in two community hospitals near the U.S.-Mexico border, participants were randomized into one of three groups. At follow-up, there was a significant difference in observed foot self-care behaviors between groups, F(2, 135) = 2.99, p < .05, as well as a significant difference within the intervention, t (47) = -4.32, p < .01, and control group, t (46) = -2.06, p < .05, for baseline and follow-up self-reported foot self-care behaviors. Baseline diabetes self-efficacy was significantly and positively correlated with both baseline (r = .335, p < .001) and follow-up ( r = .174, p < .05) foot self-care behaviors.