Participation in daily life activities at two months after stroke predicts long-term health-related quality of life.

BACKGROUND: After stroke, many patients experience problems with participation in daily activities. Improving participation is the main goal in stroke rehabilitation. However, the longitudinal relationship between participation and health-related quality of life (HRQoL) remains unclear. OBJECTIVES: This study aimed to examine (1) the predictive value of participation at two months on long-term HRQoL and (2) the longitudinal relationship between participation and HRQoL. METHODS: In this multicenter, prospective cohort study, patients were assessed at two and 12 months after stroke. Participation was measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation - Participation. HRQoL was assessed with the three-level version of the EuroQoL five dimensions questionnaire index score. RESULTS: This study included 291 patients. Mean age was 66.6 ± 12.4 years, 64.3% were male and mean National Institutes of Health Stroke Scale (NIHSS) was 2.5 ± 2.9. Multivariable linear regression, adjusted for demographic characteristics, stroke characteristics, physical and cognitive impairment, showed that a higher level of participation at two months correlated with a higher HRQoL at one year (B = .004; 95% CI =.002-.005). Patients whose participation improved had a greater increase in HRQoL, compared to patients without improvement (0.080 ± .21 versus -.054 ± .21; p < .001). CONCLUSIONS: The level of participation at two months post-stroke predicts HRQoL at one year. Improvement in participation during the first year after stroke is associated with improvement in HRQoL. We recommend including the assessment of participation in daily activities at follow-up visits.

Practice variation in the informed consent procedure for thrombolysis in acute ischemic stroke: a survey among neurologists and neurology residents.

BACKGROUND: Obtaining informed consent for intravenous thrombolysis in acute ischemic stroke can be challenging, and little is known about if and how the informed consent procedure is performed by neurologists in clinical practice. This study examines the procedure of informed consent for intravenous thrombolysis in acute ischemic stroke in high-volume stroke centers in the Netherlands. METHODS: In four high volume stroke centers, neurology residents and attending neurologists received an online questionnaire concerning informed consent for thrombolysis with tissue-type plasminogen activator (tPA). The respondents were asked to report their usual informed consent practice for tPA treatment and their considerations on whether informed consent should be obtained. RESULTS: From the 203 invited clinicians, 50% (n = 101) completed the questionnaire. One-third of the neurology residents (n = 21) and 21% of the neurologists (n = 8) reported that they always obtain informed consent for tPA treatment. If a patient is not capable of providing informed consent, 30% of the residents (n = 19) reported that they start tPA treatment without informed consent. In these circumstances, 53% of the neurologists (n = 20) reported that the resident under their supervision would start tPA treatment without informed consent. Most neurologists (n = 21; 55%) and neurology residents (n = 45; 72%) obtained informed consent within one minute. None of the respondents used more than five minutes for informed consent. Important themes regarding obtaining informed consent for treatment were patients' capacity, and medical, ethical and legal considerations. CONCLUSION: The current practice of informed consent for thrombolysis in acute ischemic stroke varies among neurologists and neurology residents. If informed consent is obtained, most clinicians stated to obtain informed consent within one minute. In the future, a shortened information provision process may be applied, making a shift from informed consent to informed refusal, while still considering the patient's capacity, stroke severity, and possible treatment delays.

Early cognitive and emotional outcome after stroke is independent of discharge destination.

BACKGROUND AND PURPOSE: Cognitive and emotional problems occur frequently after stroke. Patients with minor stroke are more likely to be discharged home. This paper compares early cognitive and emotional outcomes in patients discharged home after stroke versus patients discharged to inpatient rehabilitation, and examines the effect of cognitive and emotional outcomes on long-term participation. METHODS: In this multicenter prospective cohort study, patients with stroke were assessed at two months with the Hospital Anxiety and Depression Scale (HADS), the Checklist for Cognitive and Emotional Consequences following Stroke (CLCE-24) and the Montreal Cognitive Assessment (MoCA). One year post stroke, participation was assessed with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P Restriction). RESULTS: The study included 332 patients. Two months post stroke, anxiety and cognitive problems were equally prevalent among patients discharged home (n = 243; 73%) and patients discharged to inpatient rehabilitation (n = 89; 27%) (HADS-A = 4.8 ± 3.9 versus 4.6 ± 4.0, p = 0.747; MoCA < 26: 66.7% versus 70.8%, p = 0.477; CLCE-cognition = 3.0 ± 2.9 versus 3.3 ± 2.8, p = 0.499). Depressive symptoms were less severe in patients discharged home (HADS-D = 4.3 ± 3.9 versus 5.5 ± 3.8, p = 0.010). In patients discharged home, cognitive complaints were predictive of long-term participation (B = - 2.03; 95% CI - 3.15, - 0.90), while cognitive or emotional outcomes were not predictive in patients discharged to inpatient rehabilitation. CONCLUSIONS: Cognitive and emotional problems at two months post stroke were comparable between patients discharged home and those discharged to inpatient rehabilitation. For patients discharged home, cognitive complaints were predictive of long-term participation.