Post-Stroke Health Impacts Merit New Emphases in Stroke Survivor Care

Care for survivors of ischemic stroke should focus more on improving patients’ social roles and executive function, suggests a large observational cohort study by Cleveland Clinic researchers published online by the journal Neurology.

“After a stroke, people who have only mild disability often have ‘hidden’ problems that can really affect their quality of life,” says the study’s lead author, Irene L. Katzan, MD, MS, a neurologist in Cleveland Clinic’s Cerebrovascular Center. “The social participation and executive functioning skills are areas that have not received a lot of attention in stroke rehabilitation. We need to better understand how these areas affect people’s well-being and determine strategies to help optimize their functioning.”

One of the largest studies of its kind

The study reviewed 2,320 individuals with ischemic stroke seen in Cleveland Clinic’s outpatient cerebrovascular clinic from early 2015 through early 2017. The aim was to examine their post-stroke health in eight domains and identify factors associated with domain scores. Slightly more than half of these patients (N = 1,195) met the inclusion criteria of having a documented modified Rankin Scale (mRS) score and completing patient-reported outcome surveys.

The 1,195 study participants had a mean age of 62 and a median mRS score of 1 (interquartile range, 0-2); 81 percent were white. Excluded patients were significantly older, were more likely to be African American and single, had lower incomes, and had higher mRS and NIH Stroke Scale scores.

Patients completed their outcome surveys as part of routine care at a median of 99 days after their stroke. The following eight domains were evaluated:

• Executive function
• Physical function
• Satisfaction with social roles
• Fatigue
• Anxiety
• Depression
• Pain interference
• Sleep disturbance

Domains were assessed using validated instruments — the Patient-Reported Outcomes Measurement Information System (PROMIS) and the Neuro-QoL — that use the same scoring system that is calibrated to the general U.S. population. This allowed comparison of symptom severity across domains and aided in the clinical interpretation of results. Data were collected via tablets using the Cleveland Clinic-developed Knowledge Program electronic platform.

“This represents one of the largest analyses of patient-reported outcomes after stroke collected as part of routine care,” observes Dr. Katzan, who is also Director of the Center for Outcomes Research and Evaluation for Cleveland Clinic’s Neurological Institute.

Principal findings

In all domains of health assessed, a significant proportion of patients reported meaningfully worse symptoms and reduced function compared with the general population, the researchers reported. The domains most affected were as follows:

• Physical function, with 63 percent of study participants having scores meaningfully worse than the general population
• Satisfaction with social roles, with 58 percent scoring meaningfully worse than the general population
• Executive function, with 46 percent scoring meaningfully worse than the general population

The domains least affected included anxiety, depression and sleep disturbance.

Outcomes varied by stroke severity and other patient characteristics. Patients with no residual deficits (mRS score of 0, indicating no symptoms) were indistinguishable from the general population across all domains. Reduced physical function, executive function and social role satisfaction correlated with mRS and NIH Stroke Scale scores. Disability, lower income and female sex were associated with worse scores in multiple domains.

Notably, advancing age correlated with worse physical function but with lower levels of anxiety, depression and sleep disturbance. “This suggests that stroke takes a bigger emotional toll on younger people than on their older counterparts,” Dr. Katzan says, likely due to the greater impact stroke can have on plans and expectations for those earlier in life.

Time to tweak post-stroke care?

While noting that the study benefited from its large sample size, its collection of data as part of routine care (which bolsters generalizability) and its provision of population benchmarks, Dr. Katzan also acknowledges some limitations. These include the omission of health domains related to communication, the fact that not all eligible patients were able to complete the outcomes surveys, and a relatively young patient population (mean age of 62 versus the mean age of 69 for stroke patients overall) composed of patients with relatively mild stroke from a single institution.

Nevertheless, she says, the study offers important insights on ways to potentially enhance stroke care that will make a difference to patients. “Depression screening is a standard part of stroke management,” she notes, “and these findings suggest that focus should also be on patients’ executive function and potential difficulties with social adjustment.”