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its not just a minor stroke

• APSS Telehealth Presentation
• Teri Green, RN PhD
• Calgary Stroke Program
• Faculty of Nursing/University of Calgary
• June 2008

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An Examination of Male Patient, Wife-Caregiver,
and Marital Dyad Outcomes Over a Three-Month
Period Following Minor Stroke
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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
• the effect of minor stroke on patients
  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

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RESEARCH QUESTIONS

• Primary 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?

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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)

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Inclusion/Exclusion Criteria

• Inclusion

• Exclusion

• Male patient with a wife-caregiver
• Minor stroke (NIHSSlt4, mRSlt2, BIgt65)
• d/c home within 7 days
• MMSE 24
• Able to provide informed consent
• Able to read/speak English

• No identified spousal caregiver
• Moderate/severe stroke
• Extended hospital stay
• MMSE lt 24
• Unable to provide informed consent
• Unable to read/speak English

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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

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Demographic Characteristics
Patient 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() No Yes Retired 3 (8) 25 (66) 10 (26) 8 (21) 21 (55) 9 (24)
Education Level n () high school High School graduate Post-secondary 7(18) 13 (34) 18 (47) 3 (8) 8(21) 27 (71)
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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)

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Stroke Severity Functional Outcomes
Paired t-test Paired t-test Paired t-test Paired t-test
Discharge X (SD) 3-months X (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
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Changes in Psychosocial Measures between
Discharge and 3-months Post-discharge
ANOVA ANOVA ANOVA ANOVA
Discharge X (SD) 3-months X (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) 0.989 0.186
BCOS (15-105) 1 and 3-mo 57.13 (8.70) 57.80 (8.70) 0.201 (2) 0.819
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Changes in Depression and Marital Function
between Discharge and 3-months Post-discharge
Discharge X (SD) 3-months X (SD) MANOVA t(df) p 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
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Patient and Wife-caregiver Mean BDI-II Scores
Over Time
Patient and Wife-caregiver Mean BDI-II Scores
Over Time
Patient and Wife-caregiver Means FADGFS Scores
Over Time
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Patient and Wife-caregiver Mean FADGFS Scores
Over Time
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Associations Between Outcome Variables

• Patient
• HRQOL depression
• r-.577, plt0.001 (discharge)
• r-.662, plt0.001 (1-month post-discharge)
• r-.495, p0.002 (2-months post-discharge)
• r-.758, plt0.001 (3-months post-discharge)
• Depression wife-caregivers perception of
  marital function
• r.442, p0.005 (discharge)
• r.376, p0.020 (2-months)
• r.610, plt0.001 (3-months)

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Associations Between Outcome Variables

• Wife-caregiver
• Depression wife-caregivers perception of
  marital function
• r .362, p0.026 (discharge)
• r.538, plt0.001 (1-month)
• r.334, p0.040 (2-months)
• r.578, plt0.001 (3-months)
• Wife-caregivers perception of marital function
  and caregiver strain
• r-.517, plt0.001 (1-month)
• r-.742, plt0.001 (2-months)
• r-.620, plt0.001 (3-months)

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Predictors of Marital Function at 3-months
OR 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
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Qualitative Data

• Transitional framework
• Passage from one life condition or status to
  another
• process
• time
• perception
• Content analysis
• Chick Meleis (1986). Transitions A Nursing
  Concern
• Hsieh Shannon (2005)

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Content Analysis

• Overarching Themes
• Being vulnerable
• Realization of the new self and changing
  relationships
• Subthemes
• Masculine image
• Hyper-vigilance
• Loss

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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

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Being Vulnerable

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

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Realization

• Increasing awareness and insight
• Apprehension about ability to put their lives
  back together
• Continuity of the family
• Maintenance of relationships

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• Adaptation
• Acceptance and denial
• Incorporation of physical deficits
• Ongoing challenges of emotional and cognitive
  changes
• Stabilization changing priorities
• Recognition of need for continuous adaptation

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Key Threads

• Masculinity imposed limitations, life-changes
• Hyper-vigilance protective monitoring, control
• Loss physical, emotional, social

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Masculinity

• I was surprised by the long term effects of the
  strokenot prepared for the loss of energy and
  changes in mood, thinking and personality.
• The stroke has made me useless. I cant do the
  things for my family like protect them. If an
  intruder came in I couldnt even defend my
  family. I wouldnt even have the strength to
  fight off a child.

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Masculinity

• The largest challenge has been the feelings of
  depression that have been part of life since the
  stroke. Its a struggle to accept that I am not
  the person I used to be, that I cant contribute
  like I used to, it seems like Im not worthwhile
  as I was before.
• I am feeling blue and I cry at the drop of a
  hatfear and anxiety are new to me.

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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.

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Loss

• I am feeling the burden of having to make many
  life decisions because my husband doesnt want to
  make any decisions himself.
• I feel trapped by my husband and sometimes I
  would like to run awayI have to spend all my
  time with him and this has negatively impacted my
  relationship with friends and family.
• I am feeling overwhelmedthe whole family system
  is disrupted.

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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.

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Participants 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
  beenI 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 thingsPreviously 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.

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CONCLUSIONS

• its 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)

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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

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Thank You!

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