Persson J, Holmegaard L, Karlberg I, Redfors P, Jood K, Jern C, Blomstrand C, and Forsberg-Wärleby G. Spouses of Stroke Survivors Report Reduced Health-Related Quality of Life Even in Long-Term Follow-Up: Results From Sahlgrenska Academy Study on Ischemic Stroke. Stroke. 2015
They derived their cohort from a Swedish ischemic stroke study that enrolled 600 consecutive patients under the age of 70 with ischemic stroke. After seven years, spouses of stroke survivors and age- and sex-matched controls were identified for comparison. The unit of analysis was survivor and spouse dyad and control and spouse dyad. 248 stroke survivor and 245 control dyads were included after excluding stroke survivors who had deceased or become single. Importantly, those who were excluded had greater disability at 3 months than those who were included. The outcome was self-reported health-related quality of life measured by the multidimensional Short Form 36 tool after controlling for multiple demographic and stroke outcome variables.
Notably, the median NIHSS for stroke survivors had been zero and the median mRS had been only 2. Regardless, even after 7 years, spouses of stroke survivors suffered significantly lower health in multiple domains as compared to spouses of controls. Attributes of the stroke survivor that predicted poor spousal health included the survivor’s levels of disability, depression and cognitive impairment. Perceived lack of social support also predicted poorer spousal mental and emotional health.
It is surprising that minor strokes in young persons with relatively good functional outcomes lead to persistent spousal health consequences. Patients who have strokes before 70 likely have predisposing vascular risk factors (some of which, such as diabetes, can require continued, laborious management) that may be responsible for this study’s findings; there is possible significant residual confounding as the dyads are only matched for age and sex.
If we are to believe the findings, it is worth noting that Sweden has a nationalized healthcare system with near universal coverage, excellent literacy and a high GDP per capita. Extrapolating their findings to developing nations where healthcare and social resources are scant underscores the importance of stroke prevention.
I hate the fact that stroke prevention is the first thought based on this. I think the first thing to do is for stroke medical professionals to solve and prevent the neuronal cascade of death. See Dr. Michael Tymianski and Dr. Moskowitz about that That would prevent tons of disability. It will be damned difficult but that is what leaders do. They solve the difficult problems.
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Thank you for your response. We fully agree that prevention of stroke is of top priority. We also agree that shared risk factors can be an important factor. A recent study by Starby et al, 2014, studying 2505 ischemic stroke patients showing that before the stroke onset, 67% of the patient was diagnosed with hypertension, 44% heart disease and 24% diabetes. The study also suggests that the influence of well-established vascular risk factors on developing ischemic stroke may often be similar in young patients compared to older patients. Qualitative interview studies of stroke survivors one year after a mild stroke from our research group (Carlsson et al 2004, Carlsson et al 2005), showed that even in absence of physical impairments, invisible impairments such as mild cognitive decline and mental fatigue had impact on participation in everyday life, ability to work and social relationship. The respondents struggled to cope with its consequences, experienced often the everyday life as uncertain and were in need of support. Previous research in our group (Gosman-Hedström et al, 2008) on a Swedish elderly stroke population (70+ at stroke onset) has also showed that stroke survivors with minor stroke at onset were also more often in need of informal care, particularly with complex tasks compared with population controls. Thus, consequences with visible impairments such as loss of motor function and aphasia, but also less visible cognitive and emotional impairments and fatigue may have a long lasting impact on spouse’s everyday life, roles and responsibilities, economy, leisure, and family- and social relationships. The life changes and the provided support by informal caregivers may thereby also have an impact on their mental and physical condition. Although, for younger stroke survivors, the stroke disease may in some cases be the top of an iceberg of a progressive vascular disease. Among causing factors an unhealthy lifestyle and present risk factors are likely to be shared by the spouses which in turn may affect the general health of the spouses. Hence, it is important for the society to provide support to reduce the burden on spouses and health promotion to prevent unhealthy lifestyle.
Than you for engaging in the conversation! The findings you refer to in your response here are certainly eye-opening, especially for physicians who manage patients primarily in the in-patient setting and are unaware of the long-term consequences for a person after even a minor stroke (by NIHSS definitions). The NIHSS, like many scales including mRS, often fail to capture the patient-level outcomes of stroke, and I appreciate your contribution to furthering this notion. It is clear that your findings add to a tremendous amount of data regarding the patient-level and societal costs of stroke and underscore the importance of prevention, treatment and post-stroke support. Neal S Parikh