Daily life after stroke in elderly people. Evaluation of stroke unit care focusing on daily activities, resource use and costs, assistive devices and health-related quality of life

Abstract

Aims: The overall aims of this thesis were: a) to compare stroke unit (SU) care and its continuum with care on general wards (GW) for elderly patients, concerning resource use and costs for care and rehabilitation focusing on assistive technology in a one-year follow-up and, b) to explore the use and cost of assistive devices (ADs), ability in daily activities and self-rated health-related quality of life (HRQL) longitudinally.Methods: Two hundred and forty-nine persons >70 years were followed in a randomized, prospective study evaluating SU care after acute stroke. The patients were interviewed and observed four times during the first year by two registered occupational therapists. In two of the studies the patients were followed longitudinally.Results: There were no statistically significant differences in total resource use and costs for care and rehabilitation between the SUs and the GWs during the first year after acute stroke. Costs in relation to the severity at stroke onset showed statistically significant differences, indicating that patients with severe stroke were treated at a higher cost.Informal care widely exceeded the care provided by the community.The total cost of ADs was 2% of the total costs of care and rehabilitation during the first year. One third of the patients had ADs before stroke. After one year the majority of the patients with stroke used ADs. There was a statistically significant difference between the SU group and the GW group in the proportion of patients who had supplementary ADs prescribed between 0-3 months after stroke; the patients at the SU had a higher number of uncomplicated and cheap ADs prescribed. The ADs had a large impact and were prescribed at low cost. Different types of ADs were needed at different stages in the rehabilitation process. Constant routine evaluation of elderly patients with stroke is recommended during the first year after stroke.High concordance was found between the assessments in the Functional Independence Measure (FIMTM) and the Barthel Index (BI). The assessments in the 7-level FIMTM polarize, and the intermediary levels are rarely used, suggesting that a 5-level FIM is sufficient.There were no statistically significant differences between the SU group and the GW group regarding dependence or HRQL as assessed longitudinally. There were statistically significant differences in daily activities and HRQL as assessed with the 5-level FIM and the Nottingham Health Profile (NHP) in patients who used at least one AD and those who did not.Conclusions: Since the majority of the patients with stroke used ADs one year after acute stroke but at relatively low cost, assistive technology must be considered to be one of the best tools for maintaining the highest possible level of daily activity in this patient group. Regular routine evaluations are required both for best use of resources and adaptation to individual needs. The 5-level FIM proved to be useful, but further research into its clinical utility is required. More attention should be paid to the role of spouses as caregivers in stroke survivors, since informal care carries a far greater burden than the care provided by the community. Support schemes of all types are required to relieve the spouses