Quality of Life After Stroke
Impact of Stroke Type and Lesion Location
Background and Purpose Little attention has been focused on the relationship between neurological lesions and quality of life (QL) in stroke research. The purpose of this study was to analyze the impact of stroke types and lesion locations on QL.
Methods The study sample was composed of 441 stroke patients. Lesion locations and stroke types were divided into 194 left-sided and 173 right-sided lesions, 61 infratentorial strokes (55 infarctions and 6 hemorrhages), and 335 supratentorial strokes (204 [sub]cortical infarctions, 82 lacunar infarctions, and 49 hemorrhages). Six months after stroke, QL was assessed with the Sickness Impact Profile. Age-adjusted QL scores were expressed in standard scores.
Results Although patients with left-sided lesions had more speech pathology (P<.001), there was slightly more QL deterioration in patients with right-sided lesions. Patients with infratentorial strokes reported better overall functioning than patients with supratentorial strokes (P=.02). Patients with lacunar infarction had less dysfunction compared to patients with (sub)cortical lesions (P<.001). There was no difference in QL between supratentorial (sub)cortical infarcts and hemorrhages. Lesion locations and stroke types did not affect patients’ emotional distress. Severely impaired QL patterns were related significantly to older age (P<.001), comorbidity (P=.02), stroke severity (P<.001), and supratentorial lesions (P=.02).
Conclusions There is only a weak relationship between lesion laterality and QL. Survivors of hemorrhagic strokes do not evidence more QL impairment than survivors of ischemic strokes. Stroke per se is not unequivocally followed by emotional discomfort. In addition to stroke type, patient and clinical characteristics are also important in explaining impaired QL patterns.
Over the years quality of life (QL) has been defined in many different ways. One speaks, for example, of need satisfaction,1 health-related subjective experiences,2 or psychosocial and physical well-being.3 Most researchers today adopt a multidimensional approach to QL assessment.4 A broad consensus has emerged that at least four dimensions should be included in a QL assessment: physical, functional, psychological, and social health. The physical health dimension refers primarily to disease-related symptoms. Functional health comprises self-care and physical activity level. Cognitive functioning, emotional status, and general perceptions of health, well-being, life satisfaction, and happiness are the central components of the psychological life domain. Social functioning includes the assessment of social contacts and interactions.
Apart from studies on the impact of specific stroke factors on depression5 6 7 8 9 10 11 12 and neuropsychological impairments,13 few studies have focused systematically on the relationship between types of stroke and lesion locations and patients’ QL. In a 4-year follow-up study, Niemi et al14 found that patients with either a right or left hemisphere lesion had more frequently evidenced QL deterioration than patients with no localizable or brain stem lesions. However, the impact of other stroke characteristics (such as [sub]cortical infarction, hemorrhage, or supratentorial and infratentorial stroke locations) on patients’ QL was not considered.
Stroke type may have considerable consequences for the QL after stroke. An intracerebral hemorrhage results in a greater initial mortality, but longer-term mortality (>1 year) and functional status of these patients appear to be comparable to those of the survivors of a cerebral infarction.15 Yet the underlying disease mechanisms of these two types of stroke may lead to differences in cerebral function and accordingly to differences in QL outcomes. Previous studies have demonstrated that patients with a lacunar infarction fare better than those with (sub)cortical infarctions in terms of vascular events, recurrences, and survival.16 However, the impact of these stroke types on QL has not been investigated thoroughly.
It has been suggested that stroke lesion location can be of paramount importance for the patient’s QL. Some clinicians argue that left hemisphere lesions with aphasia in particular will result in a poor QL. Others suggest the opposite, referring to the devastating effects that right hemisphere lesions with anosognosia, neglect, and spatial disorientation may have on social functioning and thus on QL.
The present study was undertaken to describe the QL of patients 6 months after stroke and to investigate the impact of stroke type and lesion location on patient’s QL.
Subjects and Methods
The study sample consisted of 441 patients who had had a stroke 6 months earlier. They were the survivors of an original cohort of 760 consecutively admitted stroke patients who participated in a multicenter quality of care study in the Netherlands. Two hundred fifty-eight patients died after the stroke, and 17 patients declined to participate in the study. For 44 communicative patients, no QL data were collected during the follow-up interview. The reason for this was that the patient burden associated with the length of the interview was unacceptably high, and therefore the research assistant had to stop the interview prematurely. Characteristics of these patients as well as the refusers in terms of stroke type, lesion location, age, and sex were comparable to those of the study sample.
Clinical data were abstracted from the medical and nursing charts by trained research assistants. The variables concerned were age, sex, comorbidity (presence of cancer ≤5 years, chronic obstructive pulmonary disease, psychiatric disorders, mental decline, or diabetes mellitus), previous stroke, stroke severity, and stroke type. Stroke severity, defined in terms of level of consciousness at stroke onset, was assessed with the Glasgow Coma Scale.17 Because of the possible presence of aphasia, the verbal component of this scale was deleted. When a patient had a maximum score on the eye and motor components, he/she was considered to be alert. Computed tomography (CT) data were available for 430 patients (97.5%). The scans were made routinely within 2 weeks after the stroke and were evaluated by local radiologists.
The stroke types could be divided into 335 supratentorial strokes (204 subcortical and cortical infarctions, 82 lacunar infarctions, and 49 intracerebral hemorrhages) and 61 infratentorial strokes (55 infarctions and 6 hemorrhages). For 45 patients the stroke types were unknown or incompletely described. As concerned lesion location, 194 patients had left-sided and 173 patients had right-sided lesions (for 74 patients lesion laterality was undetermined or there were infratentorial strokes).
A hemorrhage was considered to be present if CT showed evidence of a recent intracerebral hemorrhage. The diagnosis of lacunar stroke was made if there was a clinical picture of one of the lacunar syndromes and the CT was compatible with that diagnosis.16
The patients were interviewed 6 months after stroke. Handicap, defined as any limitation in the patient’s social role, was measured with the modified Rankin scale,18 whereas QL was assessed with the Sickness Impact Profile (SIP).19 The SIP is a reliable and valid 136-item measure that defines QL strictly in behavioral terms.20 The scale is composed of 12 subscales measuring a broad range of dysfunctions. An aggregated score can be obtained for the total SIP, as well as for each subscale individually. Additionally, various subscale scores can be aggregated into a physical and a psychosocial dimension score. The physical dimension refers mainly to disabilities (eg, body care, ambulation, and mobility). The psychosocial dimension focuses on alertness behavior, emotional behavior, social interaction, and communication. Since the large majority of the patients (80%) was retired at stroke onset, the SIP subscale “work” was excluded from all analyses. By convention, scores are presented as a percentage of maximal dysfunction ranging from 0% to 100%. The SIP was administered verbally.
One hundred twelve patients (25%) were not communicative because of severe speech, language, and cognitive disorders. Of these 112 patients, 79% had supratentorial strokes and 58% had left-sided lesions. To avoid the problem of not evaluating QL in a subgroup of patients in which this is highly relevant, these patients were not excluded from the study but rather were rated by a proxy respondent (most typically the partner).
To distinguish between QL effects related to stroke and those attributable to aging, SIP scores of the stroke patients were compared with reference SIP data collected in an open Dutch population of the elderly (n=132; age range, 61 to 75 years; 45% male).21 Differences between the mean SIP scores of the stroke patients and those of the nonstroke elderly subjects were converted to standard SIP scores (standard SIP score=difference between a given mean SIP score of stroke group and mean SIP score of reference group divided by the standard deviation of SIP scores in the reference group). The standard scores indicate how many standard deviations the SIP scores of stroke patients fall above (or below) the scores of the general population of comparable age. Cluster analysis was performed to identify homogeneous subgroups of patients with specific QL patterns. Differences between frequencies were analyzed with χ2 tests. Differences in SIP scores of stroke patients in relation to the reference data, hemispheric lesion laterality, and stroke types were analyzed with paired and two-group t tests. We also performed (age-adjusted) χ2 tests to study the relationship between specific QL patterns on the one hand and patient and clinical features on the other.
The mean age of the original cohort was 73 years. Fifty-two percent were male. Mortality at 6 months after stroke was 33.9% (258/760). There was no difference in mortality between patients with left and right hemisphere lesions (114/342 [33.3%] and 94/289 [32.5%], respectively; P=.90). The mortality rates of patients with supratentorial (sub)cortical infarction, supratentorial hemorrhages, and lacunar infarction were 31.9% (109/342), 45.9% (51/111), and 9.3% (10/107), respectively (P<.001).
The characteristics of the study sample in relation to both lesion laterality and supratentorial stroke types are summarized in Table 1⇓. No significant association was found between hemispheric lesion location and patients’ sociodemographic and clinical characteristics. As could be expected, however, patients with lacunar infarction were significantly younger and had less severe strokes and fewer poststroke handicaps compared to patients with supratentorial infarctions and hemorrhages.
Fig 1⇓ depicts the original mean percent SIP scores for both the study group and the reference group of nonstroke elderly subjects. In comparison with the reference data, stroke patients on average showed consistent patterns of disabilities, with a high level of dysfunction in household management and recreation.
Fig 2⇓ shows the differences between stroke patients and the reference group expressed in standard scores. When adjusting for age-specific effects, stroke patients reported particularly high levels of dysfunction in body self-care, communication, and eating (>2.6 SDs above SIP reference scores), as well as household management and ambulation (>1.7 SDs). Less severe dysfunctions were reported in sleep, emotional behavior, and social interactions. At the aggregated level, more disability was observed in physical than in psychosocial functioning when compared with the reference population (P<.001).
Few relationships between hemispheric lesion locations and QL were found. Patients with left-sided lesions on average performed better in body care and movement (P=.02) but had, as was expected, substantially more speech pathology than those with right-sided lesions (P<.001) (Fig 3⇓).
No significant differences in QL profiles were found between supratentorial (sub)cortical infarcts and hemorrhages. With the exception of emotional discomfort (P=.28), patients with lacunar infarction reported significantly less dysfunction in all QL categories compared with patients with (sub)cortical lesions (physical dimension scores, P<.001; psychosocial dimension scores, P<.001; and overall SIP scores, P<.001) (Fig 4⇓).
Compared with all supratentorial strokes, patients with infratentorial strokes reported better functioning, as indicated by the overall SIP score (P=.02). At the subscale level, statistically significant differences were observed in household management (P<.001) and mobility (P=.01) only.
Cluster analysis revealed that stroke patients’ QL could be described with a three-cluster solution. The SIP scores of the majority of patients (60%) reflected mildly impaired QL. One third (33%) of the patients scored high (indicating more dysfunction) on both the physical and (to a lesser extent) psychosocial dimensions, whereas a small subgroup of patients (7%) had high levels of psychosocial dysfunction (Fig 5⇓).
The sociodemographic and clinical characteristics of these three subgroups are summarized in Table 2⇓. Mildly impaired QL was related significantly to younger age, male sex, and infratentorial and lacunar strokes. Serious QL deterioration was frequently seen in patients who had suffered a severe stroke and in patients with larger supratentorial strokes. However, patients with overall dysfunctions (ie, both the physical and psychosocial domains) tended to be older and to have more comorbid conditions than patients who experienced primarily psychosocial problems. Analyses adjusting for age largely supported the above findings. Although QL no longer was related to sex, severely impaired QL patterns remained significantly associated with comorbidity (P=.02), stroke severity (P<.001), and supratentorial stroke type (P=.02).
Six months after stroke, patients on average reported substantial limitations in virtually all life areas but particularly in household management and recreation. However, after adjusting for age, a somewhat different picture emerged, with poststroke deterioration in QL manifested primarily in basic activities such as body self-care, ability to communicate, and eating. In general, the physical domain appeared to be more affected than the psychosocial domain in these patients.
With the exception of the ability to communicate, the QL profiles of patients with lesions in the left hemisphere were slightly better compared with those of patients with lesions in the right hemisphere. The somewhat poorer QL profiles of patients with right hemisphere lesions may be related to neurological disturbances in terms of neglect of left body space, impaired awareness of the disease, and spatial disorientation. It was striking that patients with right-sided brain lesions also reported problems in communication. This lends support to the view that communication is dependent not only on language skills but also on additional abilities associated with orientation, self-awareness, motor performance, and prosody.
In comparison with patients who suffer from lacunar infarcts, patients with larger supratentorial strokes (both infarcts and hemorrhages) showed a significant deterioration in practically all life domains with the exception of emotional distress. QL, however, was unrelated to the type of (sub)cortical lesion. Although patients with supratentorial hemorrhages had suffered more severe strokes, resulting in higher rates of impaired consciousness at stroke onset and poststroke mortality, they did not evidence more QL impairment than survivors of supratentorial ischemic strokes. Similar patterns of recurrence and functional outcome for survivors of hemorrhagic versus ischemic stroke have been reported by Franke and colleagues.15
Estimates of the incidence of poststroke depression range from 22% to 50%.7 8 House et al9 could not demonstrate a clear relationship between mood disturbances and lesion laterality. Studies from the Baltimore group observed more depressive symptoms in patients with left frontal lesions10 and left hemisphere anterior lesions,11 whereas others found that high depression scores are also correlated with anterior and posterior lesions of the right hemisphere.12 In the present study the patients reported relatively low levels of emotional distress. Furthermore, no association was found between emotional dysfunction and location of hemispheric lesion or stroke type. These results suggest that stroke per se may not result in emotional problems but that such problems result from a complex interaction between patients’ personal traits, social circumstances, living arrangements, and functional abilities.
Using cluster analysis, we grouped patients into three relatively homogeneous groups. The first and largest group (60%) consisted of patients with mildly impaired QL. The second group (33%) was severely impaired in physical and psychosocial life domains. The third and by far smallest group (7%) reported problems in the psychosocial domains in particular. None of these QL patterns were related to lesion laterality. However, mild QL impairment was more often reported by patients with infratentorial lesions than by patients with supratentorial lesions. The absence of cognitive disturbances appears the most likely explanation for this finding. Severely impaired QL patterns were not only related to stroke types in which cortical regions were involved but also to other patient characteristics and clinical features, including older age, comorbidity, and stroke severity.
A well-considered choice of suitable QL instruments should be based not only on the clinimetric properties of the measures but also on the specific research questions, the relevance to the objectives of the study, and the specific characteristics of the stroke patients under study. In this study we chose the SIP to assess a wide range of QL domains in depth. The subscales assessing communication, cognitive alertness, emotional distress, and social functioning are particularly relevant for use in stroke outcome studies. The physical dimension contains items measuring a broad range of activities of daily living, mobility, and complex physical activities. Floor effects and especially ceiling effects, which are common to most specific disability scales, are therefore less likely. (Disability scales often address only a narrow range of basic daily functions. As a result of this restricted range, health improvement or deterioration may not be detected because these changes can occur beyond the end points of the scale.) Because of its length the SIP is primarily suitable for cross-sectional studies. A limitation of the SIP is that the items do not incorporate important aspects of patient’s psychological status in terms of subjective health, feelings of well-being, and life satisfaction.
The SIP depends on the patient’s self-report, as do other QL instruments. This method of data collection is less suitable for patients with serious communication disorders. In many stroke studies addressing QL issues, patients with severe impairments have therefore been excluded from QL assessments.14 22 23 24 25 This creates the clinical problem of not evaluating QL in a subgroup of patients in which this is highly relevant. It is for this reason that we have included these patients and have assessed their QL via ratings provided by significant others. Relatively little is known about the validity of proxy assessments. A major methodological difficulty is that studies of the concordance between patient and proxy responses, by definition, can be based only on score agreement between communicative patients and their significant others. Thus, even in the case of complete concordance one cannot necessarily generalize the findings to the target population of noncommunicative patients. However, because the scale items are not focused on subjective feelings or perceptions but rather on the patient’s actual performance or behavior (just as, for example, the Barthel Index or the Rankin scale), the SIP may be more appropriate for use in a proxy form than any other QL measure in that it is designed to assess primarily observable behavior.
To summarize, the results of this study indicate the following: (1) age-adjusted QL deterioration 6 months after stroke occurs primarily in basic activities such as body self-care, communication, and eating; (2) except for communication disorders, there is only a weak relationship between hemispheric lesion location and QL profiles; (3) survivors of hemorrhagic stroke do not report more QL impairment than survivors of ischemic stroke; (4) relatively better QL is reported by patients with lacunar infarction and infratentorial strokes; (5) lesion laterality and stroke type do not have an impact on emotional distress; and (6) three specific poststroke QL patterns can be identified, which are mainly related to age, comorbidity, stroke severity, and stroke type.
To our knowledge, our study provides one of the first detailed descriptions of QL profiles in relation to specific stroke characteristics. Future studies should also focus on other but less clinically oriented aspects that might explain poststroke QL impairments, such as patients’ living environment, social circumstances, and the use of and perceived need for healthcare services. These studies can help to further identify patients who are particularly prone to serious QL deterioration. The availability of such risk profiles could in turn facilitate the development of community-based rehabilitative programs aimed at reducing the devastating effects of stroke and improving patients’ QL.
This study was supported by the Netherlands Heart Foundation (NHS 40.004) and Ontwikkelingsgeneeskunde (OG 1991-037). Dr Limburg is a Clinical Investigator of the Netherlands Heart Foundation. We wish to thank Professor Dr H. van Crevel of the Department of Neurology, Academic Medical Center, Amsterdam, for his helpful advice in preparing this manuscript.
- Received July 12, 1994.
- Revision received December 1, 1994.
- Accepted December 1, 1994.
- Copyright © 1995 by American Heart Association
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