Health problems in elderly patients during the first post-stroke year

Article (PDF Available)inUpsala journal of medical sciences 117(3):318-27 · May 2012with36 Reads
DOI: 10.3109/03009734.2012.674572 · Source: PubMed
Abstract
A wide range of health problems has been reported in elderly post-stroke patients. The aim of this study was to analyse the prevalence and timing of health problems identified by patient interviews and scrutiny of primary health care and municipality elderly health care records during the first post-stroke year. A total of 390 consecutive patients, ≥65 years, discharged alive from hospital after a stroke event, were followed for 1 year post-admission. Information on the health care situation during the first post-stroke year was obtained from primary health care and municipal elderly health care records and through interviews with the stroke survivors, at 1 week after discharge, and 3 and 12 months after hospital admission. More than 90% had some health problem at some time during the year, while based on patient record data only 4-8% had problems during a given week. The prevalence of interview-based health problems was generally higher than record-based prevalence, and the ranking order was moderately different. The most frequently interview-reported problems were associated with perception, activity, and tiredness, while the most common record-based findings indicated pain, bladder and bowel function, and breathing and circulation problems. There was co-occurrence between some problems, such as those relating to cognition, activity, and tiredness. Almost all patients had a health problem during the year, but few occurred in a given week. Cognitive and communication problems were more common in interview data than record data. Co-occurrence may be used to identify subtle health problems.
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Upsala Journal of Medical Sciences. 2012; 117: 318327
ORIGINAL ARTICLE
Health problems in elderly patients during the rst post-stroke year
LENA OLAI
1,2,3
, LARS BORGQUIST
4
& KURT SVÄRDSUDD
1
1
Department of Public Health and Caring Sciences, Uppsala University, Family Medicine and Preventive Medicine
Section,
2
Centre for Clinical Research, Dalarna, Sweden,
3
Dalarna University, School of Health and Social Studies,
Falun, Sweden, and
4
Linköping University, Medical and Health Sciences, Linköping, Sweden
Abstract
Background. A wide range of health problems has been reported in elderly post-stroke patients.
Aim. The aim of this study was to analyse the prevalence and timing of health problems identied by patient interviews and
scrutiny of primary health care and municipality elderly health care records during the rst post-stroke year.
Methods. A total of 390 consecutive patients, 65 years, discharged alive from hospital after a stroke event, were followed for
1 year post-admission. Information on the health care situation during the rst post-stroke year was obtained from primary
health care and municipal elderly health care records and through interviews with the stroke survivors, at 1 week after
discharge, and 3 and 12 months after hospital admission.
Results. More than 90% had some health problem at some time during the year, while based on patient record data only 48%
had problems during a given week. The prevalence of interview-based health problems was generally higher than record-
based prevalence, and the ranking order was moderately different. The most frequently interview-reported problems were
associated with perception, activity, and tiredness, while the most common record-based ndings indicated pain, bladder and
bowel function, and breathing and circulation problems. There was co-occurrence between some problems, such as those
relating to cognition, activity, and tiredness.
Conclusions. Almost all patients had a health problem during the year, but few occurred in a given week. Cognitive and
communication problems were more common in interview data than record data. Co-occurrence may be used to identify
subtle health problems.
Key words: Documentation, health problem, nursing, prevalence, time course
Introduction
It is well known that post-stroke patients have health
problems ranging from minor difculties to fatal
events. Even in patients deemed to have recovered
3 months after a stroke, functional abilities and
quality of life may still be impaired (1). Survivors
of a mild stroke may have some degree of disability
and need to change their life-styles for up to 1 year
after the stroke incident (2). Other stroke survivors
may have to cope with serious permanent cognitive
decline (3).
Previous studies have indicated a wide range of
health problems after a stroke incident, including
pain, fever, infections, falls, depression, anxiety, emo-
tionalism, confusion, fatigue, etc. (412). Most of
these studies covered hospital patients; only a few
covered nursing home patients and post-stroke
patients living at home. This selection of study pop-
ulation may have caused higher health problem prev-
alence than would have been found in a more
representative post-stroke population. Moreover,
health problem assessments in these post-stroke
patients were usually based on clinical examinations
Correspondence: Lena Olai, RN, PhD, Department of Public Health and Caring Sciences, Family Medicine and Prevention Section, PO Box 564, SE-751
22 Uppsala, Sweden. E-mail: lena.olai@pubcare.uu.se
(Received 9 February 2012; accepted 5 March 2012)
ISSN 0300-9734 print/ISSN 2000-1967 online 2012 Informa Healthcare
DOI: 10.3109/03009734.2012.674572
with a neurological focus. We have not found
any studies with a broader, longitudinal approach
where the change of health situation can be assessed
over time.
This study was designed as a comprehensive proj-
ect, where a fairly large and representative sample of
stroke patients was followed during 1 year after the
stroke event. In a previous report the ability of
hospital-based nurses, physicians, physiotherapists,
and occupational therapists to give a correct prognosis
assessment regarding these patients was tested (13),
and in another report survival, hazard function for a
new event, and health care utilization among these
patients were analysed (14).
In this report the prevalence of health problems in a
broad sense during the rst stroke year was measured,
based on data from patient interviews, data from
primary health care records, and patient records
from assisted accommodation and nursing homes.
The aim of the present study was to analyse the
prevalence and timing of health problems identied
through patient interviews and scrutiny of primary
health care and municipality elderly health care
records during the rst post-stroke year.
Study population and methods
Setting
The study was performed in the cities of Falun (pop-
ulation 55,000) and Borlänge (population 47,000),
central Sweden, with similar age and sex distributions
as the Swedish national population (15). Both cities are
served by Falun General Hospital, the only hospital in
the area. Since admission to hospital in Sweden is free of
charge for the patient, virtually all patients with clinical
signs and symptoms indicating stroke are admitted
(except some already institutionalized) (16). Moreover,
patient fees for hospital out-patient clinics, appoint-
ments with general practitioners, and municipal support
are all heavily subsidized by central and local govern-
ments, which means that private nancial resources are
seldom an obstacle to health care utilization.
All Swedish residents have a unique 12-digit per-
sonal identication number (PIN), given at birth or
immigration and used in all ofcial documents and
registers. The PIN is an excellent and highly reliable
tool for record linkage and retrieval.
Study population
During the period 1 September 1999 to 31 May 2001 a
total of 432 patients 65 years of age or older, living at
home before admission and having no pre-admission
dementia diagnosis, were cared for on an in-patient
basis at the Department of Internal Medicine (stroke
unit or general ward) after an acute stroke (index
admission), dened as intracerebral haemorrhage, brain
infarction, or stroke of undetermined pathological type
(ICD10 codes I61, I63, and I64) (17). Forty-two
potential participants died at the Department of Internal
Medicine, and the 390 survivors constitute the study
population of this report.
Data collection
Figure 1 shows the patient ow through the study.
One week after discharge there was a standardized
face-to-face interview with the patients in their
homes, assisted accommodations, or nursing homes,
repeated at 3 and 12 months after admission by two
registered nurses. In case of aphasia or cognitive
problems a next of kin was asked to participate to
help interpret answers. Overall, 93% of the eligible
patients were interviewed at least once. Forty inter-
views were performed in duplicate independently
by the two observers with excellent agreement
(kappa 0.95). Moreover, all primary health patient
records and all municipal elderly health care nursing
records regarding the study population were
scrutinized.
Interviews. In the patient interviews information
was sought on education, marital status, cohabitation,
functional ability, Mini Mental State Examina-
tion (MMSE) (18), Hospital Anxiety and Depression
Scale (HAD) (19), The Nottingham Health
Prole (NHP) (20), self-reported health, and health
problems. Functional ability was estimated using
a Katz Activity of Daily Living (ADL) assessment,
ranging from completely independent, grade A (=1)
to completely dependent, grade G (=7) (21). All
instruments are validity- and reliability-tested with
good results. The part of the interview focused on
medical or nursing problems was based on a pre-
prepared form made for this study.
The HAD scale has 14 items, 7 on anxiety and 7 on
depression, each with a four-point verbal rating scale
scored 03, giving total scores ranging from 0 to 21.
Scores of 810 on a subscale have been claimed to
indicate possible pathology, and scores 11 as denite
cases(19). The NHP questionnaire, tested in the
general population and in various patient populations,
including stroke patients, measures discomfort (20).
Part I, used in this study, consists of 38 yes/
no questions forming six dimensions: energy (3 state-
ments), physical mobility (8 statements), sleep (5 state-
ments), emotional reactions (9 statements), social
isolation (5 statements), and pain (8 statements).
Statements were weighed within each area, resulting
Health problems during the rst post-stroke year 319
in scores ranging from 0 to 100, with 0 indicating no
problems.
The participants were asked to grade their self-
reported health on a ve-degree ordinal scale, ranging
from poor (=1) to excellent (=5) and to grade their
sense of loneliness, ranging from never (=0) to several
times a week (=3). Health problems were measured
with a list of 30 medical or nursing problems and an
indenite number of open alternatives. The patients
were asked which of these or other health problems
they had experienced after the stroke or after the pre-
vious interview and whether the symptom was new or
exacerbated. Possible responses were yesor no.
Patient record scrutiny. Information on appointments
with and home calls from the primary health care
centre (PHCC) staff (all caregiver categories) and
municipal elderly health care support was obtained
by scrutiny of PHCC and municipal elderly health
care records regarding health problems, diagnoses,
and date of appointment or care given. The mean
number of PHCC notes during the follow-up year was
41.5 (median 23, interquartile range 1048), and the
mean number of municipal record notes was
135.3 (median 124, interquartile range 57205). All
recorded problems were registered. No distinction
was made between the concepts of complications,
Participated in any interview n = 343
Participated in all interviews n = 263
Participated in no interview n = 34, of whom 14 were very ill and died
during follow up, 2 moved from the area, and 18 declined participation
Eligible n = 314
Interviewed n = 284
Declined interview n = 28
Language problems n = 2
Eligible n = 368
Interviewed n = 339
Declined interview n = 18
Too ill or language
problems n = 11
Decreased n = 38
Moved out of the
area n = 3
Decreased n = 7
Moved out of the area
n = 2
12 months after
index admission
3 months after
index admission
1 week after
discharge
Decreased n = 13
Decreased n = 13
Study population n = 390
(Stroke unit
n = 184)
(Medical ward
n = 206)
Geriatric ward
n = 224
Still in hospital n = 15
Eligible n = 340
Interviewed n = 309
Declined interview n = 25
Too ill or language
problems n = 6
Figure 1. Flow chart of the study population.
320 L. Olai et al.
sequels, or stroke-related disability, to avoid classi-
cation uncertainty.
The health problems documented during the inter-
views and the diagnoses and health problems found
after patient record scrutiny were classied into key
words, each coded as yes/no, according to the Well-
being, Integrity, Prevention, and Safety (VIPS) clas-
sication for nursing documentation in patient
records (22). The VIPS key words and their contents
are presented in Table I. The information on health
problems based on interview data was available at
1 week after discharge from hospital and at 3 and
12 months after hospital admission, whereas the
information based on patient record scrutiny was
available continuously during the rst post-
stroke year. To facilitate comparison of the two
ways of measuring health care problems the patient
record-based data were computed with the same
time-frame as the interview data in addition to the
continuous mode.
Register data. Mortality and hospital admission data
covering the rst post-stroke year were obtained from
the national Cause of Death Register, covering all
deaths among Swedish residents, and the Hospital
Discharge Register, covering all hospital admissions
in Sweden.
Ethical considerations
All subjects in the study population gave oral
informed consent to participate, the standard
procedure at the time. The study was approved on
several occasions during the planning and data col-
lection, rst by the Research Ethics Committee at
Uppsala University and later by the National Research
Ethics Board.
Statistical considerations
Data were analysed using the SAS software, version
9.2 (23). Survival, health care utilization, and diag-
noses were 100% complete, and post-morbid state
data, based on interviews, were 91% complete.
Functional ability and self-rated health were ordinal
variables and were therefore tested with ordinal logistic
regression. MMSE, HAD, and NHP were continuous
butmoderatelyskewedtowardshighor low values.They
were tested withlinear regression basedon original data,
linear regression based on log-transformed data, and
ordinal logistic regression based on grouped data. All
methods gave similar results, and therefore only results
based on ordinal logistic regression are shown. To
obtain the levels of these variables, functional ability,
MMSE, self-rated health, HAD, and NHP were com-
puted with the least square mean function of the SAS
procedure General Linear Model (linear regression),
adjusting for the inuence of age, sex, marital status,
stroke number, loneliness, and education (covariates).
The prevalence of the VIPS key words based on
interview data was analysed with nominal logistic
regression, with the key word entered as dependent
variable, and time and the covariates as independent
variables, providing Pvalues for trends across time.
Table I. Key words and their content in the Well-being, Integrity, Prevention, and Safety (VIPS) classication for nursing documentation.
Key word Content
Communication Speech impairment, aphasia, apraxia
Cognition, development Memory decits, concentration difculty, understanding of health and illness, lack of initiative or motivation,
attention impairment, difculties with planning and organizing, post-stroke dementia
Breathing, circulation Respiratory problems, aspiration, dyspnoea, coughing, heart problems, deep vein thrombosis, bleeding, body
temperature, oedema, cyanosis
Nutrition Swallowing difculties, nausea, vomiting, appetite loss, weight loss
Elimination Urinary tract problem, bladder or bowel incontinence, diarrhoea, constipation
Skin Integument, lesions, ulcers, wound infection, sweating
Activity Paralysis, falls, spasticity, contracture, deteriorated condition, activity limitations
Sleep Fatigue, day-time sleepiness, tiredness, restlessness, sleeping problems
Perception with pain Shoulder pain, pain syndrome, headache
Perception other than pain Perception and co-ordination decits, vision or hearing limitation, sensibility impairment, balance
disturbance, dizziness
Psycho-social Inability to control emotions, pathological crying, anxiety, uneasiness, stressfulness, social deprivation,
personality change, uncertainty, irritability, depression
Well-being Deterioration, stroke recurrence
Composite assessment Other health problems
Health problems during the rst post-stroke year 321
The same procedure was used for patient record
data computed with the same time-frame as the
interview data.
The record-based VIPS key worddata were collected
continuously on a daily basis. However, for illustration
purposes the day-by-day prevalence was transformed to
week-by-week prevalence. It was calculated using a set
of variables, each variable representing a specicweek
during the year (week-by-week matrix). Having a spe-
cic VIPS key word during a specicweek(=1) or not
(=0)was indicatedin thecorrespondingweeks variable.
Summing the individual matrices and dividing the vari-
able for each week by the number of exposed patients
produced the weekly proportion of patients with a given
VIPS key word, adjusted for non-exposure (being in
hospital or deceased). Logistic regression was used to
test the prevalence change across the year.
Simultaneous occurrence, or co-occurrence, of
more than one VIPS key word per patient per mea-
surement occasion was analysed with the substring
feature available in the SAS software and using factor
analysis with varimax oblique rotation. Both methods
yielded the same results. Only two-tailed tests were
used. To account for the many tests performed,
P<0.005 was regarded as statistically signicant.
Results
Characteristics of the study population
At the index admission, 75% were admitted for their
rst ever stroke, and 223 (57%) were women. Mean
age was 79.4 years for women and 76.8 years for
men, and half of the women and one-third of the men
were living alone in their own homes. Forty-seven per
cent were treated at a stroke unit, and 57% were trans-
ferred to the Department of Geriatrics for further care
and recovery, where 13 (3%) of the patients died. The
mean number of in-hospital days at the Department of
Medicine was 7.4 (median 6, interquartile range 39),
and at the Department of Geriatrics 30.9 (median 27,
interquartile range 1441). Three-quarters of the
patients were discharged back to their homes, while
the rest were discharged to assisted accommodation
or nursing homes. One week after hospital discharge
two-thirds of the patients were able to maintain
their personal hygiene and were mobile without assis-
tance, and slightly less than 6 out of 10 could dress
independently.
Change of health situation over time
The levels of functional ability, MMSE, self-
rated health, HAD, and NHP were stable across
the rst post-stroke year after adjustment for the
inuence of the covariates (Table II). The cumulative
period prevalence of the interview-based VIPS key
words since discharge or last interview and the patient
record-based key words arranged in a similar time-
frame are shown in Table III. Generally, the preva-
lence of the interview-based VIPS key words across all
three measurement occasions was higher than the
record-based ones, with a few exceptions. Based on
Table II. Functional ability according to Katz Activity of Daily Living, Mini Mental State Examination score, self-rated health, Hospital
Anxiety and Depression scale, and Nottingham Health Prole scale as measured on three occasions during the rst post-stroke year, after
adjustment for the inuence of age, sex, marital status, stroke number, loneliness, and education.
Time of measurement
1 week after
discharge
3 months after
index admission
12 months after
index admission
Pfor
trend
Functional ability (17) 2.4 2.2 2.3 0.73
Mini Mental State Examination (030) 22.3 24.0 22.6 0.50
Self-rated health (15) 2.4 2.3 2.2 0.12
Hospital Anxiety and Depression scale
Depression (021) 4.3 4.3 4.2 0.37
Anxiety (021) 3.7 3.3 3.3 0.09
Nottingham Health Prole
Energy (0100) 38.2 36.4 36.4 0.97
Physical mobility (0100) 32.5 30.3 33.4 0.45
Sleep (0100) 23.1 22.1 22.8 0.75
Emotional reactions (0100) 20.4 20.4 18.4 0.19
Social isolation (0100) 18.0 16.6 18.1 0.63
Pain (0100) 9.6 10.0 11.2 0.51
322 L. Olai et al.
Table III. Period prevalence of health problems according to Well-being, Integrity, Prevention, and Safety (VIPS) classication key words as reported at interview and found in primary health care
and municipal elderly health care records, measured on three occasions during the rst post-stroke year, after adjustment for the inuence of age, sex, marital status, stroke number, loneliness,
education, and for non-exposure (hospital admissions and mortality).
Health problems
reported at interviews
Health problems in
patient records
1 week after
discharge
3 months
after index
12 months
after index
Pfor
trend
1 week after
discharge
3 months
after index
12 months
after index
Pfor
trend
Health problems, total, % 82.2 87.0 97.2 <0.0001 43.3 55.2 91.5 <0.0001
Perception 47.3 51.5 69.6 <0.0001 9.7 13.2 42.4 <0.0001
Activity 27.9 33.9 64.2 <0.0001 9.6 12.5 35.3 <0.0001
Sleep 36.0 40.6 62.4 <0.0001 10.9 14.4 41.3 <0.0001
Cognition 19.8 23.2 42.5 <0.0001 2.2 2.9 11.0 <0.0001
Pain 19.9 21.8 32.2 <0.0005 12.0 16.5 50.6 <0.0001
Elimination 13.6 16.1 32.1 <0.0001 19.0 23.4 50.4 <0.0001
Nutrition 14.2 16.4 29.3 <0.0001 6.0 7.9 25.4 <0.0001
Breathing or circulation 8.6 10.6 25.4 <0.0001 7.9 11.3 44.3 <0.0001
Communication 12.8 14.5 24.9 <0.0001 3.5 4.2 8.7 =0.005
Psycho-social 12.2 13.4 20.4 <0.0001 8.2 10.5 28.6 <0.0001
Skin 1.6 2.1 6.9 <0.0001 6.1 8.5 32.2 <0.0001
Miscellaneous 2.9 3.5 8.5 <0.0005 1.3 1.9 10.3 <0.0001
Health problems during the rst post-stroke year 323
interview data 82% reported any VIPS key word at the
rst, 87% at the second, and 97% at the third inter-
view. The corresponding prevalence based on record
data was 43, 55, and 92%.
To obtain a better view of the timing of problem-
reporting, VIPS key word week prevalence based on
record scrutiny over time is shown in Figure 2. The
total VIPS key word prevalence increased as the
patients were discharged from hospital, peaked at
8% 1218 weeks after index admission, and then
gradually decreased to 4%. All individual key words
followed the same pattern, except Skinproblems,
which were fairly constant from week 12 and
onwards.
In Figure 3, interview VIPS key word prevalence is
plotted against prevalence based on record scrutiny.
The most frequently reported VIPS key words from
the interviews were Perception,Activity,Sleep,
and Cognition, while the most common ndings
based on records were Pain,Elimination,
Breathing or circulation,Perception, and Sleep.
The interview-based key words were more prevalent
than the record-based ones at 1 week and 3 months,
but at 12 months the prevalence difference was less
pronounced.
Based on interviews there was co-occurrence
between the VIPS key words Cognition,Activity,
Sleep,Pain,Perception,andPsycho-social.
A total of 538 (61.6%) interviews contained various
combinations of these key words. Other combinations
were infrequent. Based on patient record data there
was similar co-occurrence between the VIPSkey words
Breathing or circulation,Elimination,Sleep,
Pain,Perception,andPsycho-social. A total of
3,167 (54.1%) patient record notes contained various
combinations of these key words.
Discussion
Functional ability, MMSE, self-rated health, degree
of depression, anxiety, and NHP did not change
during the rst post-stroke year. The rank order of
health problems based on patient interviews and
patient record scrutiny differed somewhat. The total
prevalence of record-based health problems was mod-
erate, peaked in the early part of the rst post-stroke
year, and then declined substantially.
Strengths of this study included that the study
population comprised all patients in the area fullling
the inclusion criteria and who survived the acute
stroke phase. The population was large enough for
the purpose of the study, representing more than 90%
of the total stroke population, regardless of inclusion
criteria, during the recruitment period (14). The
data were collected with validity- and reliability-
tested instruments. The documentation of health
problems in the patient interviews and the complete
set of hospital and PHCC patient records and munici-
pality elderly health care records during the rst post-
stroke year were performed in such a way that all
health problems mentioned or noted were recorded.
The patient record data covered notes from physi-
cians as well as nurses, occupational therapists, and
physiotherapists. Most of the notes were nursing
documentation. The PHCC records were computeri-
zed, which meant that notes had to be included in a
standardized format.
The limitations of this study include that the
patients in the interviews were instructed to report
problems occurring after a given point in time (the day
of discharge in the rst interview, or the previous
interview in the second and third). In addition to
memory problems the patients may have had difcul-
ties in differentiating problems occurring before and
after the specied point in time, or may even have
reported cumulative data across the year. However,
the information obtained from the interviews gave
supplementary information to that obtained from
patient records. Another limitation might be the
fact that no control group of stroke-free patients
was available to allow for separation of stroke-
related health problems from other problems.
A large number of health problems were recorded.
Sometimes presumably identical problems were
worded in different ways, and some problem wording
overlapped. In order to facilitate the understanding
and analysis of the health problems, the VIPS classi-
cation was adopted. VIPS was originally created and
validity-tested to allow for systematic nursing docu-
mentation (22), but it also proved to be suitable
for our classication of health problems in patient
records. Of the original 15 VIPS key words,
10
9
8
7
6
5
4
3
2
1
Population with documented
health problem (%)
0
0481216202428
Follow-up time (weeks)
32 36 40 44 48 52
Figure 2. The prevalence of all health problems combined, based
on primary health care and municipal elderly health care records
during the rst post-stroke year, adjusted for non-exposure (hos-
pital admissions and mortality), week by week.
324 L. Olai et al.
Sexualityand Spiritual/culturalwere not used in
the present study, and Composite assessmentand
Well-beingwere amalgamated to Miscellaneous.
As far as we know the continuous serial measure-
ments used for patient record data in this study have
not been used before. Serial measurements, resem-
bling our interview data collection technique, have
been used by others for various stroke-related disabil-
ity outcomes, such as depression (3,6,12), anxiety (6),
function (3), falls (4,6) and fractures (4,11), fatigue
(9,24), cognition (3), dementia (25), and pain (4,6).
Whether or not the depression or anxiety prevalence
changes during the rst post-stroke year is controver-
sial, but it has been suggested that depression may
vary over time, conrming its dynamic nature (26).
All but one of the record-based health problems
analysed in this study had the same time-course as the
total health problem prevalence presented in Figure 2.
There may be a number of explanations for the
decrease in prevalence over time. It may be attribut-
able to registration bias, if long-term health problems
are no longer reported, although since all but one
health problem followed the same course across time
this alternative seems unlikely. A second possibility
might be that the health problems were solved or
healed. A third possibility could be that the decline
might be attributable to selective mortality, the most
severely ill people being those who died during follow-
up. However, in the analyses each subject was com-
pared with him- or herself longitudinally by means of
adjustments made (use of covariates), making this
possibility less likely.
We found reporting differences between health
problems based on interviews and those based on
patient records (Figure 3). The completeness of nurs-
ing documentation has been studied in a Danish
hospital. Of all nursing problems known, one-third
was documented, another third was known by the
70
60
50
40
30
20
10
0
0102030
Interview data (%)
Activity Activity
Activity
Perception
Perception
Perception
Nutrition
Nutrition
Nutrition
Pain
Pain
Pain
Skin
Skin
Skin
Misc Misc
Misc
Elimination
Elimination
Elimination
Breathing/circulation Breathing/circulation
Breathing/circulation
Patient recored data (%)
70
60
50
40
30
20
10
0
Patient recored data (%)
70
60
50
40
30
20
10
0
Patient recored data (%)
Phychosocial
Phychosocial
Phychosocial
Sleep
Sleep
Sleep
Communication
Communication
Communication
Cognition Cognition
Cognition
40 50 60 70 0102030
Interview data (%)
40 50 60 70
0102030
Interview data (%)
40 50 60 70
ab
c
Figure 3. Health problem reporting across time with VIPS key word prevalence based on patient interviews in relation to those based on record
scrutiny at 1 week after discharge (a), and 3 (b) and 12 months (c) after index admission. Misc =Miscellaneous.
Health problems during the rst post-stroke year 325
staff but not documented, and one-third was known
only by the patients (27). Others have found that
patients identify severe problems that are unknown
to the nursing staff (2729), and that there is inade-
quate staff ability to identify unmet needs (30). In this
study the view of both parties was taken into account.
These discrepancies in reporting may be attributable
to different views of health problems. For instance,
Pain,Elimination, and Breathing or circulation
problems may be effectively handled by health care
staff, and they may not be very annoying to the
patient. On the other hand, Perceptiveand
Cognitiveproblems are not easily communicated,
and unvoiced problems will not be addressed (31).
Neither the patient nor the health care professionals
may have the words or the tools to handle these
problems, and the professionals may not ask about
problems for which they do not have a solution.
Furthermore, vague symptoms such as tiredness,
sleep problems, low mood, and forgetfulness are often
considered by patients (32) and health care staff to be
normal in old age.
There are three lessons to be learnt from this study.
First, the situation during the rst post-stroke year
may not be as bad as previously thought. The cumu-
lative reporting method, usually used in studies sim-
ilar to the present one, appears to indicate that the
level of health problems is high. The alternative
method used in this study, a continuous time series
of health problems as reported in patient records,
provides a more straightforward estimate of health
problem prevalence. In this comparative study the
cumulative method indicated health problems in
more than 90% of the study population versus 8%
or less using the continuous time series method.
It should be pointed out that the results given
in Table III are cumulative period prevalence data
covering a fairly long time period, whereas the results
in Figure 2 are week prevalence based on a week-by-
week matrix. The reason for the difference at the time
of the rst interview, 43% versus 8%, is the wide range
of days in hospital, the rst interview being held 5
185 days after the index hospital admission; with the
serial method this time difference could be controlled
for, but not with the cumulative method. The cumu-
lative method probably overestimates the health prob-
lem level, whereas the continuous serial method may
underestimate it.
The second lesson is that the health care organiza-
tion may be efcient and effective when dealing with
concrete hands-onproblems, but may lack the cor-
responding skill in identifying more subtle problems,
such as cognitive or communication problems. Such
problems cannot easily be treated or affected, but
should nonetheless be identied.
The third lesson concerns co-occurrence of health
problems. In this study we found frequent co-
occurrence between Cognition,Activity,Sleep,
Pain,Perception», Psycho-social,Breathing and
circulation, and Eliminationhealth problems.
Appelros et al. (10) found similar co-occurrence.
Detection of one of these health problems should
lead to consideration of the others. The awareness
of this co-occurrence may help health care profes-
sionals in their assessment of stroke patientshealth
status.
Conclusions
In conclusion, most stroke survivors had some health
problem during the rst year, but only 48% were
reported in records during a given week. The health
problems peaked early after discharge and then
declined. There were differences in prevalence rates
between interview and record data, with the main
discrepancies regarding perception, cognition, and
communication. There was co-occurrence between
some of the health problems, which might be used to
identify unvoiced health problems.
Acknowledgements
This study was supported by grants from the Vårdal
Foundation, Centre for Clinical Research Dalarna,
the Dalarna County Council, and Uppsala University.
None of the funders had any inuence of the content
of this paper.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
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Health problems during the rst post-stroke year 327
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