Health-Related Quality of Life and Loneliness for Ischemic and

Hemorrhagic Stroke Survivors Living in Appalachia

Laurie Theeke PhD, Patricia Horstman MSN, Taura Barr PhD, Stacey Culp PhD, Jennifer Domico RN, Ann Noelle Lucke-

Wold, Laurie Gutman MD

West Virginia University This study was funded by the West Virginia University School of Nursing

Research Fund

Significance• Negative psychological outcomes of stroke are associated with

poorer quality of life and impact stroke recovery (Huang et al., 2010; DeWeerd, L et al. 2011; Hilari, 2010)

• Poor quality of life and functional ability after stroke may be mediated by social support (Huang et al., 2010)

• Nearly half of stroke survivors experience depression and those who experience depression are less likely to regain baseline function (Muus et al., 2010 & Muus et al. 2011)

• Loneliness is a major predictor of depression, functional decline, and mortality in older adults… the most likely population to suffer stroke (Perrisinotto et al, 2012)

• Loneliness is linked to cardiovascular disease and hypertension which are both linked to stroke (Hawkley et al 2006 & Momtaz et al 2012)

Purpose• To characterize QoL and loneliness in a sample of

rural Appalachian stroke survivors within one year of stroke.

• To examine the relationships among the quality of life domains and loneliness

• To compare quality of life and loneliness based on stroke type, hemorrhagic versus ischemic

• To evaluate the predictive value of loneliness on QoL in this population

Design & Methods• Descriptive, cross-sectional design

• Using purposive sampling, surveys were mailed to 590 stroke survivors (pre-marked with ICD-9 stroke diagnosis codes) who had been discharged from 2 different hospitals ; an academic hospital and a teaching hospital

• 121 ischemic and hemorrhagic stroke survivors living in West Virginia completed the surveys which gathered data on: -sociodemographics and co-morbidities-health behaviors (current smoking and ETOH behavior)-type of rehabilitation after stroke-quality of life (using 13 subscales from the Neuro-QOL survey)

• loneliness (using the 3-item UCLA Loneliness Scale). Purposive sampling

through mailed self-administered surveys that were pre-marked with ICD-9 stroke diagnosis codes

Results: Sample Description• N = 121, Mean age 67.18 (SD 13.77)• 89 (74%) Ischemic Stroke survivors • 32 (26%) Hemorrhagic stroke survivors• 58% Female• 51% Married, 22% Widowed, 20% Sep/Divorced• 92% High School Educated or Higher• 67% Living with one or more adults, 27% Lived alone• 70% Retired• 99(82%) Current Non-smokers, 96 (79%) report no

ETOH use

Results: Co-morbidities Based on Stroke TypeCo-morbidity Ischemic

N (%)Hemorrhagic N(%) X2 p

Hypertension No 12 (14.1) 4 (13.6) .002 .965

Yes 73 (85.9) 25 (86.2)

Cancer No 65 (82.3) 25 (83.3) .017 .897

Yes 14 (17.7) 5 (16.7)

Lung Disease No 66 (84.6) 25 (86.2) .042 .837

Yes 12 (15.4) 4(13.8)

Heart Disease No 36 (42.4) 16 (55.2) 1.432 .231

Yes 49 (57.6) 13 (44.8)

Emotional No 63 (81.8) 17 (56.7) 7.239 .007*

Yes 14 (18.2) 13 (43.3)

Arthritis No 31 (38.3) 15 (48.4) -.948 .330

Yes 50 (61.7) 16 (51.6)

Variable Ischemic Hemorrhagic SignificanceMean SD Mean SD t p

Ability to Participate in Social Roles and Activities 31.00 8.54 27.35 9.44 2.00 .047 *

Anxiety 18.45 7.90 22.69 7.64 2.62 .010 **

Applied Cognition – Executive Function 31.29 9.31 27.72 8.33 7.91 .059

Applied Cognition – General Concerns 28.39 8.72 22.96 10.61 2.85 .005 **

Depression 15.86 7.94 17.90 7.72 1.25 .212Emotional and Behavioral Dyscontrol 17.62 7.56 18.71 7.78 0.69 .488Fatigue 21.10 8.13 23.68 8.16 1.54 .127Lower Extremity Function (Mobility 32.02 8.44 32.22 7.89 0.12 .906Positive Affect and Well-Being 33.34 8.39 33.38 8.46 .024 .981Satisfaction with Social Roles and Activities 27.61 8.78 25.99 10.01 .861 .391

Sleep Disturbance 17.64 6.05 20.31 7.26 2.03 .045 *Stigma 12.07 5.74 13.29 6.97 .972 .333Upper Extremity Function (Fine Motor, ADL) 35.54 7.64 35.64 7.18 .067 .947

UCLA Loneliness Scale (3-Item) 4.67 1.88 4.96 2.09 .717 .475

Mean Comparisons of QoL and Loneliness based on Stroke Type

Loneliness Scores Based on Rehab Type after Hospital Discharge

Other Important Findings-Participants who were discharged to home reported a

better QoL when compared to those who were discharged to a nursing home.

-Stroke survivors who continued to smoke were less satisfied with social roles and activities and reported higher mean depression scores.

-A history of emotional, nervous or psychiatric problems negatively correlated with all QoL domains and loneliness scores.

-Loneliness predicted poorer QoL on all domains, even when controlling for age, gender, and significant co morbidities.

Conclusions• Interventions that target loneliness in stroke

survivors could potentially:-diminish psychological sequelae including depression-enhance quality of life-influence ability to regain baseline function-potentially impact mortality given the most recent link between loneliness and mortality in older adults.

Future Research• Intervention study aimed at diminishing

Loneliness in a sample of stroke survivors

• Examine relationships between loneliness and physiological measures of immunity and inflammation in persons with cardiovascular disease

Limitations

• Cross-sectional design eliminates establishing causal relationships

• Homogenous vulnerable sample• Convenience sampling• Self-report of psychosocial variables