The Predictive Role of Cognitive Impairment on Discharge Destination, Post Discharge Fall Incidence and Carer Stress Level of Stroke Patients in Rehabilitation Stroke Unit of Tuen Mun Hospital.

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Authors (including presenting author) :
Chao MC(1), Lam CM(1), Cheung TY(1)
Affiliation :
(1)Department of Occupational Therapy, Tuen Mun Hospital
Introduction :
Stroke is a major cause of disability in Hong Kong and incurs a high cost to stroke survivors, their carers and society (Woo et al., 2014). Over the years, post stroke quality of care remains a crucial topic among different stakeholders, while increasing attention has been drawn to the role of post stroke cognitive impairment on post stroke quality of life (Bushnell et al., 2018).
Objectives :
To investigate the predictive role of cognitive impairment on discharge destination, post discharge fall incidence and carer stress level of stroke patients in Tuen Mun Hospital. Also, to examine the difference in domain-specific cognitive functioning among stroke patients with respect to different discharge destinations.
Methodology :
•A prospective correlational study which retrieved clinical information of stroke patients referred to Rehabilitation Stroke Unit of Tuen Mun Hospital with a post discharge 1 month telephone follow-up. •Inclusion criteria: (1) First-ever stroke based on medical record (2) Aged 18 or above (3) Able to complete Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) (4) Signed consent form. •Subjects would be divided into two groups according to their discharge destinations, including group 1: ‘Home and ADL independent’ (patients returning to home and independent in ADL without need of carer support); group 2: ‘Home with carer attendance’ (return home with carer support) or ‘Institution’ (old age home, nursing home, care & attention home, hostel or infirmary) in which patients in group 2 require more assistance in ADL. •Correlation between cognitive measures of HK-MoCA, functional measures including Modified Barthel Index (MBI) and Hong Kong version of Functional Test for the Hemiplegic Upper Extremity (FTHUE-HK), discharge destinations, post discharge fall incidence, carer stress level and other variables were studied. •Normality was checked and subsequently Mann–Whitney U tests, sequential Spearman’s rho and multivariate logistic regression analysis were used for statistical analysis.
Result & Outcome :
•A total of 310 stroke patients were studied (Male=186; Female=124) from March 2018 to December 2018. •92 subjects were identified in group 1 (independent discharge destination group) and 218 subjects were identified in group 2 (dependent discharge destination group). •Patients with dependent discharge destination had significantly poorer hemiplegic upper limb functions as measured by FTHUE-HK (Z= -4.59, p< 0.001), required more assistance in ADL as measured by MBI (Z= -13.68, p< 0.001), had lower HK-MoCA scores (Z= -9.65, p< 0.001) and poorer performance in all HK-MoCA subdomains: visuospatial/executive (Z= -4.90, p< 0.001), naming (Z= -5.73, p< 0.001), attention (Z= -8.16, p< 0.001), language (Z= -7.23, p< 0.001), abstraction (Z= -5.44, p< 0.001), delayed recall (Z= -6.60, p< 0.001) and orientation (Z= -8.35, p< 0.001) as measured by HK-MoCA, required more carer assistance in ADL (Z=-16.12, p< 0.001), had higher fall incidence rate (Z= -3.44, p=0.001) and higher carer stress level (Z= -12.34, p< 0.001) post discharge. •Meanwhile, based on the results from different models of logistic regression analysis, HK-MoCA score is also consistently identified as one of the significant predictors to discharge destinations (B=0.12, p< 0.001), post discharge fall incidence (B= -0.11, p< 0.001) and carer stress level (B= -0.42, p< 0.001). Conclusion: Cognitive impairment as measured by HK-MoCA shows significant predictive role in stroke patients’ discharge destination, post discharge need of carer assistance in ADL, fall incidence and carer stress level as revealed by this study. While falls among stroke survivors could bring catastrophic consequences which further heighten carer’s distress, findings of this study are hoped to serve as reference for Occupational Therapists in Hong Kong to redirect their emphasis on cognitive rehabilitation, fall prevention and carer education along stroke survivors’ disease journey.

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