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Predictors of dependency in post-discharge activities of daily living among stroke in-patients managed in a comprehensive stroke unit

Background. Stroke remains a leading cause of disability, but high­quality medical care may contribute to better outcomes. The aim of the study was to identify predictors of dependency in stroke patients discharged from a comprehensive stroke unit. Materials and methods. Patients with a cerebral stroke consecutively admitted in 2010–2018 to our stroke center, general hospital­based and operating as a comprehensive stroke unit, were included in the study. All patients were thoroughly examined and received appropriate evidence­based treatment; both upon admission and before discharge they were assessed using common stroke scales. Patients’ data were prospectively entered in a special register. If the Barthel index at discharge was ≥ 85, the treatment goal was considered achieved, if Barthel index was ≤ 80 — not achieved. In order to assess the influence of 40 variables on the risk for dependency, the method of constructing and analyzing logistic regression models was used. Results. Six hundred and seventy­seven patients aged 20 to 95 years (median 65.9 years), of them 271 (40.4 %) women, were enrolled. 80.8 % of participants had ischemic stroke, and 19.2 % — hemorrhagic stroke. The median baseline National Institutes of Health Stroke Scale score was 10. The time of admission to the stroke center ranged from < 24 hours (17.5 % of patients) to over 180 days (17.2 % of patients), and 59.7 % of the participants were hospitalized within first 30 days from the stroke onset. According to the univariate analysis, 27 characteristics had a statistically significant correlation with the risk of treatment failure, including the type and subtype of stroke, age, atrial fibrillation, recurrent stroke, severe neurological deficits, cognitive impairment and significant functional limitations upon admission, certain neurological impairments, such as decreased level of consciousness, dysphagia, hemianopia, hemiparesis and elevated blood inflammation markers (C­reactive protein, erythrocyte sedimentation rate). In multivariate analysis, age (odds ratio (OR) 1.06; 95% confidence interval (CI) 1.03–1.10 on average per additional year, p < 0.001), recurrent stroke (OR 2.8; 95% CI 1.3–6.2, p = 0.01), initial Barthel index (OR 0.97; 95% CI 0.95–0.98 on average per each point decrease; p < 0.001), modified Rankin scale score (OR 1.7; 95% CI 1.0–2.8 on average per each point increase; p = 0.05) and Rivermead mobility index (OR 0.87; 95% CI 0.76–0.99, p = 0.05) as well as baseline arm scores in the National Institutes of Health Stroke Scale items (OR 1.5; 95% CI 1.1–1.9 on average per each additional point, p = 0.003) and late admission to the stroke center (OR 9.6 %; 95% CI 3.1–29.4, p < 0.001, if over 180 days from stroke onset) showed strong and independent association with risk of dependency after discharge. The area under the operational curve 0.95 (95% CI 0.93–0.97) indicates an excellent consistency of the prognostic model. Conclusions. Patient’s age, severity of the initial impairments and the period of the disease had the greatest impact on risk for remaining dependant after discharge from the comprehensive stroke unit. Identifying independent predictors of functional outcome can help to improve prognostication and optimize decision­making on treatment strategy.