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 (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 Type Co-morbidityIschemic N (%) Hemorrhagic N(%)X2p HypertensionNo12 (14.1)4 (13.6) Yes73 (85.9)25 (86.2) CancerNo65 (82.3)25 (83.3) Yes14 (17.7)5 (16.7) Lung DiseaseNo66 (84.6)25 (86.2) Yes12 (15.4)4(13.8) Heart DiseaseNo36 (42.4)16 (55.2) Yes49 (57.6)13 (44.8) EmotionalNo63 (81.8)17 (56.7) * Yes14 (18.2)13 (43.3) ArthritisNo31 (38.3)15 (48.4) Yes50 (61.7)16 (51.6)

VariableIschemicHemorrhagicSignificance MeanSDMeanSDtp Ability to Participate in Social Roles and Activities * Anxiety ** Applied Cognition – Executive Function Applied Cognition – General Concerns ** Depression Emotional and Behavioral Dyscontrol Fatigue Lower Extremity Function (Mobility Positive Affect and Well-Being Satisfaction with Social Roles and Activities Sleep Disturbance * Stigma Upper Extremity Function (Fine Motor, ADL) UCLA Loneliness Scale (3-Item) 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