Factors predict the stroke specific quality of life in post stroke aphasia patients in Pakistan

Abstract

Background: Understanding the factors that predict stroke-specific QoL in post-stroke aphasia patients in Pakistan is crucial for developing targeted interventions and improving the rehabilitation process.
Objective: To determine the factors that predicted the stroke-specific quality of life in post-stroke aphasia patients in Pakistan. 
Methodology: This cross-sectional analytical study was conducted over 18 months from June 2021 to December 2022 at RHS Rehabilitation Centre Islamabad Pakistan. A total of n=134 independent participants with fluent and non-fluent aphasia at least six months post-stroke, and able to follow one-step commands were included in the study through a non-probability convenient sampling technique. The stroke-specific quality of life (SS-QoL) scale was used to assess the quality of life in the participants, while the list of predictors was developed from the literature. SPSS version 21 was used for statistical analysis.

Result: A multiple regression was run to predict the quality of life from marital status, gender, family status, patient's socioeconomic status, types of strokes, types of aphasia, and comorbidities. These variables statistically significantly predicted quality of life {F(13,120)=10.366, p<0.001}. All variables cause 47.8% (Adj. R²=0.478) variance in stroke-specific quality of life in aphasia patients.

Conclusion: The male gender, married marital status, middle and upper socioeconomic status, ischemic stroke compared to hemorrhagic stroke, fluent aphasia, and cardiac disease compared to other comorbidities positively affect the quality of life in post-stroke aphasia patients. However, age and the family system did not show any impact on the quality of life.

INTRODUCTION

Stroke is the most well-known reason for handicaps and a main source of mortality around the world [1].In Pakistan, the load of stroke and complications are huge [2]. One of the common complications related to stroke is aphasia which is the loss of language due to damage in the left lobe of the brain; the changes that are also observed are emotional and psychosocial and Speech impairment or weakness of one side of the body can happen [3]. In addition, aphasia is suggested to a vast forecaster of a bad quality of life after a stroke [4].

Aphasia is present in 21–38% of acute stroke patients and is associated with high short- and long-term morbidity, mortality, and expenditure[5]. Recovery from aphasia is possible even in severe cases. While speech-language therapy remains the mainstay treatment of aphasia[6]. A valid prognosis of aphasia could be made within 1 to 4 weeks after the stroke depending on the initial severity of aphasia. Initial severity of aphasia was the only clinically relevant predictor of aphasia outcome. Sex, handedness, and side of stroke lesion were not independent outcome predictors, and the influence of age was minimal[7].

Quality of life (QoL) remains an important post-stroke outcome and a crucial challenge for medical care. Special attention should be paid to QoL in post-stroke patients with aphasia because it is a common post-stroke disorder with high prevalence [8, 9]. In recent studies, the severity of aphasia seemed strongly correlated with QoL, even more so than cancer or Alzheimer's disease perhaps because our modern society relies on fast and efficient communication in the oral and written modalities[10, 11]. Therefore, identifying and managing specific factors such as impaired language and communication after stroke is essential to improve patients’ QoL[4].

Quality of life is affected in Aphasia after stroke which includes the following socio-economic factors age, gender, level of education, marital status, occupation, and monthly income [12]. The clinical factors that had significant associations with Quality of life after stroke Aphasia were; level of dependence and disability, type of stroke, side of the lesion, type of aphasia, and level of language impairment[13]. Social isolation, emotional distress, and most of the co-morbidities (hypertension, depression, diabetes, and cardiac disease) affect the quality of life after stroke aphasia [12, 14].

Prior studies have investigated the variables that affect the quality of life after a stroke in patients with aphasia from different populations. To the best of the authors' knowledge, no research has been done on the population of Pakistan. Given that bio-psychosocial variables, including aphasia type, age, and kind of stroke, are important determinants of quality of life unique to post-stroke aphasia patients. Investigating their relationship with this outcome in the Pakistani population is vital, therefore. Thus, the objective of this study was to determine the variables influencing stroke-specific quality of life among Pakistani patients with post-stroke aphasia in Pakistan.

METHODOLOGY

Study design: This was a cross-sectional analytical study conducted in the RHS Rehabilitation Centre (No: RHS/EC/08-12-2021-04), Islamabad from January 2021 and December 2022. This study was approved by the Research and Ethical Committee (REC) Health Education Research Foundation (HERF) (HERF/Research/REC/No-2021-012). And was carried out according to the principles stated in the Declaration of Helsinki. Written informed consent was obtained from participants as well as from the caregivers to participate in the study. 

Participants: The independent participants with fluent and non-fluent aphasia at least six months post-stroke, and able to follow one-step commands were included in the study. The stroke patients diagnosed with Global aphasia, having cognitive impairment, and/or unable to communicate were excluded from this study. A non-probability convenience sampling technique was used for sample collection.

Outcome measures: To predict the quality of life of post-stroke aphasia patients the following factors age, gender, marital status, family status, socioeconomic status, type of stroke, type of aphasia, and comorbidities were included after a thorough review of literature and discussion with clinical experts. Based on the WHO disability assessment scale, the SS-QOLS is a measure for assessing the quality of life of stroke patients. The scale consists of 12 categories with between three and six items each, a total of 49 questions. A minimum score of 1 (total help needed) and a maximum score of 5 (no help needed) are assigned to each question on a 5-point Likert scale. Both verbal and nonverbal techniques are used to obtain the data using a questionnaire. Values vary from 49 to 245; higher values indicate a greater quality of life, while lower levels indicate a worse quality of life[15]. Although the participants were able to communicate through writing to avoid recall bias the presence of a caregiver was ensured for the accuracy of data collection. 

Sample size: A total of n=136 sample size was calculated through G power, keeping effect size medium (0.15), α error margin at 0.05. To avoid β error probability, the power (1- β) was set at 0.90% and the total number of predictors was 8.   A total of n=298 stroke patients were evaluated for the inclusion criteria and n=134 subjects fulfilled the inclusion criteria. 

Statistical methods: The data was presented in the table and graphs as mean±Sd and n(%). The multiple linear regression test was applied to predict the quality of life after a specific stroke aphasia. The dummy variables were created of categorical variables including gender, marital status, family status, socioeconomic status, type of stroke, type of aphasia, and comorbidities, while the age was in continuous variable. The SPSS version 28 was used for data analysis.

RESULTS

The mean age of the n=134 study participants was 64.87±7.90 years. A total of n=66 (49.3%) was male and the remaining n=68 (50.7%) were females. The mean score of stroke-specific quality of life (SS-QoL) showed that the mean score of the participants was 50.60±16.93. The frequency distribution can be seen in Figure 1. 

Figure 1: Frequency distribution of SS-QoL

A multiple regression model was run to predict the quality of life from age, marital status, gender, family status, patient's socioeconomic status, types of strokes, types of aphasia, and comorbidities. This model significantly predicted quality of life {F (13,120) =10.366, p<0.001}. All variables cause 47.8% (Adj. R2=.478) variance in stroke-specific quality of life in aphasia patients.

Table1. Quality of life predictors among post Stroke aphasia patients

Individually, post-stroke aphasia patients' quality of life (QoL) was not significantly impacted by age or family system (p<0.05). However, compared to married people, stroke patients with aphasia were shown to have a significantly worse Qol if they were single (p=0.043), although widowhood or widowerhood (p<0.05) were not significant predictors. In terms of gender, male participants significantly predicted higher Qol compared to female participants (p=0.022). When compared to participants from lower socioeconomic backgrounds, higher-class participants significantly predicted better Qol (p<0.001), while middle-class participants did not (p=0.103). When compared to those who had hemorrhagic stroke, participants with ischemic stroke significantly predicted improved Qol (p<0.001). Furthermore, compared to fluent aphasia, non-fluent aphasia significantly predicted Qol (p<0.001). While diabetes was not a predictor of Qol (p=0.720) in post-stroke aphasia, participants with heart illness significantly predicted higher Qol (p<0.001) as compared to hypertension. (Table 1)

DISCUSSION

The main objective of the study was to predict the quality of life after stroke aphasia. It was hypothesized that there is a significant effect of age, gender, marital status, family status, socioeconomic status, type of stroke, type of aphasia, and comorbidities on quality of life after stroke aphasia. The result showed that all factors significantly predicted the quality of life in post-stroke aphasia patients, except age and family status.

The current study showed a non-significant impact of age and quality of life in aphasia because most of the participants were severely affected where lot of help was needed to perform their daily tasks. In a previous study, age has not been associated with improved QoL in patients with stroke aphasia[16].  Some studies showed that younger individuals showed greater improvement in communication-related QoL [17, 18]. As Hyejin Lee et al conducted a study on aphasia where they also observed the quality of life with associated factors Age is one of them where they showed that age affects the quality of life on the basis of the severity of aphasia [12].

Marital status is a significant predictor of quality of life in aphasic patients.  The current study showed that a higher score shows an improved quality of life in married than the others who are single, widow, and widower. Because married people are dependent on their spouse, they have their caretakers and are emotionally strong because of their motivational level but the other participants who were single, widows or widowers had decreased quality of as they are already in some way mentally or emotionally targeted. A recent study was conducted in South Korea at the national level where differences in quality of life depending on marital status in men and women were observed. The EQ-VAS scores of men were a more sensitive indicator of the decline in the quality of life that occurred with marriage problems than the decline associated with single status. However, the decline in QOL associated with single status was greater than that associated with marriage problems using the EQ-5D [19]. 

In the current study, the females had decreased quality of life after post-stroke aphasia. The possible reasons are bio-psychosocial differences between males and females regarding illnesses. Generally, females have a lower quality of life than males due to sociocultural problems, challenges by their traditional household activities ignorance of their healthcare needs, and increased depression, stress, and anxiety. These factors further reduce the quality of life with chronic illnesses like stroke [20, 21]. On the other hand, a previous study showed improved quality of life in females rather than males because females are fluent, decreased repetitions, increased information content, and comprehensive speech [22].

Quality of life in aphasia after stroke showed a significant impact on socioeconomic status the current study showed improved quality of life in the upper class while the lower class and middle class showed decreased quality of life because there may be the reason of financial issues, no support, loss of awareness and no treatment facilities are provided. Previous studies in support of the current study that there is a relation between the severity of aphasia the socioeconomic status. When there is high income the quality of life improves while the family with low socioeconomic status have decreased QoL [23, 24].

In a study conducted by Mariana Mendes Bahia et al on quality of life after post-stroke aphasia and differences between fluent and non-fluent aphasia, the result showed a high score in fluent aphasia which shows that better quality of life than the non-fluent aphasia[25]. Non-fluent aphasia may cause difficulty in communication which affects the psychologically due to depression, anxiety, stress social isolation, and dependency on caregivers to communicate and participate in any task that involves effort or energy. These all reasons decrease the quality of life in post-stroke aphasia patients [12]. The current study also showed that there is variation between fluent and non-fluent aphasia regarding the quality of life after post-stroke aphasia.

A current study showed that the type of stroke is a significant predictor of quality of life after post-stroke aphasia; the ischemic stroke has better QoL than the hemorrhagic stroke because decreases the cognitive abilities and increases the severity of aphasia. A study was conducted by Seo KC et al on Post-stroke Aphasia to evaluate the quality of life on Ischemic Versus hemorrhagic stroke which supported the current study[26]. A study reported that aphasia due to hemorrhagic stroke positively impacts the quality of life than ischaemic stroke. The hemorrhage may cause dislocation of the AF fiber bundles due to compression effects of the hematoma, but in ischaemic stroke, these AF fiber bundles completely destroyed[10]. So an ischemic stroke has less effect the speech and comprehension than a haemorrhagic stroke[27].

The current study showed that family status does not have a significant impact on quality of life after stroke aphasia although the joint family system had a higher score in quality of life than the other family system. The literature suggests that in South Asia, the joint family system positively impacts the quality of life in chronic illnesses than the other family systems. Because the joint family system supports them physically, emotionally, mentally, and socially which improves the quality of life[28].

The literature suggests that presence of the comorbidities including hypertension, diabetes mellitus, and cardiac disease can affect the quality of life after stroke[29]. In the current study, it was observed that the presence of comorbidities leads to decreased Qol in patients with aphasia. The result of the current study suggested that post-stroke aphasia patients with hypertension had low QOL as compared to cardiac disease.  Hyperglycemia and cardiac disease i.e. atrial fibrillation reduce the blood supply to the brain which impairs the cerebral auto-regulation and decreases cerebral perfusion, which aggravates the injury to the blood-brain barrier due to ischemia, which may further aggravate the stroke and aphasia[30]. Hypertension may also contribute to reduced cerebral blood flow and perfusion, induce an ischemic effect, and cause shrinkage of the brain, which may triple the risk for cognitive decline and dementia. These factors also affect the aphasia and may reduce the Qol [31].

There are Psychological factors like depression, anxiety, and stress which were not studied, may affect the results of current research. 

CONCLUSION

It is concluded that the male gender, married marital status, middle and upper socioeconomic status, ischemic stroke compared to hemorrhagic stroke, fluent aphasia, and cardiac disease compared to other comorbidities positively affect the quality of life in post-stroke aphasia patients. However, the age and family system did not show any impact on the quality of life. It is recommended that multiple-centered studies, to predict the quality of life with large sample size as well as with more detailed bio-psychosocial factors, must be considered.

DECLARATIONS & STATEMENTS

Author’s Contribution

NIB, STS and RH substantial contributions to the conception and design of the study.

SWS and UH: acquisition of data for the study.

AO and SS: interpretation of data for the study.

STS and RH: analysis of the data for the study.

NIB and RH: drafted the work.

NIB, SWS, UH, AO, SS, STS and RH: revised it critically for important intellectual content.

NIB, SWS, UH, AO, SS, STS and RH: final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.

Ethical Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Research and Ethical Committee of Health Education Research Foundation (HERF/Research/REC/No-2021-012) as well as from the Ethical Committee of RHS Rehabilitation Centre, (No: RHS/EC/08-12-2021-04).

Consent Statement

Written informed consent was obtained from participants as well as from the caregivers to participate in the study.

Data Availability Statement 

The data that support the findings of this study are available on request from the corresponding author. The data is not publicly available due to privacy or ethical restrictions

Acknowledgments 

Thanks to the participants of this study for sharing their personal experiences with pain 

Conflicts of Interest 

The authors declare no conflict of interest.

Funding

This research received no funding. The authors declare that no funds, grants, or other support were received during the conduction of research and preparation of this manuscript.

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