Abstract
[Purpose] To identify factors that affect the return to solitary living of patients with stroke who had lived alone prior to stroke onset. [Participants and Methods] From January 2017 to March 2020, we enrolled a total of 103 patients with stroke who had lived alone prior to stroke onset and retrospectively analyzed their age, gender, length of hospital stay, outcome (return to living alone or not), functional independence measure at discharge, and social score at discharge. We also analyzed the relationship between the above factors and the outcome. [Results] Functional independence measure and social score at discharge were significantly associated with the outcome. The cutoff value of the functional independence measure at discharge was 91 (area under the curve: 0.91; sensitivity: 0.96; specificity: 0.72), while the rate of return to living alone was 23.5% when the social score was ≥3. The sensitivity and specificity for return to living alone were 0.91 and 0.88, respectively, when cutoff values of the functional independence measure and social score at discharge were 91 and 3, respectively. [Conclusion] Social factors and ability to perform activities of daily living are important for return to solitary living for patients with stroke who lived alone prior to stroke onset.
Keywords: Stroke, Living alone, Return home
INTRODUCTION
During discharge of stroke patients, in addition to the patients’ abilities to perform activities of daily living (ADL), a wide variety of factors, such as age, gender, family structure, area of residence, and social resources are considered1). Of these factors, many studies have pointed out the importance of number of family members living together1,2,3,4,5). In Japan, however, the number of single-person households is increasing every year; 28.8% of all households were living alone in 20216). This trend is steadily spreading around the world7, 8). Compared to cases in which the family members live together, these single-person households often do not receive adequate support and patients are less likely to return home1, 9,10,11). Therefore, it is necessary for stroke patients living alone to be more independent in performing their personal tasks and a need for higher abilities of ADL than stroke patients living with their family members2, 12, 13).
In addition, single-person households are often estranged from their relatives, have no support person nearby, and may have financial problems such as receiving public assistance14, 15). In such cases, it is often difficult to establish a support system16, 17), which may lead to a lower return home rate, increased medical costs due to prolonged hospitalization, and a lower quality of life of the patient18,19,20).
Living alone may increase incidence of lifestyle-related diseases as well as incidence and severity of stroke21,22,23,24). Thus, it can be inferred that the number of stroke patients living alone are likely to increase as the number of single-person households increase, and a system to support stroke patients living alone will be a necessity in the future. To provide appropriate support, it is necessary to clarify the criteria under which a patient can return home to live alone. Although there have been previous reports on ADL ability2, 12, 13), no study has comprehensively investigated the social factors, including those mentioned above. Therefore, the purpose of this study is to clarify the criteria, including the social factors in addition to ADL ability required for returning to live alone.
PARTICIPANTS AND METHODS
This was a retrospective cohort study performed at the Kizawa Memorial Hospital in Gifu, Japan. An opt-out procedure was established for data collection so that the participants could withdraw from the study at any time. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Kizawa Memorial Hospital (2020-025).
Patients with stroke who were admitted to the neurosurgical ward of Kizawa Memorial Hospital between January 2017 and March 2020 and living alone before stroke onset were included in the study. Exclusion criteria included traumatic brain injury, progressive brain disease, infratentorial disease, death, and patients who were transferred to other departments due to severe complications.
The medical records of included patients were reviewed for age, gender, discharge destination, length of hospital stay, and functional independence measure (FIM) at discharge. Regarding the discharge destination, return home was defined as patients who returned home to living alone and who had lived alone before stroke onset. No-return home was defined as patients who could not return home due to discharge to a facility such as nursing homes for the elderly or transfer to a hospital, or who lived with other family members.
The social score was also calculated from the conference records and medical social worker records. The content of the social score was based on the study by Sawamura et al.17) who reported the disincentives to returning home in stroke patients who were living alone before stroke onset. Specifically, the social score was calculated based on the number of items that fell into the following five categories: (1) absence of a key person, (2) absence of a neighborhood support person, (3) financial problems, (4) receipt of public assistance, and (5) difficulty in coordinating long-term care insurance services at the time of discharge. The “absence of a key person” referred to cases that had no person registered as the key person on the hospitalization application form. The “absence of a nearby supporter” referred to cases where the key person on the admission application form did not live in the same city or same neighborhood. “Financial problems” referred to cases where the hospitalization fees were in arrears or financial problems were mentioned in the record of conferences. “Receipt of public assistance” referred to patients who were eligible for public assistance at the time of discharge from the hospital. “Difficulty in coordinating long-term care insurance services at the time of discharge” referred to cases where the patient’s home was located in a mountainous area and long-term care services such as daycare services were not available, or the patient’s home was a rented apartment that could not be renovated. The higher the social score, the poorer the social environment surrounding the patient.
A logistic regression model was used to calculate the adjusted odds ratio (OR) with 95% confidence intervals (CI) for the discharge destination (return home or non-return home) associated with FIM at discharge or the social score. We used multivariable logistic regression to control for confounding roles of age, length of hospital stay, and gender.
For FIM at discharge, receiver operating characteristic (ROC) curves were drawn, and cutoff values were calculated using the Yoden index. For the social score, rate of return to living alone was calculated for each score. Sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) of the combined index containing FIM’s cutoff value and social score were also calculated. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan)25). A value of p<0.05 was considered statistically significant.
RESULTS
A total of 103 patients were included in the study (Fig. 1); 50 patients were “return home living alone” and 53 patients were “no-return home”, with an overall return home rate of 48.5%. Patients’ age, gender, length of stay, FIM at discharge, and social scores are shown in Table 1.
Fig. 1.
Flow chart of the inclusion process.
Table 1. Patient characteristics.
| All patients (n=103) | Return home patients (n=50) | No-return home patients (n=53) | |
| Age (years) | 71.1 ± 14.3 | 67.2 ± 13.8 | 74.7 ± 14.1 |
| Length of hospital stay (days) | 62.8 ± 55.6 | 81.9 ± 54.8 | 42.5 ± 49.9 |
| Gender (female/male) | 42/61 | 15/35 | 27/26 |
| FIM at discharge | 90.7 ± 31.0 | 80.5 ± 10.7 | 49.1 ± 23.1 |
| Social score | 1.0 (0.0–2.0) | 0.0 (0.0–4.0) | 1.0 (0.0–0.4) |
Data are shown as mean ± standard deviation and median (25th percentile–75th percentile).
FIM: functional independence measure.
The results of the logistic regression analysis for the discharge destination are shown in Table 2. The FIM at discharge (adjusted OR=1.11, 95% CI=1.06–1.16; p<0.01) and social score (adjusted OR=0.33, CI=0.16–0.68, p<0.01) were significantly related to the discharge destination.
Table 2. Results of logistic regression analysis for the discharge destination.
| Adjusted OR | 95% CI | |
| Age (years) | 0.98 | 0.94–1.03 |
| Length of hospital stay (days) | 1.00 | 0.99–1.01 |
| Gender (female/male) | 0.35 | 0.08–1.43 |
| FIM at discharge** | 1.11 | 1.06–1.16 |
| Social score** | 0.33 | 0.16–0.68 |
OR: odds ratio; CI: confidence interval; FIM: functional independence measure.
*p<0.05, **p<0.01.
The ROC curve for FIM at discharge based on the Youden index had an area under the curve (AUC) of 0.913 (CI=0.858–0.967). The cutoff value obtained from this ROC curve was 91, with a sensitivity of 0.960, specificity of 0.717, PPV of 0.950, and NPV of 0.762.
Social scores and return home rates are shown in Table 3. Social scores ranged from 0 to 4, with no patient scoring 5. The return-to-home rates for patients with a social score of 0, 1, 2, 3, and 4 were 68.4, 35.5, 36.0, 23.0, and 25.0%, respectively.
Table 3. Social scores and the rate of return home to living alone.
| Social score | Return home (n=50) | No-return home (n=53) | Return home rate (%) |
| 0 | 26 | 12 | 68.4 |
| 1 | 11 | 20 | 35.5 |
| 2 | 9 | 16 | 36.0 |
| 3 | 3 | 10 | 23.1 |
| 4 | 1 | 3 | 25.0 |
| 5 | 0 | 0 | - |
Return home ratio: Number of return home patients/Number of patients with the same social score.
The sensitivity, specificity, PPV, and NPV for the cutoff value of 91 for FIM at discharge combined with the social score are shown in Table 4. In cases where the social score cutoff value was “1”, the patient was predicted to be able to return home if the social score was 0 and the FIM was ≥91. Conversely, a patient was predicted to have difficulty in returning home when the social score was greater than 1 or the FIM at discharge was ≤90. Table 4 shows the sensitivity, specificity, PPV, and NPV when the cutoff value of FIM at discharge was fixed at 91 points, while the cutoff value of social score was varied.
Table 4. Combined index of FIM at discharge and social score.
| Cutoff value of social score | Sensitivity | Specificity | PPV | NPV |
| 1 | 1.00 | 0.48 | 0.67 | 1.00 |
| 2 | 0.89 | 0.70 | 0.76 | 0.85 |
| 3 | 0.91 | 0.88 | 0.89 | 0.89 |
| 4 | 0.76 | 0.94 | 0.93 | 0.783 |
Sensitivity, specificity, PPV, and NPV were obtained by combining the cutoff value of FIM at discharge and social scores.
FIM: functional independence measure; PPV: positive predictive value; NPV: negative predictive value.
DISCUSSION
To the best of our knowledge, this is the first study to report on return home criteria for stroke patients who were living alone before their illness, including ADL ability and social factors. Our study results revealed that in addition to the ADL ability, social factors such as the absence of a key person or support person, financial problems, receipt of public assistance, and difficulty in coordinating long-term care insurance services affected the return home of stroke patients who had been living alone before stroke onset. The cutoff value for ADL related to return home was an FIM of 91 at discharge, and the addition of social factors to this criterion was shown to improve the accuracy of prediction.
Many previous studies have used the FIM when evaluating the ADL ability to predict discharge destination of stroke patients; similarly, we employed the FIM as a measure of ADL ability in this study1, 10, 12, 26,27,28). In this study, the cutoff value of the FIM at discharge to return home for stroke patients who were living alone before stroke onset was 91. Miura et al.12) reported a total FIM cutoff value of 104 to return home for stroke patients who lived alone before stroke onset, and Sato et al.2) reported that the cutoff value for returning home for stroke patients without a caregiver was 101. The cutoff value in the present study was 91 points, which was a slightly lower cutoff value than those reported in previous studies. However, AUC for the usefulness of the examination was 0.913, indicating good predictive accuracy for the patients in this study. There are few reports on the return home of stroke patients who live alone, making a simple comparison of cutoff values difficult. This might be due to the differences in the size of the municipality of the area where the hospital was located or in the social resources such as the day care services.
Although the specificity was as high as 0.96 at this cutoff value, the sensitivity was 0.72, which was lower than the specificity. In other words, it can be interpreted that patients with a low ADL ability could not return to live alone, but there were patients who could not return to live alone even if they had a high ADL ability. This suggests that other factors that cannot be predicted by the ADL ability alone may be involved in the return home of patients to living alone after stroke.
Recently, it has been reported that not only ADL ability but also social factors such as family structure1,2,3,4,5, 29), economic issues30,31,32), and coordination of social resources such as long-term care insurance services and the community33,34,35) are involved in the return home of stroke patients. Sawamura et al.17) found that the following factors inhibited the return to living alone of stroke patients who had lived alone before the illness: patient’s abilities such as higher brain dysfunction, motor paralysis, and ADL ability; human resources such as family and supporters; financial problems; adjustment of long-term care insurance; difference between the patient’s wishes and reality. Based on this report, we defined social score using five items: (1) absence of a key person, (2) absence of a neighborhood supporter, (3) financial problems, (4) receipt of public assistance, and (5) difficulty in coordinating long-term care insurance services upon discharge. In other words, the higher the social score, the more the likelihood of the patient having problems in his/her social background. Since these factors were not independent of each other, and to some extent were assumed to have the possibility of occurring in a chain, the corresponding items were added together to form the social score in this study.
There are several previous studies supporting the components of this social score. With regard to human resources, Ottiger et al.13) reported the circumstances in which stroke patients with low ADL ability can return home to live alone if they receive appropriate support from family members and supporters. Other studies have claimed that the number of family members is an important condition for stroke patients to return to living alone2,3,4,5, 29). Regarding economic issues such as financial problems and public assistance, poor living conditions and the possibility of limited public social support due to poverty14, 15) can easily predict the difficulty of returning to solitary living. In addition, it has been reported that economic problems are not merely a matter of deprivation, but also increase the incidence of lifestyle-related diseases36) as well as the incidence and severity of stroke24). Thus, it is possible that these problems may indirectly reduce the ADL abilities of stroke patients and inhibit their return to solitary living. Indeed, some studies have demonstrated that financial problems influence the discharge destination30,31,32). Others have reported that the appropriate use of social resources such as long-term care insurance and the community is important for enabling stroke patients to return to living alone37). In fact, studies by Morita et al.38) and Asakawa et al.3) have also highlighted the importance of understanding the patient’s living environment before discharge and planning appropriate support. Thus, in addition to the report by Sawamura et al.17), many other studies have revealed social problems of stroke patients that are similar to the social score established in this study. Therefore, the social score in this study was considered to have some validity.
The results of this study show that higher the social score, lower the rate of return to living alone, suggesting that social problems of stroke patients affect rate of return to living alone.
Logistic regression analysis with discharge destination as the objective variable revealed significant influence of social score in addition to the FIM at discharge. Therefore, we hypothesized that combining the social score with FIM at discharge would potentially be more accurate in predicting the likelihood of returning home to live alone. Accordingly, we fixed the cutoff value of FIM at 91 points and calculated the sensitivity, specificity, PPV, and NPV for each cutoff value of the social score. Thus, when the cutoff value of social score was set to 3 (i.e., 3 or more points were considered at risk), the sensitivity and specificity were 0.91 and 0.88, respectively, showing a significant improvement in the sensitivity compared to the FIM evaluation alone. Compared with the sensitivity and specificity reported in previous studies2, 12) that investigated return to solitary living, the results of this study appear to be as accurate or more accurate.
The possibility of return to solitary living is of great significance for patients’ quality of life20); consequently, higher sensitivity and specificity in predicting its prognosis are desirable. Therefore, the clinical utility of our model, which comprehensively assessed social factors and ADL abilities of stroke patients, was considered to be high. In addition, this social score can be evaluated predictively to some extent from the early stage of hospitalization. According to previous studies, by predicting the cutoff value of the FIM, it is possible to predict whether a patient can return to a solitary life at a relatively early stage, such as the acute or subacute stage of hospitalization. It is essential for patients to have extensive social support and a good living environment to live alone, and stroke guidelines recommend providing information on available welfare resources from the early stage of stroke. In other words, it is highly beneficial to predict the prognosis of such patients at an early stage of hospitalization.
This study has some limitations. The first is that this was a single-center, retrospective cohort study, and the external validity of the study results may not have been sufficient, given the differences in FIM cutoff values among other reports. Therefore, future multicenter studies with larger cohorts, including urban and underpopulated areas, should be conducted. Second, with regard to the evaluation of the social score, items such as the presence or absence of financial problems and “difficulty in coordinating long-term care insurance services at the time of discharge” may be influenced by the subjectivity of the evaluator, and more objective indicators concerning the annual income and savings of the patients and population ratio of social resources in the community need to be established.
Third, this study did not specifically address the improvements in physical function or modifications in social environment that might have occurred during hospitalization. Therefore, a more comprehensive, longitudinal study that incorporates such changes remains warranted. Fourth, this study did not consider patients’ preferences for discharge destinations. For example, it is possible that patients may not wish to return to solitary residences even if they have high ADL capacity. Therefore, future studies should also include “the patient’s own wishes” in their study design. Finally, since the goal of this study was the return to solitary confinement itself, data on “How long was the patient actually able to live at home?” and the level of satisfaction are unknown. In future studies, follow-up after discharge from hospitals and evaluation of quality of life will be important.
In this study, we investigated the impact of social factors as well as ADL ability on the return to living alone of stroke patients who had been living alone before stroke. The results revealed that social factors such as a key person, support person, and financial problems were involved in the return to living alone of stroke patients who had been living alone before their illness, in addition to ADL ability. Specifically, the cutoff value for ADL was an FIM of 91 or higher at discharge, and combining this with a cutoff value of 3 for the social score improved the accuracy of prediction. This study provides important information for the appropriate support of stroke patients living alone, which is expected to become increasingly common in the future.
Conflicts of interest
The authors declare that there are no conflicts of interest.
Acknowledgments
The authors thank all participants in this study. We would like to thank Editage (http://www.editage.com) for English language editing.
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