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Health-Related Quality of Life in Patients With Poststroke Emotional Incontinence

Published:August 29, 2011DOI:https://doi.org/10.1016/j.apmr.2011.04.016

      Abstract

      Chen Y-K, Wong KS, Mok V, Ungvari GS, Tang WK. Health-related quality of life in patients with poststroke emotional incontinence.

      Objective

      To assess the effect of poststroke emotional incontinence (PSEI) on health-related quality of life (HRQOL).

      Design

      Cross-sectional observational study.

      Setting

      Psychiatric clinic.

      Participants

      Stroke survivors (N=385; consecutive series) discharged from the acute stroke unit between December 2004 and June 2007.

      Interventions

      Not applicable.

      Main Outcome Measures

      Chinese (Hong Kong) version of the 36-Item Short Form Health Survey (SF-36) for HRQOL.

      Results

      Fifty-eight (15.1%) patients had PSEI. After adjustment for possible demographic and clinical confounders, subjects with PSEI had significantly lower physical and mental summary scores, particularly in the General and Mental Health, Social Function, and Role–Emotional subscales of the SF-36.

      Conclusion

      PSEI has an independent effect on HRQOL. Longitudinal studies of stroke are warranted to confirm and extend this finding.

      Key Words

      List of Abbreviations:

      ANCOVA (analysis of covariance), ASU (Acute Stroke Unit), BI (Barthel Index), EI (emotional incontinence), GDS (Geriatric Depression Scale), GH (General Health), HRQOL (health-related quality of life), MCS (Mental Component Summary), MH (Mental Health), MMSE (Mini-Mental State Examination), NIHSS (National Institutes of Health Stroke Scale), PCS (Physical Component Summary), PSEI (poststroke emotional incontinence), RE (Role–Emotional), SF (Social Function), SF-36 (36-Item Short Form Health Survey)
      EMOTIONAL INCONTINENCE (EI) is defined as uncontrollable episodes of laughing, crying, or both.
      • Parvizi J.
      • Arciniegas D.B.
      • Bernardini G.L.
      • et al.
      Diagnosis and management of pathological laughter and crying.
      Poststroke emotional incontinence (PSEI) usually begins within weeks of a stroke and lasts for weeks to several years.
      • Kim J.S.
      Pathologic laughter after unilateral stroke.
      The bursts of laughter or crying can be triggered by a mild emotional stimulus or occur for no apparent reason, usually continuing for several seconds to several minutes and frequently recurring, sometimes dozens of times per day. PSEI occurs in 11% to 52% of stroke survivors
      • Schiffer R.
      • Pope L.E.
      Review of pseudobulbar affect including a novel and potential therapy.
      assessed at 3 to 6 months after stroke. In Chinese patients, the reported prevalence is 17.9%.
      • Tang W.K.
      • Chan S.S.
      • Chiu H.F.
      • Ungvari G.S.
      • Wong K.S.
      • Kwok T.C.
      Emotional incontinence in Chinese stroke patients—diagnosis, frequency, and clinical and radiological correlates.
      PSEI is distressing and embarrassing for both patients and their families. It is socially disabling and may interfere with stroke rehabilitation. However, health professionals mainly have neglected the condition.
      Health-related quality of life (HRQOL) is a broad multidimensional construct referring to aspects of people's lives that are associated with their health.
      • Salter K.L.
      • Moses M.B.
      • Foley N.C.
      • Teasell R.W.
      Health-related quality of life after stroke: what are we measuring?.
      HRQOL has been used as an outcome measure in stroke research.
      • Salter K.L.
      • Moses M.B.
      • Foley N.C.
      • Teasell R.W.
      Health-related quality of life after stroke: what are we measuring?.
      Determinants of stroke survivors' HRQOL include age, sex,
      • Kim J.S.
      • Choi-Kwon S.
      Poststroke depression and emotional incontinence: correlation with lesion location.
      poststroke depression and anxiety, and physical function.
      • Tang W.K.
      • Chen Y.K.
      • Lu J.Y.
      • et al.
      Microbleeds and post-stroke emotional lability.
      As a common poststroke complication, PSEI also may influence HRQOL adversely. Functional impairment, such as sexual dysfunction, has been reported to be more frequent in patients with PSEI.
      • Choi-Kwon S.
      • Kim J.S.
      Poststroke emotional incontinence and decreased sexual activity.
      However, no study has attempted to evaluate the effect of PSEI on HRQOL of stroke survivors. Hence, we set out to explore the effect of PSEI on HRQOL in Chinese patients with stroke.

      Methods

       Participants

      This study was part of a large project that recruited 519 consecutively admitted patients with ischemic stroke for a poststroke psychiatric interview 3 months after stroke.
      • Tang W.K.
      • Chen Y.K.
      • Lu J.Y.
      • et al.
      Microbleeds and post-stroke emotional lability.
      Three hundred eighty-five of the 519 patients formed the present study sample. They were selected from patients with ischemic stroke admitted to the Acute Stroke Unit (ASU) at the Prince of Wales Hospital in Hong Kong between December 2004 and June 2007. Patients were invited to attend a research clinic and were offered participation in the study if they (1) were 18 years or older, (2) had an acute first or recurrent ischemic stroke, (3) scored 15 or higher on the Cantonese version of the Mini-Mental State Examination (MMSE) on admission, (4) were of Chinese descent and fluent in the Cantonese dialect, (5) had an HRQOL assessment, and (6) were willing and able to give informed consent. Patients were excluded if they (1) had a central nervous system disease other than stroke, (2) had significant aphasia or dysarthria to the extent of precluding meaningful communication, (3) had a recurrent stroke within 3 months after the index stroke, or (4) remained hospitalized with the index stroke.
      Basic sociodemographic and clinical data, including age, sex, total years of formal education, prior stroke, vascular risk factors, and National Institutes of Health Stroke Scale (NIHSS) score on admission, were retrieved from the ASU Stroke Registry by a research nurse.
      The study protocol was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong. Each participant signed a consent form.

       Diagnosis of PSEI

      Psychiatric interviews were conducted 3 months after the index stroke at a research clinic in the same hospital. A psychiatrist (W.K.T.) administered a structured questionnaire to patients and their relatives to establish the diagnosis of PSEI according to criteria of Kim and Choi-Kwon.
      • Kim J.S.
      • Choi-Kwon S.
      Poststroke depression and emotional incontinence: correlation with lesion location.
      PSEI was considered present if patients showed excessive or inappropriate laughing, crying, or both compared with their premorbid state. If both the patient and cohabitating relative(s) agreed that excessive or inappropriate laughing or crying occurred on 2 or more occasions since the latest stroke, the diagnosis of PSEI was established.

       Assessment Instruments

      A trained research assistant evaluated the health-related quality of life (HRQOL) of all subjects 3 months after the index stroke at the research clinic during a face-to-face interview. Physical and cognitive function and depressive symptoms were assessed concurrently given the previously reported associations between these variables and HRQOL.
      • Tang W.K.
      • Chen Y.K.
      • Lu J.Y.
      • et al.
      Microbleeds and post-stroke emotional lability.
      • Fruhwald S.
      • Loffler H.
      • Eher R.
      • Saletu B.
      • Baumhackl U.
      Relationship between depression, anxiety and quality of life: a study of stroke patients compared to chronic low back pain and myocardial ischemia patients.
      • Verhoeven C.L.
      • Post M.W.
      • Schiemanck S.K.
      • van Zandvoort M.J.
      • Vrancken P.H.
      • van Heugten C.M.
      Is cognitive functioning 1 year poststroke related to quality of life domain.
      • 1
        The Chinese (Hong Kong) version of the 36-Item Short Form Health Survey
        • Ware Jr, J.E.
        • Kosinski M.
        • Bayliss M.S.
        • McHorney C.A.
        • Rogers W.H.
        • Raczek A.
        Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study.
        (SF-36) was used to assess HRQOL. The SF-36 focuses on the subjective perception of health and contains 8 subscales, covering General Health (GH), Mental Health (MH), role limitations due to emotional problems (Role–Emotional [RE]), role limitations due to physical problems (Role–Physical), Social Function (SF), Vitality, Bodily Pain, and Physical Function. Two composite scores, Physical Component Summary (PCS) and Mental Component Summary (MCS),
        • Ware Jr, J.E.
        • Kosinski M.
        • Bayliss M.S.
        • McHorney C.A.
        • Rogers W.H.
        • Raczek A.
        Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study.
        were calculated. The sum for scores of the 8 subscales ranges from 0 to 100; a higher value indicates better HRQOL. Cronbach α for the subscales in the original Chinese version ranged from .63 to .92.
        • Lam C.L.
        • Gandek B.
        • Ren X.S.
        • Chan M.S.
        Tests of scaling assumptions and construct validity of the Chinese (HK) version of the SF-36 Health Survey.
      • 2
        The Barthel Index
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: the Barthel Index.
        (BI) measures basic level of activities of daily living. The BI has a maximum of 100 points and covers 10 personal activities: feeding, personal hygiene, bathing, dressing, toilet, bladder control, bowel control, chair/bed transfer, ambulation/wheelchair, and stair climbing. Internal consistency (Cronbach α) of the BI Chinese version ranged from .87 to .91.
        • Chen C.C.H.
        • Bai Y.Y.
        • Huang G.H.
        • Tang S.T.
        Revisiting the concept of malnutrition in older people.
      • 3
        The Cantonese version of the MMSE
        • Chiu H.F.K.
        • Kee H.C.
        • Chung W.S.
        • Kwong P.K.
        Reliability and validity of the Cantonese version of Mini-Mental State Examination: a preliminary study.
        measured subjects' global cognitive function. This version has been validated
        • Chiu H.F.K.
        • Kee H.C.
        • Chung W.S.
        • Kwong P.K.
        Reliability and validity of the Cantonese version of Mini-Mental State Examination: a preliminary study.
        and widely used in the cognitive assessment of Chinese patients with stroke.
        • Wen H.M.
        • Mok V.C.
        • Fan Y.H.
        • et al.
        Effect of white matter changes on cognitive impairment in patients with lacunar infarcts.
        • Tang W.K.
        • Chan S.S.
        • Chiu H.F.
        • et al.
        Frequency and determinants of poststroke dementia in Chinese.
      • 4
        The Chinese version of the 15-item Geriatric Depression Scale (GDS)
        • Lim P.P.
        • Ng L.L.
        • Chiam P.C.
        • Ong P.S.
        • Ngui F.T.
        • Sahadevan S.
        Validation and comparison of three brief depression scales in an elderly Chinese population.
        rated the presence and severity of depressive symptoms. The GDS has sensitivity of 89% and specificity of 73% to detect poststroke depression.
        • Tang W.K.
        • Ungvari G.S.
        • Chiu H.F.
        • Sze K.H.
        Detecting depression in Chinese stroke patients: a pilot study comparing four screening instruments.
        • Tang W.K.
        • Chan S.S.
        • Chiu H.F.
        • et al.
        Can the Geriatric Depression Scale detect poststroke depression in Chinese elderly?.

       Statistical Analysis

      Statistical analyses were performed using SPSS, Version 16.0.
      SPSS, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606-6412.
      Subjects were divided into the PSEI and non-PSEI groups according to the diagnosis of PSEI. The difference in proportions between groups was analyzed by using chi-square test. Continuous data were compared by using t tests or Mann-Whitney U tests. Effects for the PSEI group in the 2 summary scores (PCS, MCS) and 8 domains of the SF-36 were analyzed by using analysis of covariance (ANCOVA), controlling for demographic and clinical variables with P<.05 in univariate analyses. Correction for multiple comparisons was applied to both the univariate analysis and ANCOVA. The 8 domains and 2 summary scores of the SF-36 were examined separately; a total of 10 times for SF-36 scores. Hence, we divided the usual level of significance (.05) by 10 (number of comparison times), reaching the final level of significance of .005 (2 sided).

      Results

      In comparison to the entire sample of 519 patients with ischemic stroke, the 385 subjects selected for this study were younger (mean ± SD age, 65.7±11.8 vs 73.9±12.0y; P<.001), more likely to be men (61.3% vs 47.2%; P<.001), and had a lower NIHSS score on admission (4.5±3.2 vs 10.1±9.3; P<.001).
      Subjects had a mean NIHSS score of 4.5±3.2, and 75 (19.5%) had a previous stroke. PSEI was diagnosed in 58 (15.1%) subjects. Comparison of demographic and clinical features between the PSEI and non-PSEI groups is listed in table 1. The 2 groups differed significantly in terms of sex distribution, frequency of diabetes and prior stroke, NIHSS score on admission, and BI, MMSE, and GDS scores. After controlling for these variables, subjects with PSEI had significantly lower scores in 4 domains (GH, SF, MH, RE) of the SF-36 (partial η2 [effect size]=.026, .037, .049, .079, respectively) and the 2 composite scores (PCS, MCS).
      Table 1Comparison of the PSEI and Non-PSEI Groups With Respect to Demographic and Clinical Characteristics
      VariablesPSEI (n=58)Non-PSEI (n=327)t2/ZPAnalysis of Covariance
      Adjusted for sex, prior stroke, diabetes, and NIHSS, BI, MMSE, and GDS scores. Effect size was described by using F, P, or partial η2.
      FPPartial η2
      Clinical variables
       Age
      t Test.
      (y)
      65.7±10.365.7±12.1−0.019.985NDNDND
       Women
      Chi-square test.
      30 (51.7)119 (36.4)4.882.027NDNDND
       Education (y)
      Mann-Whitney U test.
      4.7±4.15.7±4.7−2.259.024NDNDND
       NIHSS score
      Mann-Whitney U test.
      5.9±4.24.3±3.0−2.043.041NDNDND
       Hypertension
      Chi-square test.
      44 (75.9)230 (70.3)0.733.392NDNDND
       Diabetes
      Chi-square test.
      30 (51.7)112 (34.3)6.461.011NDNDND
       Ischemic heart disease
      Chi-square test.
      5 (8.6)25 (7.6)0.065.798NDNDND
       Prior stroke
      Chi-square test.
      17 (29.3)56 (17.7)4.207.040NDNDND
      Assessment at 3 mo poststroke
       MMSE
      Mann-Whitney U test.
      score
      24.8±3.726.2±3.2−2.948.003NDNDND
       GDS
      Mann-Whitney U test.
      score
      8.2±3.94.3±3.3−6.773<.001NDNDND
       BI
      Mann-Whitney U test.
      score
      18.4±2.419.2±1.7−4.377<.001NDNDND
      SF-36
      Mann-Whitney U test.
      domains
       PF score54.8±30.874.2±26.6−5.023<.0012.385.123.006
       GH score34.1±17.853.3±19.4−6.418<.0019.799.002.026
       VT score49.5±23.768.1±19.2−5.487<.0015.034.025.013
       SF score77.2±19.292.7±13.9−6.924<.00114.394<.001.037
       MH score56.1±22.277.6±16.7−6.938<.00119.129<.001.049
       RP score37.5±43.062.8±40.0−4.101<.0010.336.563.001
       RE score44.3±43.486.9±28.8−7.958<.00131.921<.001.079
       BP score61.0±27.080.2±23.1−5.020<.0014.835.029.013
       MCS score45.4±11.457.0±8.8−6.996<.00119.689<.001.050
       PCS score46.4±10.057.0±10.0−6.593<.0018.743.003.023
      NOTE. Values expressed as mean ± SD or n (%).
      Abbreviations: BP, Bodily Pain; ND, not done; PF, Physical Function; RP, Role–Physical; VT, Vitality.
      low asterisk Adjusted for sex, prior stroke, diabetes, and NIHSS, BI, MMSE, and GDS scores. Effect size was described by using F, P, or partial η2.
      t Test.
      Chi-square test.
      § Mann-Whitney U test.

      Discussion

      To our knowledge, this is the first study to evaluate the effect of PSEI on HRQOL of stroke survivors. Patients with PSEI had significantly lower scores on both the physical and mental aspects of the SF-36. They showed particularly significant impairment in general and mental health, social functions, and role limitations due to emotional problems. Our findings suggest that other than poststroke depression and anxiety, PSEI is a hitherto overlooked but important emotional correlate of HRQOL.
      Similar to previous studies, an apparent association between PSEI and cognitive impairment, depression, and severity of physical deficit after stroke was found.
      • Tang W.K.
      • Chan S.S.
      • Chiu H.F.
      • Ungvari G.S.
      • Wong K.S.
      • Kwok T.C.
      Emotional incontinence in Chinese stroke patients—diagnosis, frequency, and clinical and radiological correlates.
      • Tang W.K.
      • Chen Y.
      • Lam W.W.
      • et al.
      Emotional incontinence and executive function in ischemic stroke: a case-controlled study.
      When comparison between the PSEI and non-PSEI groups was made with respect to HRQOL, significant differences in the SF-36 GH, SF, MH, and RE domains and 2 summary scores were found, even after controlling for cognitive impairment, depression, and severity of physical deficit. This suggests that PSEI is an important determinant of HRQOL in stroke survivors, at least those with relatively mild physical deficits.
      This study showed that PSEI has a significant impact on both the physical and mental aspects of HRQOL. Patients with PSEI are fearful of social contacts, particularly in public places, and frequently become socially withdrawn even if physically recovered. Impairment in emotional and social functions also interferes with stroke rehabilitation.
      • Raju R.S.
      • Sarma P.S.
      • Pandian J.D.
      Psychosocial problems, quality of life, and functional independence among Indian stroke survivors.
      • Hopman W.M.
      • Verner J.
      Quality of life during and after inpatient stroke rehabilitation.
      • Eslinger P.J.
      • Parkinson K.
      • Shamay S.G.
      Empathy and social-emotional factors in recovery from stroke.
      However, the relatively small effect size (.05 for MCS, .023 for PCS) suggests that this association should be considered with caution.
      It is imperative that PSEI be treated as early as possible to avoid its negative effects on patients' social relations and quality of life. Common evaluation methods for EI include clinical interviews, chart reviews, the Pathological Laughing and Crying Scale,
      • Robinson R.G.
      • Parikh R.M.
      • Lipsey J.R.
      • Starkstein S.E.
      • Price T.R.
      Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind treatment study.
      and other questionnaires.
      • Schiffer R.
      • Pope L.E.
      Review of pseudobulbar affect including a novel and potential therapy.
      Selective serotonin-reuptake inhibitor antidepressants have good therapeutic effects on PSEI.
      • House A.O.
      • Hackett M.L.
      • Anderson C.S.
      • Horrocks J.A.
      Pharmaceutical interventions for emotionalism after stroke.
      It is likely that effective psychosocial and pharmacologic management of PSEI could improve stroke survivors' HRQOL.

       Study Limitations

      There are several limitations to this study. First, subjects were younger, more likely to be men, and had relatively milder neurologic deficits compared with a consecutively admitted cohort of patients with stroke, which limits the generalizability of results. Second, the cross-sectional design prevents exploration of causality of the relationship between PSEI and HRQOL. Third, differences in health care systems and sociocultural factors between countries or regions within China that affect stroke rehabilitation and HRQOL could further limit the generalizability of results. Fourth, subjects' global cognitive function was measured by using the MMSE, which originally was designed as only a screening tool for cognitive impairment.
      Longitudinal studies are warranted to confirm and extend the findings of this study, which ought to stimulate further research into the pathophysiologic process and treatment of this relatively neglected psychopathologic state in stroke survivors.

      Conclusions

      PSEI affects both physical and mental aspects of HRQOL in stroke survivors. Given the relatively high prevalence of PSEI, health care professionals should pay more attention to this disturbing psychopathologic complication.
      Supplier
      aSPSS, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606-6412.

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