Original research| Volume 100, ISSUE 3, P433-440.e1, March 2019

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Quality of Life Trajectories Among Stroke Survivors and the Related Changes in Caregiver Outcomes: A Growth Mixture Study

Published:August 18, 2018DOI:



      To identify the distinct quality of life (QOL) trajectories among stroke survivors, and to evaluate the associations with their caregivers’ burden, anxiety, and depression.


      This was a longitudinal dyadic study.


      Stroke survivors and their informal caregivers were enrolled upon discharge from several rehabilitation hospitals, and they were followed during this multisite longitudinal study.


      The stroke survivors (N=405, mean age=70.7y) included older adult men (52.0%), most of whom (80.9%) had had ischemic strokes. The caregivers (n=244, mean age=52.7y) included mostly women (65.2%), most of whom were the survivors’ children (50.0%) or spouses (36.1%).


      Not applicable.

      Main Outcome Measures

      Latent growth mixture modeling was used to identify the distinct QOL trajectories among the stroke survivors over the course of 12 months of recovery. The longitudinal associations between the stroke survivor QOL trajectories and the caregivers’ burden, anxiety, and depression were evaluated. A multinomial regression was then used to identify the predictors of the various survivor QOL trajectories.


      Three distinct survivor QOL trajectories were identified: high and slightly improving QOL, moderate and slightly worsening QOL, and markedly improving QOL. The caregivers’ burden, anxiety, and depression mirrored the survivors’ QOL trajectories. In the multinomial models, an older survivor age, hemorrhagic stroke, lower education, and coexisting chronic obstructive pulmonary disease or thyroid disease were significantly associated with a moderate and slightly worsening QOL trajectory. Women and blindness were associated with a markedly improving QOL survivor trajectory.


      A survivor’s QOL trajectory after a stroke was associated with their caregiver’s burden, anxiety, and depression. Those survivors belonging to the moderate and slightly worsening QOL trajectory and their caregivers, in particular, need special care, because they are at risk for the worst outcomes.


      List of abbreviations:

      CBI (Caregiver Burden Inventory), COPD (chronic obstructive pulmonary disease), HADS (Hospital Anxiety and Depression Scale), LGMM (latent growth mixture modeling), QOL (quality of life)
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        • Pucciarelli G.
        • Vellone E.
        • Savini S.
        • et al.
        Roles of changing physical function and caregiver burden on quality of life in stroke: a longitudinal dyadic analysis.
        Stroke. 2017; 48: 733-739
        • Shyu Y.I.
        • Maa S.H.
        • Chen S.T.
        • Chen M.C.
        Quality of life among older stroke patients in Taiwan during the first year after discharge.
        J Clin Nurs. 2009; 18: 2320-2328
        • White J.
        • Magin P.
        • Attia J.
        • Sturm J.
        • McElduff P.
        • Carter G.
        Predictors of health-related quality of life in community-dwelling stroke survivors: a cohort study.
        Fam Pract. 2016; 33: 382-387
        • Bhattacharjee M.
        • Vairale J.
        • Gawali K.
        • Dalal P.M.
        Factors affecting burden on caregivers of stroke survivors: population-based study in Mumbai (India).
        Ann Indian Acad Neurol. 2012; 15: 113-119
        • Denno M.S.
        • Gillard P.J.
        • Graham G.D.
        • et al.
        Anxiety and depression associated with caregiver burden in caregivers of stroke survivors with spasticity.
        Arch Phys Med Rehabil. 2013; 94: 1731-1736
        • Isaac V.
        • Stewart R.
        • Krishnamoorthy E.S.
        Caregiver burden and quality of life of older persons with stroke.
        J Appl Gerontol. 2011; 30: 643-654
        • Langhorne P.
        • Bernhardt J.
        • Kwakkel G.
        Stroke rehabilitation.
        Lancet. 2011; 377: 1693-1702
        • van Mierlo M.
        • van Heugten C.
        • Post M.W.M.
        • Hoekstra T.
        • Visser-Meily A.
        Trajectories of health-related quality of life after stroke: results from a one-year prospective cohort study.
        Disabil Rehabil. 2018; 40: 997-1006
        • Savini S.
        • Buck H.G.
        • Dickson V.V.
        • et al.
        Quality of life in stroke survivor-caregiver dyads: a new conceptual framework and longitudinal study protocol.
        J Adv Nurs. 2015; 71: 676-687
        • WHOQOL Group
        Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group.
        Psychol Med. 1998; 28: 551-558
        • de Lima M.L.
        • Santos J.L.
        • Sawada N.O.
        • de Lima L.A.
        Quality of life of individuals with stroke and their caregivers in a city of Triangulo Mineiro.
        Rev Bras Epidemiol. 2014; 17: 453-464
        • De Girolamo G.
        • Rucci P.
        • Scocco P.
        • et al.
        [Quality of life assessment: validation of the Italian version of the WHOQOL-Brief].
        Epidemiol Psichiatr Soc. 2000; 9 ([in Italian]): 45-55
        • Novak M.
        • Guest C.
        Application of a multidimensional caregiver burden inventory.
        Gerontologist. 1989; 29: 798-803
        • Greco A.
        • Pancani L.
        • Sala M.
        • et al.
        Psychometric characteristics of the caregiver burden inventory in caregivers of adults with heart failure.
        Eur J Cardiovasc Nurs. 2017; 16: 502-510
        • Zigmond A.S.
        • Snaith R.P.
        The Hospital Anxiety and Depression Scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Annunziata M.A.
        • Muzzatti B.
        • Altoe G.
        Defining Hospital Anxiety and Depression Scale (HADS) structure by confirmatory factor analysis: a contribution to validation for oncological settings.
        Ann Oncol. 2011; 22: 2330-2333
        • Burant C.J.
        Latent growth curve models: tracking changes over time.
        Int J Aging Hum Dev. 2016; 82: 336-350
        • Preacher K.J.
        • Wichman A.L.
        • MacCallum R.C.
        • Briggs N.E.
        Latent growth curve modeling.
        Sage, Thousand Oaks, CA2008
        • Ram N.
        • Grimm K.J.
        Growth mixture modeling: a method for identifying differences in longitudinal change among unobserved groups.
        Int J Behav Dev. 2009; 33: 565-576
        • Lo Y.
        • Mendell N.R.
        • Rubin D.B.
        Testing the number of components in a normal mixture.
        Biometrika. 2001; 88: 767-778
        • Nylund K.L.
        • Asparouhov T.
        • Muthen B.
        Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study.
        Struct Equ Modeling. 2007; 14: 535-569
        • Chuluunbaatar E.
        • Chou Y.J.
        • Pu C.
        Quality of life of stroke survivors and their informal caregivers: a prospective study.
        Disabil Health J. 2016; 9: 306-312
        • Bushnell C.D.
        • Reeves M.J.
        • Zhao X.
        • et al.
        Sex differences in quality of life after ischemic stroke.
        Neurology. 2014; 82: 922-931
        • Paolucci S.
        • Bragoni M.
        • Coiro P.
        • et al.
        Is sex a prognostic factor in stroke rehabilitation? A matched comparison.
        Stroke. 2006; 37: 2989-2994
        • Jeong B.O.
        • Kang H.J.
        • Bae K.Y.
        • et al.
        Determinants of quality of life in the acute stage following stroke.
        Psychiatry Investig. 2012; 9: 127-133
        • Baumann M.
        • Lurbe K.
        • Leandro M.E.
        • Chau N.
        Life satisfaction of two-year post-stroke survivors: effects of socio-economic factors, motor impairment, Newcastle stroke-specific quality of life measure and World Health Organization quality of life: bref of informal caregivers in Luxembourg and a rural area in Portugal.
        Cerebrovasc Dis. 2012; 33: 219-230
        • Carod-Artal F.J.
        • Trizotto D.S.
        • Coral L.F.
        • Moreira C.M.
        Determinants of quality of life in Brazilian stroke survivors.
        J Neurol Sci. 2009; 284: 63-68
        • Biousse V.
        • Newman N.J.
        Eye syndromes and the neuro-ophthalmology of stroke.
        Handb Clin Neurol. 2009; 93: 595-611
        • Sand K.M.
        • Midelfart A.
        • Thomassen L.
        • Melms A.
        • Wilhelm H.
        • Hoff J.M.
        Visual impairment in stroke patients—a review.
        Acta Neurol Scand Suppl. 2013; : 52-56
        • Goodwin D.
        Homonymous hemianopia: challenges and solutions.
        Clin Ophthalmol. 2014; 8: 1919-1927