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Disability in elderly patients with chronic neurological illness: Stroke, multiple sclerosis and epilepsy
Archives of Gerontology and Geriatrics 53 (2011) e227–e231
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Disability in elderly patients with chronic neurological illness: Stroke, multiple sclerosis and epilepsy ¨ zkan Tuncay Mukadder Mollaog˘lu *, Tu¨lay Kars Fertelli, Fatma O Cumhuriyet University, Health Sciences Faculty, Department of Nursing, 58140 Sivas, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 August 2010 Received in revised form 26 November 2010 Accepted 27 November 2010 Available online 21 December 2010
The aim of the study was to evaluate disability in patients with elderly stroke, multiple sclerosis (MS) and epilepsy, and to analyze its relationship with demographic characteristics. We conducted a crosssectional study involving 113 patients with neurological diseases. The data were collected with a Personal Information Form, the Rivermead Mobility Index (RMI), and the Brief Disability Questionnaire (BDQ) were used. The data were evaluated using percentage, variance analysis, the Kruskal–Wallis test and the Pearson correlation analysis. The study results demonstrate that among three disorders, the severity of disability increased in patients with stroke, epilepsy and MS, respectively. It was also found that in patients with stroke, MS and epilepsy experiencing disability in mobility, 32.7% had experienced moderate physical–social disability, and 63.3% had experienced severe physical–social disability, and that there was a significantly high relationship between mobility disability and physical–social disability. The severity of disability was found to be higher for older age, low level education, selfemployed and widows. Especially in stroke patients, disability is a common problem in patients with epilepsy and MS. Detecting the level of disability is very important for decreasing the limitation in elderly patients with neurological illness. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Disability Neurological illness Stroke Multiple sclerosis Epilepsy
1. Introduction Chronic diseases are diseases in which complete recovery is not achieved, and which continuously progress, most of the time resulting in permanent disabilities and deficiencies, spanning over a long period of life (Williams and Pace, 2009). It is accepted that most of the neurological system-related chronic diseases cause severe limitations and deficiencies in individuals. Among these, stroke, multiple sclerosis and epilepsy are commonly seen ¨ zkan Tuncay and Mollaodisorders (Smith and Elisevich, 1998; O glu, 2006). It is known that stroke is ranked third with respect to the duration of hospitalization, due to functional and neurological losses, and it negatively affects the quality of life (Cowman et al., 2010). Stroke is an important disease causing mortality and morbidity and physical and social deficiencies are developed in more than half of the patients that survive after suffering a stroke (D’Alisa et al., 2005; Caulfield and Wijman, 2008; Lundstro¨m et al., 2008). Like stroke, MS is one of the important health problems that cause disability. MS has an important place among diseases in adults that cause neurological disability without trauma (Bjartmar
* Corresponding author. Tel.: +90 346 225 2321; fax: +90 346 225 1231. E-mail addresses: [email protected], [email protected] (M. Mollaog˘lu). 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.11.031
et al., 2000). It is known that patients with MS become dependent on others in performing their activities of daily life due to the variable levels of deficiency in mobility and functional disabilities caused by MS (Einarsson et al., 2006; Mollaoglu and Ustun, 2009). Among the most important reasons that cause this dependence, loss of balance, visual disorders, fatigue, ataxia, spasticity and changes in walking have been included (Kirstein and Jaime, 2006; Smedal et al., 2006; Putzki et al., 2009). In epilepsy, which is one of the other important diseases among neurological disorders, it has been noted that changes in daily life activities may occur as a result of changes in the quality of life of an individual due to physical and psychosocial effects, frequent hospitalizations, and recurrent attacks (Birbeck et al., 2007). When all of these data were reviewed, the importance of evaluating the individual’s disability emerged, which is defined as impairment in performing a duty within a normal range or in a normal form, in individuals with neurological deficiencies. It has been reported that disability occurs as a result of restrictions in basic physical, psychological and mental functions, and each of these functions is individually important in the formation of disability, and that interventions at early stages can decrease the prevalence of disability (Curtiss et al., 2007; Fagerstro et al., 2008). Despite the presence of several studies on disability, functional status or activities of daily life primarily in the patients with stroke ¨ zkan as well as in other neurological patients (Gignac et al., 2000; O
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Tuncay and Mollaoglu, 2006) there are no studies analyzing and comparing both mobility and physical–social disability in patients with stroke, MS and epilepsy. Information to be obtained will be helpful in selecting protective, healing and rehabilitative interventions to prevent and decrease the disability, improving the health of individuals with stroke, MS and epilepsy, and rendering the nurses more effective in this field in dealing with patients with neurological disorders. In this context, the aim of this study was to determine the disability and to analyze its relationship with some sociodemographic characteristics in patients with stroke, MS and epilepsy.
2. Subjects and methods The study comprised patients with stroke, MS and epilepsy who had been treated in Cumhuriyet University Neurology Clinic between March and December 2009. Although a total of 126 patients aged older than 65 years had been treated between these dates, 4 patients did not want to participate in the study, 7 patients with stroke had impairments in their cognitive functions, and 2 patients with epilepsy had more frequent attacks; therefore, sampling was performed in 113 patients.
points = moderate and 13 points or above was considered to be severe disability (Akin and Emirog˘lu, 2007). 2.3. The procedure After acquiring permission from the Cumhuriyet University Hospital Ethics Committee, first the aim of the study was explained to the patients and their willingness to participate in the study was considered. The Neurology Clinic consists of two sections namely a Stroke Unit and the unit in which patients with other neurological disorders are accepted. The study was performed in both units. In an appropriate room in the clinic, neurological evaluation was performed and information collection forms were given to the patients by two nurses with graduate degree, who had worked in the neurology clinic for many years, who at the same time had participated in academic studies on neurology nursing. Some of the patient data were collected by the neurologist using patient files (duration of the disease, some medical information, some neurological examination data, etc.). This procedure was applied to stroke patients with mobility problems in their rooms. Although it varied according to the patient’s status, the duration of data collection and neurological evaluation took on average 20–30 min. 2.4. Data analysis
2.1. The study sample Patients with stroke (n = 53) formed 47%, patients with MS comprised 26.5% (n = 30) and patients with epilepsy comprised the remaining 26.5% (n = 30) of the study group. Females amounted to 61.1% of the patients, 64.6% of them were married, 47.8% were above 50 years of age, 69.0% were literate, and 3.5% did not have health insurance. 2.2. Data collection The patient information form was used to obtain data related to individuals. The Rivermead mobility index (RMI) was used to evaluate the disability in mobility, and the brief disability questionnaire (BDQ) was used to evaluate physical–social disability. Patient information form; this form, which was prepared by the researchers by making use of related literature and studies, consisted of seven questions in order to question individuals’ demographic and clinical characteristics such as ages, marital status, level of education, economical status, and duration of the disease. RMI is a single-dimensional index focusing on measuring the mobility status and consists of 14 questions and one observation about basic mobility activities. In this index, patient information about their activities such as transfer, balance, walking, climbing up the stairs, having a bath and running are collected. The points obtained from RMI varies between ‘‘0’’ and ‘‘15’’; 15 points (full points) shows that there is no problem in mobility; 14 points or below indicates that there is a problem in mobility. Since RMI is formed from a basic to a complex hierarchical structure, it is thought that as the points become lower, the severity of the problem increases (Grasso et al., 2005; Smedal et al., 2006; Akin and Emirog˘lu, 2007). RMI was improved by Collen et al. (1991) and the validity and reliability study for our country were performed by Akin and Emirog˘lu (2007). The BDQ was developed by the WHO and customized for our country by Kaplan (1995) and its validity and reliability were analyzed. BDQ is a scale consisting of 11 tables with total points of 22. It was accepted that individuals having 5 points or above from the BDQ questionnaire were considered to have physical social disability, 0–4 points = no disability, 5–7 points = mild, 8–12
The data obtained in the study were evaluated using percentage calculations, the x2-test, variance analysis, the Mann–Whitney Utest, the Kruskal–Wallis test, and the Pearson correlation test in the SPSS (version 11.0) software package. 3. Results Socio demographic and clinical characteristics of the patients involved in the study have been displayed in Table 1. When the disability level was evaluated with respect to the scale points, it was seen that according to the BDQ, all the patients experienced physical–social disability and 54.9% of them were experiencing this at a severe level; according to RMI, on the other hand, 86.7% of them had disability in mobility (Table 1). When mobility-related disability was analyzed with respect to the type of diseases that the patients had, it was found that patients with stroke had lower RMI scores and experienced more severe mobility-related disability. Patients with MS on the other hand, had a higher average score and the difference among the groups was statistically significant (p < 0.001). When BDQ points were examined in the same group, although it was not statistically significant, it was determined that disability was more severe in patients with MS than in patients with stroke and epilepsy. However, when the entire patient group was considered, it was found that patients with neurological disorders experienced disability at a moderate level (7.88 4.96) according to the RMI scale (range = 0–15 points), and at a severe level from a physical– social perspective according to BDQ scores (range = 0–22 points) (mean = 13.62 5.46) (Table 2). Furthermore, in this study, 32.7% of the patients with neurological disorders having mobility-related disability (stroke, MS and epilepsy) experienced a moderate-level, 63.3% of them, on the other hand, experienced a physical–social field disability at a severe level and there was a highly significant relationship between mobility-related disability and physical social field disability (x2 = 56.13, p < 0.001). When the relationship between BDQ and patients individual characteristics were investigated, it was found that, as the age increased, the severity of physical and social disability increased (p < 0.05); furthermore, mobility-related disability increased in individuals with in their 65–69 years (p < 0.001). It can be seen
M. Mollaog˘lu et al. / Archives of Gerontology and Geriatrics 53 (2011) e227–e231 Table 1 Characteristics of the subjects.
Table 3 The relationship between RMI- and BDQ-scores and demographic characteristics of subjects.
n (%)
Characteristics
69(61.1) 44(38.9)
Gender Female Male t Age 65–69 years 70 years t Education level Illiterate Primary–secondary school High school and above Kruskal–Wallis Occupation Unemployed Housewife Farmer Employee-officer Kruskal–Wallis Marital status Married Single Widow Kruskal–Wallis
69(52.2) 44(47.8) 35(31.0) 52(46.0) 26(23.0) 9(8.0) 65(57.5) 8(7.1) 31(27.4) 73(64.6) 19(16.8) 21(18.6) 109(96.5) 4(3.5) 5(4.4) 9(8.0) 37(32.7) 62(54.9)
a c
15(13.3) 98(86.7)
RMI˙
BDQ
Characteristics
Gender Female Male Age 65–69 years <70 years Education level Illiterate Primary–secondary school High school and above Occupation Unemployed Housewife Farmer Employee-officer Marital status Married Single Widow The existence of health insurance, existent Nonexistent Physical–social disability (BDQ) No disability (0–4 points) Mild level disability (5–7 points) Moderate level disability (8–12 points) Severe level disability (13 points or above) Mobility disability (RMI) There is no problem in mobility (15 points) There is problem in mobility (14 points or below)
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13.48 5.22 13.84 5.86 0.34
7.48 4.94 8.50 4.99 1.06
12.61 4.74 14.72 5.99 2.08a
9.64 4.17 5.94 5.08 4.24c
15.11 6.27 13.23 5.06 12.38 4.75 4.702
4.80 4.73 8.67 4.44 10.42 4.30 21.51c
17.44 4.53 13.60 5.11 17.88 3.87 11.45 5.69 13.38a
6.56 4.24 7.28 4.92 4.63 3.77 10.35 4.68 13.56a
10.63 5.52 13.37 5.25 17.19 4.26 14.09c
11.95 3.27 7.73 5.07 4.71 3.08 21.72c
p < 0.05. p < 0.001.
Stroke is usually termed a cerebrovascular accident and together with loss of movement and sensation that emerge in the upper and lower extremities across the lesioned brain hemisphere, shows itself as balance and perception problems throughout the body, in addition to perception, sensation and motor integration disorders, and disability develops as a result of these disorders (Hoffman et al., 2003). For this reason, the presence of disability in patients with stroke is an expected finding and the results of our study show similarities with the results of the other studies showing that stroke causes disability (Widar and Ahlstro¨m, 2002; Lundstro¨m et al., 2008). The fact that disability was to a higher degree in patients with stroke when compared to patients with other neurological problems, together with loss of movement and sensation developing in relation to the lesion on brain hemisphere, can be explained by the relationship between the activities of daily life and visual perception disorders in patients with stroke (Teasel, 2003). This, on the other hand indicates that during the practices for activities of daily life, visual perception disorders should be considered and evaluated. In this study, it was determined that both physical–social and mobility-related disability were seen to a lesser extent in MS patients than in patients with stroke and epilepsy. In other words, it was determined that while disability was seen at a moderate level in patient with MS, it was severe in patients with stroke and epilepsy. Although there have been no studies comparing the disability among patient with MS and with other neurological disorders in the literature, there are numerous studies investigating the effect of MS on daily life activities of an individual. It was determined in the study by Einarsson et al. (2006) that only 30% of the patients with MS were totally independent in daily life activities and other patients were dependent for these activities at
that as the education level among the patients decreased, the probability of physical and social disability increased and especially disability in mobility differed among the different levels of education and this differences were statistically significant (p < 0.001). The severity of physical, social and mobility disability in patients who were self-employed and farmers was found to be higher than in other occupation groups and the difference between these groups was statistically significant (p < 0.05). When the marital status variable was analyzed, widowers were found to experience deficiency more intensely (p < 0.001). On the other hand, no significant relationship was found between sex and BDQ-RMI scales (Table 3). From the analysis of correlation between RMI and BDQ scales, it was determined that there was a statistically significant negative correlation between physical and social disability and mobilityrelated disability (r = 0.697, p < 0.001). 4. Discussion Important health problems that cause changes in neurological functions alter the functional abilities such as dressing, walking, and day care, and affect individuals’ daily life activities and capabilities (Gignac et al., 2000; Verbrugge and Yang, 2002). In this study that was performed to determine the disability in patients with neurological problems such as stroke, MS and epilepsy, it was determined that physical–social disability was seen in all of the patients; disability in mobility was seen in most of the patients. Among three neurological disorders that were examined in this study, patients with stroke were found to be the most affected group by disability. Table 2 The mean values of RMI and BDQ scores of subjects, mean S.D.
RMI score BDQ score
Stroke
Epilepsy
MS
Total
F
p
5.75 5.24 14.26 6.06
8.63 4.56 14.43 5.15
10.87 2.66 11.67 4.15
7.88 4.96 13.62 5.46
12.86 2.70
<0.001 <0.07
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certain levels. Also in a study that used RMI by Kirstein and Jaime (2006), similar to the results of our study, it was found that patients with MS experienced disability in mobility to a relatively important extent. In general, motor deficits that emerged during the course of the disease were thought to be responsible for the disability in MS (Gulick and Goodman, 2006; Stroud and Minahan, 2009). From this difference; it is thought that sensation, perception and motor disorders appear at variable levels among these three disorders and therefore, cause disability at variable levels in these diseases, and hence, the differences in psychosocial effects of these diseases on individuals. Further studies are needed to investigate this topic from both physicopathological and physicosocial aspects. Besides the neuropathic impacts of epileptic discharges, the reason for disability being more severely encountered, especially in the physical and social field in patients with epilepsy can be related to stigmatization that the patients with epilepsy pass through. In studies performed on patients with epilepsy, it was determined that due to reasons such as stigma, recurrent attacks, social humiliation because of these recurrent attacks, social isolation and social disability developed in these patients (Piazzini et al., 2008). Handling these patients with a multidisciplinary team approach, evaluating the diseases on an individual with not only the physical effects, but also with combining physicosocial effects and developing effective strategies in order to solve the problem, are the responsibilities of healthcare workers (Hosking, 2006). Among patients with neurological diseases (stroke, MS, epilepsy), the fact that most of the patients with mobility disability also experience disability in the physical–social field is another important finding of this study. This relationship was also found in a study that was performed previously (Akin and Emirog˘lu, 2003). The increasing effect of mobility disability on social disability can be related to the individual’s inability to enter the social environment due to restrictions in mobility. For this reason, it is important to activate social support factors. Indeed, it was mentioned in a study that individuals with mobility disability may develop higher levels of disability. Therefore, effective evaluation of mobility disability is important to decrease the severity of disability (Guralnik et al., 1995). We also analyzed the relationship between disability and some demographic characteristics of the patients with stroke, MS and epilepsy. Accordingly, the level of disability was found to be more severe in advanced age, low level of education, farmers, the selfemployed and widows. The results on mobility–disability and physical–social disability in patients with advanced age showed differences. While a significant correlation was found between age and disability in some studies (Cook et al., 2003; D’Alisa et al., 2005), no significant correlation was found in others (Sommerfeld and Van Arbin, 2001; Bardak et al., 2008). Besides the pathophysiological effects of the diseases on mobility, due to the probable psychosocial effects of chronic diseases, the presence of a significant correlation between age and disability was, therefore, an expected finding. The study of Litwin (2003), in which it was shown that the severity of disability was higher among the elderly with low social support should also be taken into consideration. Mobility, which is a disability environment related to the ability of an elderly to move, can be an indicator for the elderly to determine important situations such as higher level disability and falling and can be considered as a situation that increases the importance of preventing our patients from trauma and determining their social support needs. Another finding in this study is that the disability status on mobility was affected according to the level of education of the patients. When RMI point averages were considered, it was found that the average scores of illiterates were lower and as the level of education increased, the disability in mobility decreased. Similarly in another study, a higher level of education was reported to be an
important factor that decreased the severity of disability and the severity of disability was low in individuals with a high level of education (Bardak et al., 2008). Since most of the patients included in our study had a low level of education, it can be thought that the characteristics of the social assistance network in our county can be different. When rehabilitation studies are planned, this finding should necessitate the overview of characteristics in patients with low level of education. Marital status was found to be another risk factor for disability in the study. It was found that widows experienced disability both in mobility and the physical–social field at a significant degree. Similar results were also found in the study of Litwin (2003), one of the studies in which social support was found to decrease the severity of mobility. Another study showing that there was a relationship between marital status and disability was performed by Verbrugge and Yang (2002). In a study performed with patients with stroke, it was also found that mobility points of widowers were found to be lower than that in other groups. In conclusion, in this study that aimed to determine the presence of disability in patients with stroke, MS and epilepsy and investigate the relationship between the patients’ sociodemographic characteristics and disability, it was determined that in all patients, disability was present at a moderate level in mobility, at a severe level in the physical–social field, and in patients with stroke, the disability was found to be present at a more severe level when compared to patients with MS and epilepsy, and most of the patients with disability in mobility were experiencing disability in physical–social field at a more severe level, and that there was a significant correlation between disability and age, marital status, education and occupation. According to these results, in addition to performing a general assessment toward mobility, it can be suggested that, in order to decrease the risk of disability, together with the all the medical staff, nurses should take all the necessary precautions in patients with neurological deficiency during patient-related planning, and risky groups for disability should be taken into consideration; patients with disability should be followed up for lost functions and interventions for these lost functions should be emphasized, and a multidisciplinary team approach should be applied. Study limitations: That the study was realized in only one city of Turkey, was regarded as its limitation. It is advised that the some study be realized in a larger population which would represent Turkey. Besides, it is planned to assess the disability by using objective examining methods, to notice that all these findings are very important for planning health care and to do other studies as a continuation of this one. In spite of these limitations, and although there are some studies which investigate disability in neurological patients, there are no studies which determine stroke, MS and epilepsy and evaluate together these three disorders. In addition, this study calls attention to that, individuals’ personal characteristics have same effects on disability. Besides, this research is the first study to investigate disability of neurological patients in Turkey. With its all these qualities this study enables a database for further studies and we think that it also contains some important data, which is necessary for planning the care of neurological patients. Conflict of interest None. Acknowledgement The authors express their thanks to Dr. Ziynet C¸ınar of the Department of Statistics of Cumhuriyet University, for help with the statistical evaluations in this investigation.
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Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Disability in elderly patients with chronic neurological illness: Stroke, multiple sclerosis and epilepsy ¨ zkan Tuncay Mukadder Mollaog˘lu *, Tu¨lay Kars Fertelli, Fatma O Cumhuriyet University, Health Sciences Faculty, Department of Nursing, 58140 Sivas, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 13 August 2010 Received in revised form 26 November 2010 Accepted 27 November 2010 Available online 21 December 2010
The aim of the study was to evaluate disability in patients with elderly stroke, multiple sclerosis (MS) and epilepsy, and to analyze its relationship with demographic characteristics. We conducted a crosssectional study involving 113 patients with neurological diseases. The data were collected with a Personal Information Form, the Rivermead Mobility Index (RMI), and the Brief Disability Questionnaire (BDQ) were used. The data were evaluated using percentage, variance analysis, the Kruskal–Wallis test and the Pearson correlation analysis. The study results demonstrate that among three disorders, the severity of disability increased in patients with stroke, epilepsy and MS, respectively. It was also found that in patients with stroke, MS and epilepsy experiencing disability in mobility, 32.7% had experienced moderate physical–social disability, and 63.3% had experienced severe physical–social disability, and that there was a significantly high relationship between mobility disability and physical–social disability. The severity of disability was found to be higher for older age, low level education, selfemployed and widows. Especially in stroke patients, disability is a common problem in patients with epilepsy and MS. Detecting the level of disability is very important for decreasing the limitation in elderly patients with neurological illness. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Disability Neurological illness Stroke Multiple sclerosis Epilepsy
1. Introduction Chronic diseases are diseases in which complete recovery is not achieved, and which continuously progress, most of the time resulting in permanent disabilities and deficiencies, spanning over a long period of life (Williams and Pace, 2009). It is accepted that most of the neurological system-related chronic diseases cause severe limitations and deficiencies in individuals. Among these, stroke, multiple sclerosis and epilepsy are commonly seen ¨ zkan Tuncay and Mollaodisorders (Smith and Elisevich, 1998; O glu, 2006). It is known that stroke is ranked third with respect to the duration of hospitalization, due to functional and neurological losses, and it negatively affects the quality of life (Cowman et al., 2010). Stroke is an important disease causing mortality and morbidity and physical and social deficiencies are developed in more than half of the patients that survive after suffering a stroke (D’Alisa et al., 2005; Caulfield and Wijman, 2008; Lundstro¨m et al., 2008). Like stroke, MS is one of the important health problems that cause disability. MS has an important place among diseases in adults that cause neurological disability without trauma (Bjartmar
* Corresponding author. Tel.: +90 346 225 2321; fax: +90 346 225 1231. E-mail addresses: [email protected], [email protected] (M. Mollaog˘lu). 0167-4943/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2010.11.031
et al., 2000). It is known that patients with MS become dependent on others in performing their activities of daily life due to the variable levels of deficiency in mobility and functional disabilities caused by MS (Einarsson et al., 2006; Mollaoglu and Ustun, 2009). Among the most important reasons that cause this dependence, loss of balance, visual disorders, fatigue, ataxia, spasticity and changes in walking have been included (Kirstein and Jaime, 2006; Smedal et al., 2006; Putzki et al., 2009). In epilepsy, which is one of the other important diseases among neurological disorders, it has been noted that changes in daily life activities may occur as a result of changes in the quality of life of an individual due to physical and psychosocial effects, frequent hospitalizations, and recurrent attacks (Birbeck et al., 2007). When all of these data were reviewed, the importance of evaluating the individual’s disability emerged, which is defined as impairment in performing a duty within a normal range or in a normal form, in individuals with neurological deficiencies. It has been reported that disability occurs as a result of restrictions in basic physical, psychological and mental functions, and each of these functions is individually important in the formation of disability, and that interventions at early stages can decrease the prevalence of disability (Curtiss et al., 2007; Fagerstro et al., 2008). Despite the presence of several studies on disability, functional status or activities of daily life primarily in the patients with stroke ¨ zkan as well as in other neurological patients (Gignac et al., 2000; O
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Tuncay and Mollaoglu, 2006) there are no studies analyzing and comparing both mobility and physical–social disability in patients with stroke, MS and epilepsy. Information to be obtained will be helpful in selecting protective, healing and rehabilitative interventions to prevent and decrease the disability, improving the health of individuals with stroke, MS and epilepsy, and rendering the nurses more effective in this field in dealing with patients with neurological disorders. In this context, the aim of this study was to determine the disability and to analyze its relationship with some sociodemographic characteristics in patients with stroke, MS and epilepsy.
2. Subjects and methods The study comprised patients with stroke, MS and epilepsy who had been treated in Cumhuriyet University Neurology Clinic between March and December 2009. Although a total of 126 patients aged older than 65 years had been treated between these dates, 4 patients did not want to participate in the study, 7 patients with stroke had impairments in their cognitive functions, and 2 patients with epilepsy had more frequent attacks; therefore, sampling was performed in 113 patients.
points = moderate and 13 points or above was considered to be severe disability (Akin and Emirog˘lu, 2007). 2.3. The procedure After acquiring permission from the Cumhuriyet University Hospital Ethics Committee, first the aim of the study was explained to the patients and their willingness to participate in the study was considered. The Neurology Clinic consists of two sections namely a Stroke Unit and the unit in which patients with other neurological disorders are accepted. The study was performed in both units. In an appropriate room in the clinic, neurological evaluation was performed and information collection forms were given to the patients by two nurses with graduate degree, who had worked in the neurology clinic for many years, who at the same time had participated in academic studies on neurology nursing. Some of the patient data were collected by the neurologist using patient files (duration of the disease, some medical information, some neurological examination data, etc.). This procedure was applied to stroke patients with mobility problems in their rooms. Although it varied according to the patient’s status, the duration of data collection and neurological evaluation took on average 20–30 min. 2.4. Data analysis
2.1. The study sample Patients with stroke (n = 53) formed 47%, patients with MS comprised 26.5% (n = 30) and patients with epilepsy comprised the remaining 26.5% (n = 30) of the study group. Females amounted to 61.1% of the patients, 64.6% of them were married, 47.8% were above 50 years of age, 69.0% were literate, and 3.5% did not have health insurance. 2.2. Data collection The patient information form was used to obtain data related to individuals. The Rivermead mobility index (RMI) was used to evaluate the disability in mobility, and the brief disability questionnaire (BDQ) was used to evaluate physical–social disability. Patient information form; this form, which was prepared by the researchers by making use of related literature and studies, consisted of seven questions in order to question individuals’ demographic and clinical characteristics such as ages, marital status, level of education, economical status, and duration of the disease. RMI is a single-dimensional index focusing on measuring the mobility status and consists of 14 questions and one observation about basic mobility activities. In this index, patient information about their activities such as transfer, balance, walking, climbing up the stairs, having a bath and running are collected. The points obtained from RMI varies between ‘‘0’’ and ‘‘15’’; 15 points (full points) shows that there is no problem in mobility; 14 points or below indicates that there is a problem in mobility. Since RMI is formed from a basic to a complex hierarchical structure, it is thought that as the points become lower, the severity of the problem increases (Grasso et al., 2005; Smedal et al., 2006; Akin and Emirog˘lu, 2007). RMI was improved by Collen et al. (1991) and the validity and reliability study for our country were performed by Akin and Emirog˘lu (2007). The BDQ was developed by the WHO and customized for our country by Kaplan (1995) and its validity and reliability were analyzed. BDQ is a scale consisting of 11 tables with total points of 22. It was accepted that individuals having 5 points or above from the BDQ questionnaire were considered to have physical social disability, 0–4 points = no disability, 5–7 points = mild, 8–12
The data obtained in the study were evaluated using percentage calculations, the x2-test, variance analysis, the Mann–Whitney Utest, the Kruskal–Wallis test, and the Pearson correlation test in the SPSS (version 11.0) software package. 3. Results Socio demographic and clinical characteristics of the patients involved in the study have been displayed in Table 1. When the disability level was evaluated with respect to the scale points, it was seen that according to the BDQ, all the patients experienced physical–social disability and 54.9% of them were experiencing this at a severe level; according to RMI, on the other hand, 86.7% of them had disability in mobility (Table 1). When mobility-related disability was analyzed with respect to the type of diseases that the patients had, it was found that patients with stroke had lower RMI scores and experienced more severe mobility-related disability. Patients with MS on the other hand, had a higher average score and the difference among the groups was statistically significant (p < 0.001). When BDQ points were examined in the same group, although it was not statistically significant, it was determined that disability was more severe in patients with MS than in patients with stroke and epilepsy. However, when the entire patient group was considered, it was found that patients with neurological disorders experienced disability at a moderate level (7.88 4.96) according to the RMI scale (range = 0–15 points), and at a severe level from a physical– social perspective according to BDQ scores (range = 0–22 points) (mean = 13.62 5.46) (Table 2). Furthermore, in this study, 32.7% of the patients with neurological disorders having mobility-related disability (stroke, MS and epilepsy) experienced a moderate-level, 63.3% of them, on the other hand, experienced a physical–social field disability at a severe level and there was a highly significant relationship between mobility-related disability and physical social field disability (x2 = 56.13, p < 0.001). When the relationship between BDQ and patients individual characteristics were investigated, it was found that, as the age increased, the severity of physical and social disability increased (p < 0.05); furthermore, mobility-related disability increased in individuals with in their 65–69 years (p < 0.001). It can be seen
M. Mollaog˘lu et al. / Archives of Gerontology and Geriatrics 53 (2011) e227–e231 Table 1 Characteristics of the subjects.
Table 3 The relationship between RMI- and BDQ-scores and demographic characteristics of subjects.
n (%)
Characteristics
69(61.1) 44(38.9)
Gender Female Male t Age 65–69 years 70 years t Education level Illiterate Primary–secondary school High school and above Kruskal–Wallis Occupation Unemployed Housewife Farmer Employee-officer Kruskal–Wallis Marital status Married Single Widow Kruskal–Wallis
69(52.2) 44(47.8) 35(31.0) 52(46.0) 26(23.0) 9(8.0) 65(57.5) 8(7.1) 31(27.4) 73(64.6) 19(16.8) 21(18.6) 109(96.5) 4(3.5) 5(4.4) 9(8.0) 37(32.7) 62(54.9)
a c
15(13.3) 98(86.7)
RMI˙
BDQ
Characteristics
Gender Female Male Age 65–69 years <70 years Education level Illiterate Primary–secondary school High school and above Occupation Unemployed Housewife Farmer Employee-officer Marital status Married Single Widow The existence of health insurance, existent Nonexistent Physical–social disability (BDQ) No disability (0–4 points) Mild level disability (5–7 points) Moderate level disability (8–12 points) Severe level disability (13 points or above) Mobility disability (RMI) There is no problem in mobility (15 points) There is problem in mobility (14 points or below)
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13.48 5.22 13.84 5.86 0.34
7.48 4.94 8.50 4.99 1.06
12.61 4.74 14.72 5.99 2.08a
9.64 4.17 5.94 5.08 4.24c
15.11 6.27 13.23 5.06 12.38 4.75 4.702
4.80 4.73 8.67 4.44 10.42 4.30 21.51c
17.44 4.53 13.60 5.11 17.88 3.87 11.45 5.69 13.38a
6.56 4.24 7.28 4.92 4.63 3.77 10.35 4.68 13.56a
10.63 5.52 13.37 5.25 17.19 4.26 14.09c
11.95 3.27 7.73 5.07 4.71 3.08 21.72c
p < 0.05. p < 0.001.
Stroke is usually termed a cerebrovascular accident and together with loss of movement and sensation that emerge in the upper and lower extremities across the lesioned brain hemisphere, shows itself as balance and perception problems throughout the body, in addition to perception, sensation and motor integration disorders, and disability develops as a result of these disorders (Hoffman et al., 2003). For this reason, the presence of disability in patients with stroke is an expected finding and the results of our study show similarities with the results of the other studies showing that stroke causes disability (Widar and Ahlstro¨m, 2002; Lundstro¨m et al., 2008). The fact that disability was to a higher degree in patients with stroke when compared to patients with other neurological problems, together with loss of movement and sensation developing in relation to the lesion on brain hemisphere, can be explained by the relationship between the activities of daily life and visual perception disorders in patients with stroke (Teasel, 2003). This, on the other hand indicates that during the practices for activities of daily life, visual perception disorders should be considered and evaluated. In this study, it was determined that both physical–social and mobility-related disability were seen to a lesser extent in MS patients than in patients with stroke and epilepsy. In other words, it was determined that while disability was seen at a moderate level in patient with MS, it was severe in patients with stroke and epilepsy. Although there have been no studies comparing the disability among patient with MS and with other neurological disorders in the literature, there are numerous studies investigating the effect of MS on daily life activities of an individual. It was determined in the study by Einarsson et al. (2006) that only 30% of the patients with MS were totally independent in daily life activities and other patients were dependent for these activities at
that as the education level among the patients decreased, the probability of physical and social disability increased and especially disability in mobility differed among the different levels of education and this differences were statistically significant (p < 0.001). The severity of physical, social and mobility disability in patients who were self-employed and farmers was found to be higher than in other occupation groups and the difference between these groups was statistically significant (p < 0.05). When the marital status variable was analyzed, widowers were found to experience deficiency more intensely (p < 0.001). On the other hand, no significant relationship was found between sex and BDQ-RMI scales (Table 3). From the analysis of correlation between RMI and BDQ scales, it was determined that there was a statistically significant negative correlation between physical and social disability and mobilityrelated disability (r = 0.697, p < 0.001). 4. Discussion Important health problems that cause changes in neurological functions alter the functional abilities such as dressing, walking, and day care, and affect individuals’ daily life activities and capabilities (Gignac et al., 2000; Verbrugge and Yang, 2002). In this study that was performed to determine the disability in patients with neurological problems such as stroke, MS and epilepsy, it was determined that physical–social disability was seen in all of the patients; disability in mobility was seen in most of the patients. Among three neurological disorders that were examined in this study, patients with stroke were found to be the most affected group by disability. Table 2 The mean values of RMI and BDQ scores of subjects, mean S.D.
RMI score BDQ score
Stroke
Epilepsy
MS
Total
F
p
5.75 5.24 14.26 6.06
8.63 4.56 14.43 5.15
10.87 2.66 11.67 4.15
7.88 4.96 13.62 5.46
12.86 2.70
<0.001 <0.07
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certain levels. Also in a study that used RMI by Kirstein and Jaime (2006), similar to the results of our study, it was found that patients with MS experienced disability in mobility to a relatively important extent. In general, motor deficits that emerged during the course of the disease were thought to be responsible for the disability in MS (Gulick and Goodman, 2006; Stroud and Minahan, 2009). From this difference; it is thought that sensation, perception and motor disorders appear at variable levels among these three disorders and therefore, cause disability at variable levels in these diseases, and hence, the differences in psychosocial effects of these diseases on individuals. Further studies are needed to investigate this topic from both physicopathological and physicosocial aspects. Besides the neuropathic impacts of epileptic discharges, the reason for disability being more severely encountered, especially in the physical and social field in patients with epilepsy can be related to stigmatization that the patients with epilepsy pass through. In studies performed on patients with epilepsy, it was determined that due to reasons such as stigma, recurrent attacks, social humiliation because of these recurrent attacks, social isolation and social disability developed in these patients (Piazzini et al., 2008). Handling these patients with a multidisciplinary team approach, evaluating the diseases on an individual with not only the physical effects, but also with combining physicosocial effects and developing effective strategies in order to solve the problem, are the responsibilities of healthcare workers (Hosking, 2006). Among patients with neurological diseases (stroke, MS, epilepsy), the fact that most of the patients with mobility disability also experience disability in the physical–social field is another important finding of this study. This relationship was also found in a study that was performed previously (Akin and Emirog˘lu, 2003). The increasing effect of mobility disability on social disability can be related to the individual’s inability to enter the social environment due to restrictions in mobility. For this reason, it is important to activate social support factors. Indeed, it was mentioned in a study that individuals with mobility disability may develop higher levels of disability. Therefore, effective evaluation of mobility disability is important to decrease the severity of disability (Guralnik et al., 1995). We also analyzed the relationship between disability and some demographic characteristics of the patients with stroke, MS and epilepsy. Accordingly, the level of disability was found to be more severe in advanced age, low level of education, farmers, the selfemployed and widows. The results on mobility–disability and physical–social disability in patients with advanced age showed differences. While a significant correlation was found between age and disability in some studies (Cook et al., 2003; D’Alisa et al., 2005), no significant correlation was found in others (Sommerfeld and Van Arbin, 2001; Bardak et al., 2008). Besides the pathophysiological effects of the diseases on mobility, due to the probable psychosocial effects of chronic diseases, the presence of a significant correlation between age and disability was, therefore, an expected finding. The study of Litwin (2003), in which it was shown that the severity of disability was higher among the elderly with low social support should also be taken into consideration. Mobility, which is a disability environment related to the ability of an elderly to move, can be an indicator for the elderly to determine important situations such as higher level disability and falling and can be considered as a situation that increases the importance of preventing our patients from trauma and determining their social support needs. Another finding in this study is that the disability status on mobility was affected according to the level of education of the patients. When RMI point averages were considered, it was found that the average scores of illiterates were lower and as the level of education increased, the disability in mobility decreased. Similarly in another study, a higher level of education was reported to be an
important factor that decreased the severity of disability and the severity of disability was low in individuals with a high level of education (Bardak et al., 2008). Since most of the patients included in our study had a low level of education, it can be thought that the characteristics of the social assistance network in our county can be different. When rehabilitation studies are planned, this finding should necessitate the overview of characteristics in patients with low level of education. Marital status was found to be another risk factor for disability in the study. It was found that widows experienced disability both in mobility and the physical–social field at a significant degree. Similar results were also found in the study of Litwin (2003), one of the studies in which social support was found to decrease the severity of mobility. Another study showing that there was a relationship between marital status and disability was performed by Verbrugge and Yang (2002). In a study performed with patients with stroke, it was also found that mobility points of widowers were found to be lower than that in other groups. In conclusion, in this study that aimed to determine the presence of disability in patients with stroke, MS and epilepsy and investigate the relationship between the patients’ sociodemographic characteristics and disability, it was determined that in all patients, disability was present at a moderate level in mobility, at a severe level in the physical–social field, and in patients with stroke, the disability was found to be present at a more severe level when compared to patients with MS and epilepsy, and most of the patients with disability in mobility were experiencing disability in physical–social field at a more severe level, and that there was a significant correlation between disability and age, marital status, education and occupation. According to these results, in addition to performing a general assessment toward mobility, it can be suggested that, in order to decrease the risk of disability, together with the all the medical staff, nurses should take all the necessary precautions in patients with neurological deficiency during patient-related planning, and risky groups for disability should be taken into consideration; patients with disability should be followed up for lost functions and interventions for these lost functions should be emphasized, and a multidisciplinary team approach should be applied. Study limitations: That the study was realized in only one city of Turkey, was regarded as its limitation. It is advised that the some study be realized in a larger population which would represent Turkey. Besides, it is planned to assess the disability by using objective examining methods, to notice that all these findings are very important for planning health care and to do other studies as a continuation of this one. In spite of these limitations, and although there are some studies which investigate disability in neurological patients, there are no studies which determine stroke, MS and epilepsy and evaluate together these three disorders. In addition, this study calls attention to that, individuals’ personal characteristics have same effects on disability. Besides, this research is the first study to investigate disability of neurological patients in Turkey. With its all these qualities this study enables a database for further studies and we think that it also contains some important data, which is necessary for planning the care of neurological patients. Conflict of interest None. Acknowledgement The authors express their thanks to Dr. Ziynet C¸ınar of the Department of Statistics of Cumhuriyet University, for help with the statistical evaluations in this investigation.
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