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Gender and the functional outcome of elderly ischemic stroke patients
Archives of Gerontology and Geriatrics 55 (2012) 438–441
Contents lists available at SciVerse ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Gender and the functional outcome of elderly ischemic stroke patients E.H. Mizrahi a,b,*, A. Waitzman a, M. Arad a,b, A. Adunsky a,b a b
Department of Geriatric Medicine and Rehabilitation, Sheba Medical Center, Tel-Hashomer, 52621, Israel The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, 69978, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 May 2011 Received in revised form 23 August 2011 Accepted 4 November 2011 Available online 7 December 2011
The purpose of this study was to investigate the effect of gender on the functional outcome after ischemic stroke. In a retrospective chart review we studied 919 survivors of ischemic stroke admitted for rehabilitation at a geriatric rehabilitation ward of a university affiliated hospital. Functional outcome of female and male patients was assessed by Functional Independence Measurement (FIMTM) at admission and discharge. Data were analyzed by t test, Chi-square test and Linear Regression. A total number of 919 patients were admitted of whom 56% were males. A higher proportion of male patients reported ischemic heart disease (p < 0.001), hypercholesterolemia (p = 0.035), Parkinson‘s disease (p = 0.044), and previous stroke (p < 0.001). Males had also higher Mini-Mental State Examination (MMSE) scores (p < 0.001). Total FIM at admission (62.54 25.98 and 66.00 25.49; p = 0.043), and total FIM at discharge (80.39 30.35 and 85.59 29.08; p = 0.008), motor FIM at admission (40.04 18.89 and 42.51 18.47; p = 0.047) and motor FIM at discharge (56.41 23.04 and 60.44 21.84; p = 0.007) were higher among male patients. However, a trend for a borderline statistical difference was observed for FIM gains upon discharge between men and women. A multiple linear regression analysis showed that total FIM at discharge was neither associated with male nor female gender (b = 0.009; p = 0.69). The findings suggest that the functional outcome of male survivors presenting for rehabilitation after acute ischemic stroke is slightly better. After adjusting for possible covariates, gender did not emerge as an independent predictor for higher FIM at discharge, suggesting that gender should not be held as adversely affecting rehabilitation of such patients. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Gender Functional outcome Prognosis Rehabilitation Stroke
1. Introduction Stroke is the third leading cause of death in most countries, and is one of the leading causes of long-term disability. Each year, around 795,000 Americans experience a new or recurrent stroke, incurring high annual costs (Lloyd-Jones et al., 2010). The female population carries a higher burden of stroke due to longer life expectancy in women and accounts for the majority of stroke deaths (Seshadri et al., 2006; Lloyd-Jones et al., 2010). The incidence of stroke in women becomes higher than in men at the age of 80 years (Olsen et al., 2009). Over the past decade published cohort studies have consistently shown that women and men with stroke have different characteristics (Turzo and Mccullough, 2008; Vukovic et al., 2009; Jamieson and Skliut, 2010; Persky et al., 2010), with different ageand gender-specific prevalence of various cardiovascular risk factors (Andersen et al., 2010). Overall, men have better outcomes after stroke than women. Among individuals who survive stroke, women are more likely to have worse pre-stroke and post-stroke disability
* Corresponding author at: The Chaim Sheba Medical Center, Tel.:-Hashomer, 52621, Israel. Tel.: +972 3 5303398; fax: +972 3 5303399. E-mail address: [email protected] (E.H. Mizrahi). 0167-4943/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2011.11.002
(Roquer et al., 2003; Kapral et al., 2005) and have higher rates of institutionalization (Glader et al., 2003; Kelly-Hayes et al., 2003). There is a difference of opinions about the possible impact of gender on rehabilitation outcomes among stroke patients. A Norwegian study on functional outcomes after stroke found that women were six times more likely to be institutionalized at one year than men, while men were three times more likely to achieve a high score on the Barthel Index, compared to women (Wyller et al., 1997). Two recent publications have also confirmed less favorable functional outcome and high disability rates in women, compared to male patients (Appelros et al., 2010; Kong et al., 2010). A recent study has concluded that gender was not a significant predictor of total and motor FIM score at discharge (Ones¸ et al., 2009), yet, another study including 100 patients found that while at the beginning of rehabilitation functional status was worse in women than men, women‘s functional status improved equally during rehabilitation, though the difference between men and women persisted at discharge (Petruseviciene and Krisciu¯nas, 2005). The present study aimed to evaluate whether, and to what extent, gender is interrelated to overall functional outcome of a large group of elderly stroke survivors. This would assist in evaluating rehabilitation potential or possible need of applying different rehabilitation strategies for women.
E.H. Mizrahi et al. / Archives of Gerontology and Geriatrics 55 (2012) 438–441
439
assessed by the Mini-Mental State Examination (Folstein et al., 1975) within one week after admission to the rehabilitation ward.
2. Patients and methods 2.1. Setting
2.4. Data analysis The Geriatric Rehabilitation ward at our medical center is a 36bed unit. The ward utilizes an interdisciplinary team approach, where representatives from geriatrics, physiotherapy, nursing, rehabilitation therapies (physical, occupational and speech), social services, and psychology meet twice a week to evaluate the status of each patient. During these meetings, a treatment plan is established and monitored with the purpose of coordinating and integrating staff activities, and promoting effective rehabilitation. The patients undergo a typical amount of 6 h per week of physical and occupational therapy (6 days per week) which is typical of other facilities in the country. 2.2. Participants This retrospective study included 919 patients aged 60 years with ischemic stroke. Patients were consecutively admitted to our ward during a 7-years period, after a short stay in the departments of internal medicine or neurology. Stroke was diagnosed on the basis of clinical presentation of acute onset of focal neurological signs. CT or MRI scans were performed in all cases to confirm the presence of ischemic stroke. Primary inclusion criteria, other than ischemic nature of stroke, included stable medical status (enabling active rehabilitation treatment), and a length of stay and nature of ischemic stroke in the rehabilitation ward of more than seven days (assuming that a shorter extent of rehabilitation is meaningless). The study sample did not include patients with residual brain damage due to infection, trauma or surgery and patients with space occupying lesions or hemorrhagic stroke. The presence of arterial hypertension, ischemic heart disease (manifested as stable or unstable anginal syndrome), atrial fibrillation, previous stroke, diabetes mellitus and hyperlipidemia were established by medical history, obtained by interview and a complete physical examination. 2.3. Functional assessment The patients were evaluated within three days of admission by members of the rehabilitation team experienced with the FIM scale (Lincare et al., 1994), a standardized method of measuring the level of physical independence. FIM data were documented at admission and upon discharge. The dependent outcome variables that were examined included the absolute change in total and motor FIM changes during rehabilitation stay. Patient‘s cognitive status was
Patients were divided into two groups, by gender. Comparisons between the two groups, with regards to demographic and clinical characteristics, were performed using t-tests, Chi square tests and multiple regression analyses. The statistical significance level was set to 0.05. The SPSS for Windows software, version 11.0, was used for these analyses. 3. Results The data of 919 consecutive ischemic stroke survivors aged 60 and older were available. The clinico-demographic characteristics of these patients are shown in Table 1. Mean age was 75.7 7.9 years. 405 patients (44%) were females. The mean rehabilitation length of stay in our ward was 50.29 27.4, which is typical of post-acute care in our country. There were no statistically significant differences between the two groups regarding age, length of stay, hypertension or diabetes mellitus. Ischemic heart disease (22.5% vs. 35.9%, p < 0.001), atrial fibrillation (60.7% vs. 39.3%, p < 0.001), Hyperlipidemia (28.8% vs. 35.3%, p = 0.035), Parkinson‘s disease (2.5% vs. 5.1%, p = 0.044) previous stroke (14.1% vs. 28.5%, p < 0.001) and MMSE (21.5 5.6 vs. 23.2 5.2, p < 0.001) emerged as the statistically significant parameters differing between females and males, respectively shown in Table 1. Male patients presented to rehabilitation with significantly higher total (p = 0.043) and motor (p = 0.047) FIM scores, compared to female patients are shown in Table 2. Male patients were also discharged from the ward with better total (p = 0.008) and motor (p = 0.007) FIM scores. However, there was only a borderline statistical difference between females and males patients in gain in total FIM (p = 0.084) and gain in motor FIM at discharge (p = 0.073). Since the male group patients had better cognitive status and a better functional starting point, we performed a multiple linear regression analysis to test for predictors of functional outcome at hospital discharge. This showed that total FIM at discharge was independently, and inversely associated with age (b = 0.096, p < 0.001). A higher MMSE and total FIM score at admission predicted higher total FIM scores at discharge (b = 0.11, p < 0.001; and b = 0.73, p < 0.001, respectively) as shown in Table 3. None of the other variables that we tested, including gender, were predictive of higher total FIM scores at discharge.
Table 1 Patients’ demographic, clinical and cognitive characteristics, by gender. Variable
All
Females
Males
N Age (years; mean) (years; median) Length of stay (days) Diabetes mellitus (%) Hypertension (%) Ischemic heart disease (%) Atrial fibrillation (%) Hyperlipidemia (%) Parkinson‘s disease (%) Previous Stroke (%) MMSE
919 75.70 7.9 75.0 50.29 27.4 37.8 70.4 29.8 18.6 31.7 3.9 22.1 22.5 5.4
405(44%) 76.2 7.9 76.0 49.56 26.83 38.8 66.5 22.5 60.7 28.8 2.5 14.1 21.5 5.6
514(56%) 75.3 8.0 75.0 50.8 27.8 37.2 66.5 35.9 39.3 35.3 5.1 28.5 23.5 5.2
Data are mean SD. a p-Value calculated using Student’s t-test for continuous variables and x2 test for categorical variables. * Continuous variable. y Categorical variable.
pa 0.11* 0.51* 0.63y 0.37y <0.001y <0.001y 0.035y 0.044y <0.001y <0.001*
E.H. Mizrahi et al. / Archives of Gerontology and Geriatrics 55 (2012) 438–441
440 Table 2 Patients’ functional characteristics, by gender.
Table 3 Independent predicting factors of total FIM at discharge.a
Variable
Female
Male
pa
Admission total FIM Discharge total FIM Change in total FIM Admission motor FIM Discharge motor FIM Change in motor FIM
62.5 25.9 80.4 30.3 17.8 14.4 40.0 18.8 56.4 23.0 16.37 12.3
66.00 25.5 85.6 29.1 19.6 15.8 42.5 18.5 60.4 21.8 17.9 3.7
0.043 0.008 0.084 0.047 0.007 0.073
Data are mean SD. a p value was calculated using Student’s t-test for continuous variables.
Gender Age Ischemic heart disease Hypertension Diabetes Mellitus Atrial fibrillation Previous stroke Parkinson‘s disease Total FIM, admission MMSE a
B
p
0.009 0.096 0.011 0.008 0.007 0.026 0.04 0.04 0.73 0.11
0.69 <0.001 0.62 0.72 0.75 0.25 0.07 0.065 <0.001 <0.001
Data excluded from multiple linear regression analysis.
4. Discussion Female gender is often viewed as one potentially hindering the rehabilitation process with previous studies showing that female gender is associated with adverse outcomes in terms of post-stroke disability (Paolucci et al., 2006; Petrea et al., 2009). Higher age and more severe strokes have been blamed for this less favorable outcome, rather than gender (Appelros et al., 2010). This is in accordance with our results showing that after adjusting for possible covariates, gender did not emerge as an independent predictor for total FIM at discharge, and suggesting that gender per se should not be held as adversely affecting rehabilitation of such patients. This is also supported by the fact that despite the fact that females did present with lower FIM scores at admission and discharge, women have achieved similar functional gains during rehabilitation. Overall, the results support previously mentioned reports showing more post-stroke disability in females, which seems to depend not only upon pre-stroke health condition and functional ability, but also factors such as age, MMSE and FIM at admission score, rather than gender. This is also in accordance with three other studies (Folstein et al., 1975; Kapral et al., 2005; Paolucci et al., 2006) which after controlling for pre-stroke functional ability, found no gender differences in level of independence of ADL, attributing most of the differences to older age. The present study used FIM scores to investigate possible gender differences of functional outcome after stroke, and is of importance since this tool has become highly popular in recent years. The scale has few advantages over other widely used scales such as the Barthel (Wyller et al., 1997), Rankin (Kapral et al., 2005) or non-formal tools (Kelly-Hayes et al., 2003) used in earlier studies on gender and stroke functional outcomes. Use of FIM to analyze our data is advantageous since it shows lower ceiling and floor effects compared to the Barthel index (Hsueh et al., 2002; Dromerick et al., 2003). Both scales have similar reliability characteristics (Hobart et al., 2001) with some superiority of the FIM tool due to its excellent test–retest reliability (Kidd et al., 1995). In addition, while validity studies with FIM, Barthel and Rankin scales have shown similar correlation coefficients (Kwon et al., 2002) sensitivity to change in disability after stroke was superior for FIM (and its change) as reflected by its standardized response mean (Van Der Putten et al., 1999). This probably helps with measuring with greater accuracy the functional gains during rehabilitation, which in our study, proved similar in the two groups. There are few explanations concerning risk factors for stroke and adverse outcome. Some of these differences have been attributed to the effect of endogenous and exogenous hormones on the cerebrovasculature of the female brain (Ushnell, 2008) older age and higher incidence of hypertension, atrial fibrillation (Holroyd-Leduc et al., 2000; Di Carlo et al., 2003; Roquer et al., 2003; Kapral et al., 2005) total cholesterol levels (Di Carlo et al., 2003), lower HDL cholesterol and higher waist girth and body
weight (Dallongeville et al., 2004). Women are also twice as likely as men to develop post stroke depression (Paradiso and Robinson, 1998). These and other factors which affect outcome in terms of survival or stroke severity, are also associated with worse functional and cognitive status upon admission, as shown in our sample, that probably result with the mildly unfavorable functional outcome. The present study is advantageous in the sense that it comprised a large sample of patients, all of whom suffered ischemic stroke and underwent a rehabilitation program in a ward dedicated to the rehabilitation of elderly stroke patients. Above all, this is the first study focusing on the specific role of gender on rehabilitation, while using the FIM as a structured assessment tool. Possible limitations of our study result from its retrospective nature and design. There is no data on stroke severity or ischemic stroke subtype. Despite a careful adjustment made for important confounders, still other could have been considered, including the pre-stroke disability. Finally, the study may be criticized for not using a Rasch analysis, which is advantageous over linear and interval analyses. However, linear or interval FIM analyses are still popular and have been used in most of the FIM outcome studies to monitor changes during inpatient rehabilitation, simply because most FIM data do seem to conform closely enough to conventional models. We conclude that the mildly associated post-stroke adverse functional outcome in females is associated with older age, lower MMSE and lower admission FIM scores, rather than with gender. In conclusion, our findings suggest that gender is not an independent predictor for higher FIM at discharge, thus, gender should not be held as adversely affecting rehabilitation of such patients. The role of gender in the process of post-stroke recovery deserves further investigation. Conflict of interest statement All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their word. References Andersen, K.K., Andersen, Z.J., Olsen, T.S., 2010. Age- and gender-specific prevalence of cardiovascular risk factors in 40102 patients with first-ever ischemic stroke. A nationwide Danish study. Stroke 41, 2768–2774. Appelros, P., Stegmayr, B., Terent, A., 2010. A review on sex differences in stroke treatment and outcome. Acta Neurol. Scand. 121, 359–369. Dallongeville, J., Cottel, D., Arveiler, D., Tauber, J.P., Bingham, A., Wagner, A., Fauvel, J., Ferrie`res, J., Ducimetie`re, P., Amouyel, P., 2004. The association of metabolic disorders with the metabolic syndrome is different in men and women. Ann. Nutr. Metab. 48, 43–50. Di Carlo, A., Lamassa, M., Baldereschi, M., Pracucci, G., Basile, A.M., Wolfe, C.D., Giroud, M., Rudd, A., Ghetti, A., Inzitari, D., 2003. European BIOMED Study of Stroke Care Group. Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a Multicenter Multinational Hospital-Based Registry. Stroke 34, 1114–1119.
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Contents lists available at SciVerse ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Gender and the functional outcome of elderly ischemic stroke patients E.H. Mizrahi a,b,*, A. Waitzman a, M. Arad a,b, A. Adunsky a,b a b
Department of Geriatric Medicine and Rehabilitation, Sheba Medical Center, Tel-Hashomer, 52621, Israel The Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, 69978, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Received 16 May 2011 Received in revised form 23 August 2011 Accepted 4 November 2011 Available online 7 December 2011
The purpose of this study was to investigate the effect of gender on the functional outcome after ischemic stroke. In a retrospective chart review we studied 919 survivors of ischemic stroke admitted for rehabilitation at a geriatric rehabilitation ward of a university affiliated hospital. Functional outcome of female and male patients was assessed by Functional Independence Measurement (FIMTM) at admission and discharge. Data were analyzed by t test, Chi-square test and Linear Regression. A total number of 919 patients were admitted of whom 56% were males. A higher proportion of male patients reported ischemic heart disease (p < 0.001), hypercholesterolemia (p = 0.035), Parkinson‘s disease (p = 0.044), and previous stroke (p < 0.001). Males had also higher Mini-Mental State Examination (MMSE) scores (p < 0.001). Total FIM at admission (62.54 25.98 and 66.00 25.49; p = 0.043), and total FIM at discharge (80.39 30.35 and 85.59 29.08; p = 0.008), motor FIM at admission (40.04 18.89 and 42.51 18.47; p = 0.047) and motor FIM at discharge (56.41 23.04 and 60.44 21.84; p = 0.007) were higher among male patients. However, a trend for a borderline statistical difference was observed for FIM gains upon discharge between men and women. A multiple linear regression analysis showed that total FIM at discharge was neither associated with male nor female gender (b = 0.009; p = 0.69). The findings suggest that the functional outcome of male survivors presenting for rehabilitation after acute ischemic stroke is slightly better. After adjusting for possible covariates, gender did not emerge as an independent predictor for higher FIM at discharge, suggesting that gender should not be held as adversely affecting rehabilitation of such patients. ß 2011 Elsevier Ireland Ltd. All rights reserved.
Keywords: Gender Functional outcome Prognosis Rehabilitation Stroke
1. Introduction Stroke is the third leading cause of death in most countries, and is one of the leading causes of long-term disability. Each year, around 795,000 Americans experience a new or recurrent stroke, incurring high annual costs (Lloyd-Jones et al., 2010). The female population carries a higher burden of stroke due to longer life expectancy in women and accounts for the majority of stroke deaths (Seshadri et al., 2006; Lloyd-Jones et al., 2010). The incidence of stroke in women becomes higher than in men at the age of 80 years (Olsen et al., 2009). Over the past decade published cohort studies have consistently shown that women and men with stroke have different characteristics (Turzo and Mccullough, 2008; Vukovic et al., 2009; Jamieson and Skliut, 2010; Persky et al., 2010), with different ageand gender-specific prevalence of various cardiovascular risk factors (Andersen et al., 2010). Overall, men have better outcomes after stroke than women. Among individuals who survive stroke, women are more likely to have worse pre-stroke and post-stroke disability
* Corresponding author at: The Chaim Sheba Medical Center, Tel.:-Hashomer, 52621, Israel. Tel.: +972 3 5303398; fax: +972 3 5303399. E-mail address: [email protected] (E.H. Mizrahi). 0167-4943/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2011.11.002
(Roquer et al., 2003; Kapral et al., 2005) and have higher rates of institutionalization (Glader et al., 2003; Kelly-Hayes et al., 2003). There is a difference of opinions about the possible impact of gender on rehabilitation outcomes among stroke patients. A Norwegian study on functional outcomes after stroke found that women were six times more likely to be institutionalized at one year than men, while men were three times more likely to achieve a high score on the Barthel Index, compared to women (Wyller et al., 1997). Two recent publications have also confirmed less favorable functional outcome and high disability rates in women, compared to male patients (Appelros et al., 2010; Kong et al., 2010). A recent study has concluded that gender was not a significant predictor of total and motor FIM score at discharge (Ones¸ et al., 2009), yet, another study including 100 patients found that while at the beginning of rehabilitation functional status was worse in women than men, women‘s functional status improved equally during rehabilitation, though the difference between men and women persisted at discharge (Petruseviciene and Krisciu¯nas, 2005). The present study aimed to evaluate whether, and to what extent, gender is interrelated to overall functional outcome of a large group of elderly stroke survivors. This would assist in evaluating rehabilitation potential or possible need of applying different rehabilitation strategies for women.
E.H. Mizrahi et al. / Archives of Gerontology and Geriatrics 55 (2012) 438–441
439
assessed by the Mini-Mental State Examination (Folstein et al., 1975) within one week after admission to the rehabilitation ward.
2. Patients and methods 2.1. Setting
2.4. Data analysis The Geriatric Rehabilitation ward at our medical center is a 36bed unit. The ward utilizes an interdisciplinary team approach, where representatives from geriatrics, physiotherapy, nursing, rehabilitation therapies (physical, occupational and speech), social services, and psychology meet twice a week to evaluate the status of each patient. During these meetings, a treatment plan is established and monitored with the purpose of coordinating and integrating staff activities, and promoting effective rehabilitation. The patients undergo a typical amount of 6 h per week of physical and occupational therapy (6 days per week) which is typical of other facilities in the country. 2.2. Participants This retrospective study included 919 patients aged 60 years with ischemic stroke. Patients were consecutively admitted to our ward during a 7-years period, after a short stay in the departments of internal medicine or neurology. Stroke was diagnosed on the basis of clinical presentation of acute onset of focal neurological signs. CT or MRI scans were performed in all cases to confirm the presence of ischemic stroke. Primary inclusion criteria, other than ischemic nature of stroke, included stable medical status (enabling active rehabilitation treatment), and a length of stay and nature of ischemic stroke in the rehabilitation ward of more than seven days (assuming that a shorter extent of rehabilitation is meaningless). The study sample did not include patients with residual brain damage due to infection, trauma or surgery and patients with space occupying lesions or hemorrhagic stroke. The presence of arterial hypertension, ischemic heart disease (manifested as stable or unstable anginal syndrome), atrial fibrillation, previous stroke, diabetes mellitus and hyperlipidemia were established by medical history, obtained by interview and a complete physical examination. 2.3. Functional assessment The patients were evaluated within three days of admission by members of the rehabilitation team experienced with the FIM scale (Lincare et al., 1994), a standardized method of measuring the level of physical independence. FIM data were documented at admission and upon discharge. The dependent outcome variables that were examined included the absolute change in total and motor FIM changes during rehabilitation stay. Patient‘s cognitive status was
Patients were divided into two groups, by gender. Comparisons between the two groups, with regards to demographic and clinical characteristics, were performed using t-tests, Chi square tests and multiple regression analyses. The statistical significance level was set to 0.05. The SPSS for Windows software, version 11.0, was used for these analyses. 3. Results The data of 919 consecutive ischemic stroke survivors aged 60 and older were available. The clinico-demographic characteristics of these patients are shown in Table 1. Mean age was 75.7 7.9 years. 405 patients (44%) were females. The mean rehabilitation length of stay in our ward was 50.29 27.4, which is typical of post-acute care in our country. There were no statistically significant differences between the two groups regarding age, length of stay, hypertension or diabetes mellitus. Ischemic heart disease (22.5% vs. 35.9%, p < 0.001), atrial fibrillation (60.7% vs. 39.3%, p < 0.001), Hyperlipidemia (28.8% vs. 35.3%, p = 0.035), Parkinson‘s disease (2.5% vs. 5.1%, p = 0.044) previous stroke (14.1% vs. 28.5%, p < 0.001) and MMSE (21.5 5.6 vs. 23.2 5.2, p < 0.001) emerged as the statistically significant parameters differing between females and males, respectively shown in Table 1. Male patients presented to rehabilitation with significantly higher total (p = 0.043) and motor (p = 0.047) FIM scores, compared to female patients are shown in Table 2. Male patients were also discharged from the ward with better total (p = 0.008) and motor (p = 0.007) FIM scores. However, there was only a borderline statistical difference between females and males patients in gain in total FIM (p = 0.084) and gain in motor FIM at discharge (p = 0.073). Since the male group patients had better cognitive status and a better functional starting point, we performed a multiple linear regression analysis to test for predictors of functional outcome at hospital discharge. This showed that total FIM at discharge was independently, and inversely associated with age (b = 0.096, p < 0.001). A higher MMSE and total FIM score at admission predicted higher total FIM scores at discharge (b = 0.11, p < 0.001; and b = 0.73, p < 0.001, respectively) as shown in Table 3. None of the other variables that we tested, including gender, were predictive of higher total FIM scores at discharge.
Table 1 Patients’ demographic, clinical and cognitive characteristics, by gender. Variable
All
Females
Males
N Age (years; mean) (years; median) Length of stay (days) Diabetes mellitus (%) Hypertension (%) Ischemic heart disease (%) Atrial fibrillation (%) Hyperlipidemia (%) Parkinson‘s disease (%) Previous Stroke (%) MMSE
919 75.70 7.9 75.0 50.29 27.4 37.8 70.4 29.8 18.6 31.7 3.9 22.1 22.5 5.4
405(44%) 76.2 7.9 76.0 49.56 26.83 38.8 66.5 22.5 60.7 28.8 2.5 14.1 21.5 5.6
514(56%) 75.3 8.0 75.0 50.8 27.8 37.2 66.5 35.9 39.3 35.3 5.1 28.5 23.5 5.2
Data are mean SD. a p-Value calculated using Student’s t-test for continuous variables and x2 test for categorical variables. * Continuous variable. y Categorical variable.
pa 0.11* 0.51* 0.63y 0.37y <0.001y <0.001y 0.035y 0.044y <0.001y <0.001*
E.H. Mizrahi et al. / Archives of Gerontology and Geriatrics 55 (2012) 438–441
440 Table 2 Patients’ functional characteristics, by gender.
Table 3 Independent predicting factors of total FIM at discharge.a
Variable
Female
Male
pa
Admission total FIM Discharge total FIM Change in total FIM Admission motor FIM Discharge motor FIM Change in motor FIM
62.5 25.9 80.4 30.3 17.8 14.4 40.0 18.8 56.4 23.0 16.37 12.3
66.00 25.5 85.6 29.1 19.6 15.8 42.5 18.5 60.4 21.8 17.9 3.7
0.043 0.008 0.084 0.047 0.007 0.073
Data are mean SD. a p value was calculated using Student’s t-test for continuous variables.
Gender Age Ischemic heart disease Hypertension Diabetes Mellitus Atrial fibrillation Previous stroke Parkinson‘s disease Total FIM, admission MMSE a
B
p
0.009 0.096 0.011 0.008 0.007 0.026 0.04 0.04 0.73 0.11
0.69 <0.001 0.62 0.72 0.75 0.25 0.07 0.065 <0.001 <0.001
Data excluded from multiple linear regression analysis.
4. Discussion Female gender is often viewed as one potentially hindering the rehabilitation process with previous studies showing that female gender is associated with adverse outcomes in terms of post-stroke disability (Paolucci et al., 2006; Petrea et al., 2009). Higher age and more severe strokes have been blamed for this less favorable outcome, rather than gender (Appelros et al., 2010). This is in accordance with our results showing that after adjusting for possible covariates, gender did not emerge as an independent predictor for total FIM at discharge, and suggesting that gender per se should not be held as adversely affecting rehabilitation of such patients. This is also supported by the fact that despite the fact that females did present with lower FIM scores at admission and discharge, women have achieved similar functional gains during rehabilitation. Overall, the results support previously mentioned reports showing more post-stroke disability in females, which seems to depend not only upon pre-stroke health condition and functional ability, but also factors such as age, MMSE and FIM at admission score, rather than gender. This is also in accordance with three other studies (Folstein et al., 1975; Kapral et al., 2005; Paolucci et al., 2006) which after controlling for pre-stroke functional ability, found no gender differences in level of independence of ADL, attributing most of the differences to older age. The present study used FIM scores to investigate possible gender differences of functional outcome after stroke, and is of importance since this tool has become highly popular in recent years. The scale has few advantages over other widely used scales such as the Barthel (Wyller et al., 1997), Rankin (Kapral et al., 2005) or non-formal tools (Kelly-Hayes et al., 2003) used in earlier studies on gender and stroke functional outcomes. Use of FIM to analyze our data is advantageous since it shows lower ceiling and floor effects compared to the Barthel index (Hsueh et al., 2002; Dromerick et al., 2003). Both scales have similar reliability characteristics (Hobart et al., 2001) with some superiority of the FIM tool due to its excellent test–retest reliability (Kidd et al., 1995). In addition, while validity studies with FIM, Barthel and Rankin scales have shown similar correlation coefficients (Kwon et al., 2002) sensitivity to change in disability after stroke was superior for FIM (and its change) as reflected by its standardized response mean (Van Der Putten et al., 1999). This probably helps with measuring with greater accuracy the functional gains during rehabilitation, which in our study, proved similar in the two groups. There are few explanations concerning risk factors for stroke and adverse outcome. Some of these differences have been attributed to the effect of endogenous and exogenous hormones on the cerebrovasculature of the female brain (Ushnell, 2008) older age and higher incidence of hypertension, atrial fibrillation (Holroyd-Leduc et al., 2000; Di Carlo et al., 2003; Roquer et al., 2003; Kapral et al., 2005) total cholesterol levels (Di Carlo et al., 2003), lower HDL cholesterol and higher waist girth and body
weight (Dallongeville et al., 2004). Women are also twice as likely as men to develop post stroke depression (Paradiso and Robinson, 1998). These and other factors which affect outcome in terms of survival or stroke severity, are also associated with worse functional and cognitive status upon admission, as shown in our sample, that probably result with the mildly unfavorable functional outcome. The present study is advantageous in the sense that it comprised a large sample of patients, all of whom suffered ischemic stroke and underwent a rehabilitation program in a ward dedicated to the rehabilitation of elderly stroke patients. Above all, this is the first study focusing on the specific role of gender on rehabilitation, while using the FIM as a structured assessment tool. Possible limitations of our study result from its retrospective nature and design. There is no data on stroke severity or ischemic stroke subtype. Despite a careful adjustment made for important confounders, still other could have been considered, including the pre-stroke disability. Finally, the study may be criticized for not using a Rasch analysis, which is advantageous over linear and interval analyses. However, linear or interval FIM analyses are still popular and have been used in most of the FIM outcome studies to monitor changes during inpatient rehabilitation, simply because most FIM data do seem to conform closely enough to conventional models. We conclude that the mildly associated post-stroke adverse functional outcome in females is associated with older age, lower MMSE and lower admission FIM scores, rather than with gender. In conclusion, our findings suggest that gender is not an independent predictor for higher FIM at discharge, thus, gender should not be held as adversely affecting rehabilitation of such patients. The role of gender in the process of post-stroke recovery deserves further investigation. Conflict of interest statement All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their word. References Andersen, K.K., Andersen, Z.J., Olsen, T.S., 2010. Age- and gender-specific prevalence of cardiovascular risk factors in 40102 patients with first-ever ischemic stroke. A nationwide Danish study. Stroke 41, 2768–2774. Appelros, P., Stegmayr, B., Terent, A., 2010. A review on sex differences in stroke treatment and outcome. Acta Neurol. Scand. 121, 359–369. Dallongeville, J., Cottel, D., Arveiler, D., Tauber, J.P., Bingham, A., Wagner, A., Fauvel, J., Ferrie`res, J., Ducimetie`re, P., Amouyel, P., 2004. The association of metabolic disorders with the metabolic syndrome is different in men and women. Ann. Nutr. Metab. 48, 43–50. Di Carlo, A., Lamassa, M., Baldereschi, M., Pracucci, G., Basile, A.M., Wolfe, C.D., Giroud, M., Rudd, A., Ghetti, A., Inzitari, D., 2003. European BIOMED Study of Stroke Care Group. Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a Multicenter Multinational Hospital-Based Registry. Stroke 34, 1114–1119.
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