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Gender differences in disability and lifestyle among community-dwelling elderly stroke patients in Kitakyushu, Japan
998
Gender Differences in Disability and Lifestyle Among Community-Dwelling Elderly Stroke Patients in Kitakyushu, Japan Kenji Hachisuka, MD, Yuka Tsutsui, MD, Kazunari Furusawa, MD, Hajime Ogata, MD ABSTRACT. Hachisuka K, Tsutsui Y, Furusawa K, Ogata H. Gender differences in disability and lifestyle among communitydwelling elderly stroke patients in Kitakyushu, Japan. Arch Phys Med Rehabil 1998;79:998-1002. Objective: To examine whether there were differences in lifestyle and performance of activities of daily living (ADL) between men and women in a population of elderly stroke patients. Design: Case-comparison study. Material and Methods: Sixty-eight men and 34 women who were elderly stroke patients living in the community with a spouse or family members were evaluated with the self-rating Barthel Index (SRBI), Frenchay Activities Index (FAI), Stroke Impairment Assessment Set (SIAS), Functional Independence Measure (FIM), and a pedometer for physical activity. Control subjects, 30 men and 30 women, were assessedwith the FAI. Results: Among the stroke subjects, there were no significant differences in age, SRBI, motor score of the SIAS, or physical activity between men and women; however, men had significantly lower values than did women for three FIM items and the total FIM score and for 6 FAI items and the total FAI score. Among control subjects, men had significantly lower values than did women for 7 FAI items and the total FAI score (Tukey’s test, p < .05). Conclusion: Among elderly stroke patients, men received more support from family members in ADL performance and had less active lifestyles than did women, possibly because of cultural gender roles. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
A
LTHOUGH MORTALITY from stroke has been decreasing, stroke was still the second most common cause of death in Japan in 1995.l Stroke survivors usually suffer from hemiplegia, cognitive disturbances, speech disturbances, and other conditions that, despite appropriate medical or surgical treatment and rehabilitative training, cause functional disability in daily life. Therefore, maintaining functional independence in
From the Department of Rehabilitation Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan. Dr. Furusawa is currently affiliated with Nagasaki Rosai Hospital. Submitted for publication December 8, 1997. Accepted in revised form March 23, 1998. Supported by grants from the Research Committee for Subacute Myelo-OpticoNeuropathy by the Ministly of Health and Welfare Japan, and Research Projects on Aging and Health by the Ministry of Health and Welfare Japan. No commercial party having a direct financial interest in the results of the research supporting this article hasor will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Kenji Hachisuka, MD, Department of Rehabilitation Medicine, University of Occupational and Environmental Health, Japan, l-l Iseigaoka, Yahatanishi, Kitakyushu, #X07, Japan. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7908-4752$3.00/O
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activities of daily living (ADL) and improving quality of life are important for stroke patients in the chronic stage. Among elderly stroke patients with mild or moderate disability seen at our rehabilitation clinic who live at home, men seem to need more help in daily life than do women. Although we notice no difference in ADL performance between men and women among elderly stroke patients while they are in the hospital, a difference seems to arise after discharge. There are few reports, however, on gender differences in ADL performance and lifestyle, that is, how stroke patients spend each day. Wade and colleagues2 reported that analysis of social activities after stroke measured with the Frenchay Activities Index3-5 (FAI) in the United Kingdom did not support a sex-based association and that younger women had more severe initial disability after stroke, but other associations with sex reflected the preponderance of women among older patients.6 However, Hsieh and associates7in Taiwan found that men were more disabled than women in terms of functional disability, a difference that may be due to gender roles in traditional Chinese culture. Therefore, to investigate whether a gender difference exists in ADL performance and lifestyle among community-dwelling elderly stroke patients in Kitakyushu, Japan, we examined the characteristics, functional disability, lifestyle, and physical activity of participants in a community-based rehabilitation program. MATERIALS AND METHODS Subjects were selected from among all registrants in a community-based rehabilitation program sponsored by the Public Health and Welfare Bureau, Kitakyushu City,8 from 1993 through 1996. Most of the registrants were stroke patients with slight disability who had already received medical or surgical treatment and medical rehabilitation during hospitalization. They were referred by a hospital social worker or a city health office nurse to the community-based rehabilitation program for training in functional independence in communitydwelling life and for improvement of their quality of life. The program was managed by a doctor, therapists of the Welfare Center for the Disabled, and city health office nurses, and sessions were held once a week at seven different locations in the city. The sessions included examination by the doctor, instructions for ADL, group training for health promotion, and recreational activities. Because a preliminary study found that ADL performance and lifestyle were affected by age, living conditions, and impairment and disability caused by stroke, the following inclusion criteria were used for this study: cerebral infarction or hemorrhage in the chronic stage (more than 1 year after the onset); older than 54 years but younger than 75 years; living at home with a spouse or other family members; self-rating Bat-the1 Indexg,lo (SRBI) score of 70 or above; no severe aphasia; and no dementia or depression. One hundred forty-six participants who fulfilled the first three inclusion criteria were selected by the therapists, who were not informed of the
GENDER
DIFFERENCES
IN DISABILITY
purpose of the study. When the participants attended the sessions,they were asked to complete the SRBI; there were 107 participants whose SRBI score was 70 or above. After five were excluded because of total aphasia, dementia, or depressive disorders according to the DSM-IV criteria,11 there were 102 participants, 68 men and 34 women. The SRBI is devised based on Granger’s modification12 of the Barthel Index13 and allows the evaluation of the basic ADL of many stroke patients. It consists of 13 main items and 2 supplementary items; possible scores range from 0 (cannot do any items) to 100 (can do all items). The validity, test-retest reliability, and intermethod reliability have been established.9v10 One of the characteristic features of the SRBI is a scale of ADL capability, although the original Barthel index13 and Wade’s modification14 examine ADLpe$ormance. In an interview we asked the subjects questions related to their characteristics. The severity of hemiplegia was evaluated by the doctor using the motor score of the Stroke Impairment Assessment Set (SIAS).16 The motor score consists of the knee-mouth, finger function, hip flexion, knee extension, and foot pat tests, each of which is rated on a 6-level scale from 0 (no voluntary movement) to 5 (as smoothly as on the unaffected side). The motor score ranges from 0 to 30, and its validity and reliability have been reported. l6 Actual ADL performance was evaluated by the doctor using the Functional Independence Measure (FIM).17-19The FIM consists of 18 ADL items with a 7-level scale from 1 (total dependence) to 7 (complete independence); its total score ranges from 18 to 126. Its validity and reliability have been established.17~18 Because the FIM measures performance rather than ADL capability, an ADL item was regarded as dependent when a subject could perform it independently but did not do so. While the stroke patients were in a waiting room, they were asked to complete a questionnaire of the FALzF4which was devised to measure activities reflecting a higher level of independence and social survival.5 The FAI consists of 15 items with a 4-level scale from 0 to 3 giving a total score from 0 (inactive) to 4.5 (highly active). In recent years the FAI has been used as a scale or prototype instrument for evaluating lifestyle in stroke patients.20-22 To examine physical activity in daily life, 70 consecutive stroke patients (49 men and 21 women) were asked to wear a pedometera at their waist belt above the hip joint on the noninvolved side, from the time of rising in the morning until retiring at night for 7 days. l5 The average number of steps per day was obtained as an index of physical activity in daily life. Control subjects for the FAI evaluation were 30 men and 30 women recruited from the database of the subacute myelooptico-neuropathy study (unpublished data). The database contained 1,000 elderly community residents who had been randomly selected from the electoral register as the controls. Inclusion criteria for the recruitment were: no serious diseases; no disability; and living at home with a spouse or other family members. To match the age distribution of the stroke subjects, 5 men and women aged 55 to 59 years, 20 men and women aged 60 to 69 years, and 5 men and women aged 70 to 74 years were randomly selected from among persons on the database who fulfilled the inclusion criteria. The FAI questionnaire was sent to the 60 control subjects by mail. Data are presented as means 2 standard deviations, and statistical analyses were performed with the SPSS 6.15 for Windows.b The two-tailed student’s t test, x2 test (or Fisher’s exact test if necessary), and Mann-Whitney U test were used to compare differences in data between men and women stroke patients. One-way analysis of variance (ANOVA) with Tukey test was used to compare differences in the age and FAI scores
AND
LIFESTYLE,
999
Hachisuka
among men and women stroke patients and controls. Differences with p < .05 were regarded as significant. RESULTS Profiles of the stroke group. Between the men and women in the elderly stroke patient group, there were no significant differences in age, years after the onset, or SRBI scores(t test or Mann-Whitney U test, p > .05), or in disease, side of hemiplegia, or disturbance of communication (x2 test, p > .05). More of the men lived with their spouses, whereas more women lived with other family members (x2 test, p < .OOl) (table 1). The mean ages of the elderly men and women stroke patients and the men and women control subjects were 64.4 ? 5.4, 65.1 + 4.3, 65.1 + 5.3 and 65.0 t 5.5 years, respectively, and there were no significant differences in age among the groups (one-way ANOVA, p > .05). Motor scores of the SZAS. There were no significant differences between the men and women stroke patients in the 5 motor scores or the total score of the SIAS (Mann-Whitney U test, p > .05) (table 2). Scores of ADL. Although no significant difference was found between men and women in the elderly stroke patient group for any SRBI item or for the total score of the SRBI (Mann-Whitney U test, p > .05) (table 3), the men had significantly lower values than did the women for three FIM items (bathing, upper dressing, and lower dressing) and for the total score of the FIM (Mann-Whitney’s U test, p < .05) (table 4). Scores of the FAZ in elderly stroke patients and controls. Among the elderly stroke patients, the scores of 6 FAI items (preparing main meals, washing up, washing clothes, light housework, heavy housework, and local shopping) and the total FAI score were significantly lower for the men (total FAI score, 12.0 -C7.3) than for the women (total FAI score, 23.1 t 9.6) (Tukey test, p < .05) (table 5). Among the control subjects, the scores of 7 items (preparing main meals, washing up, washing clothes, light housework, heavy housework, local shopping, and gainful work) and the total score were significantly lower Table
1: Characteristics
of Stroke Stroke
Patients
Men
Women
(n = 68)
Age (yrs), mean +- SD Years after onset, mean 2 SD
64.4
SRBI,
93.7
mean
Disease, no. infarction
cation, Yes No Living, With
8.6
65.1
14.3
7.9 i: 4.6 95.1
2 6.9
35
17
33
17
36
16
32
18
17 51
8 26
50
8
18
26
no.
P
Value NS* NS* NS+
NS
of communino.
NS
no. a spouse
With other members
i
(n = 34)
NS
Hemorrhage Side of hemiplegia, Right Left Disturbance
2 5.4
6.6 t 45.0
2 SD
Patients
1.001
family
Abbreviation: NS, not significant by the x2 test. * Not significant by the ttest; + not significant by the Mann-Whitney Utest.
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GENDER
Table
2: Motor
Scores
DIFFERENCES
Knee-mouth
test
Finger function Hip flexion test
test
Knee extension Foot pat test
test
Value
2.5 2 1.4
2.5 2 1.4
NS
2.0 t 1.7 3.7 + 1.0 3.3 i 1.1
1.8 t 1.6 3.5 + 0.6
NS NS
3.1 2 0.7 2.3 2 1.0
NS NS
13.3 -+ 4.6
NS
+ 6.0
Utest.
for the men (total score, 26.8 ? 8.0) than for the women (total score, 34.6 5 4.0) (Tukey’s test, p < .05). The scores of 11 items and the total score for men in the stroke patient group were significantly lower than those for control group men, and the scoresof 8 items and the total score for women in the stroke patient group were significantly lower than those for control group women (Tukey’s test, p < .05). Rehabilitative training and physical activity. Elderly men stroke patients received significantly more rehabilitative training than elderly women stroke patients, both at the hospital (frequency during the most recent 3 months, 7.8 2 12.4 and 3.4 i 5.1, t test, p < .05) and at home (minutes per day, 59.5 t 46.2 and 11.3 +- 16.4; t test, p < .OOl). However, there was no significant difference in physical activity in daily life between men and women elderly stroke patients (steps per day, 3,161 2 2,233 and 3,624 + 1,060, respectively; t test,p > .05). DISCUSSION Because gender difference, if present, may be subtle, it is necessary to sample patients whose characteristics and impairments are identical and to apply appropriate instruments for evaluation. The disabilities and handicaps caused by stroke are affected by age, severity of hemiplegia, complications, rehabilitative treatment, dementia, depression, and life conditions. To compare ADL performance and lifestyle, factors affecting disability and handicap should be controlled as much as possible. Moreover, ADL capability should also be identical in 3: Scores
of the
Stroke Men (n = 68)
SRBI
Group Women
(n = 34)
pValue
Drinking
4.0 2 0.0
4.0 t 0.0
-
Eating Upper
dressing
5.8 t 1.0 4.7 +- 0.9
5.9 2 0.4 4.9 L 0.3
NS NS
Lower dressing Grooming
6.3 t 1.7 4.9 t 0.9
6.8 + 1.2 5.0 + 0.0
NS NS
Bathing Bladder
5.0 + 2.2 8.4 I 2.9
5.4 t 1.7 8.2 + 2.7
NS NS
Bowel control Chair transfer Toilet transfer
9.2 rf- 2.0 14.7 + 1.3 5.9 k 0.5
9.3 t 1.8 14.8 t 1.4 5.9 t 0.5
NS NS NS
Bath transfer Gait Stairs
0.9 ? 0.3 14.7 2 0.6 9.4 + 2.2
0.9 t 0.4 14.6 t 1.4 9.6 t 2.0
NS NS NS
Total
93.7
95.1
NS
control
2 8.6
2 6.7
Values reported as mean t SD. “Drinking” pvalue not analyzed. data for the two supplementary items are not shown because were applied for testing of only a small number of subjects. Abbreviation: NS, not significant by the Mann-Whitney Utest.
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Men (n = 68)
P
(n = 34)
Values reported as mean + standard deviation. Abbreviation: NS, not significant by the Mann-Whitney
Table
4: Scores
of the FIM
Stroke
(n = 68)
13.8
Hachisuka
Table
Women
2.4 2 1.4
Total
LIFESTYLE,
Group
Mell Score on the SIAS
AND
of the SIAS
Stroke Motor
IN DISABILITY
The they
Eating
Group Women
pwue
(n = 34)
NS
6.7 2 0.6 6.8 t 0.7 5.0 2 2.5
6.9 2 0.6 6.8 L 1.0 6.2 k 1.6
NS c.01
dressing dressing
5.2 k 2.2
6.7 t
1.01
Toilet
5.2 + 2.1 6.6 i- 1.2
6.6 t 1.3 6.8 -t 1.0
<.OOl NS
Bladder control Bowel control
6.5 2 1.3 6.6 2 1.0
6.7 t 0.9 6.6 t 0.8
NS NS
Bed transfer Toilet transfer
6.4 t 0.6 6.4 t 0.6
6.3 t 0.6 6.2 t 0.6
NS NS
Bath transfer Walking
6.0 r 1.3 6.3 2 0.5
6.2 2 0.6 6.0 t 1.0
NS NS
Stairs Understanding
5.9 2 1.4 6.5 2 0.9
6.1 t 0.7 6.7 t 0.7
NS NS
Expression Social intercourse
6.2 ? 1.2 6.4 t 0.9
6.3 t 1.1 6.5 t 0.7
NS NS
Problem Memory
6.3 t 1.1 6.5 i: 1.1
6.6 t 0.8 6.7 t 0.8
NS NS
Grooming Bathing Upper Lower
Total
solving
112.1
Values reported as mean + SD. Abbreviation: NS, not significant
k 13.7
117.0
t
by the Mann-Whitney
1.2
11.7
1.05
Utest.
the two groups. Therefore, we used the inclusion criteria described above for the selection of stroke patients in this study. Because elderly men and women stroke patients did not differ in age, years after the onset, ADL capability evaluated with the SRBI, diseases, disturbance of communication, or side of hemiplegia, we could appropriately compare the degrees of the ADL performance and lifestyle in the two groups. The subjects in this study were registrants in communitybased rehabilitation programs administered by a municipal welfare office. The registrants were stroke patients living at home with slight disability in the chronic stage, and there were no biases toward geographic distribution of the patients’ homes or referring hospitals. Registrants living alone were excluded from the study, stroke patients with severe disability were not enrolled in this program, and patients in a hospital or nursing home were not included. However, we consider the subjects representative of community-dwelling elderly stroke patients with slight disability living at home with family members and we believe this sample was a good model for examining gender differences in ADL performance and lifestyle. Among the stroke patients in this study, the elderly men tended to live with their spouses and the elderly women with other family members. One possible reason for this difference is the shorter life expectancy of men (76.4 years in men and 82.8 years in womenl). For statistical analysis, the subjects were not divided into those living with their spouses and those living with other family members because no differences in the ADL performance and lifestyle were found. However, if persons living with their spouses tended to depend more easily on their spouses for assistance,the inclination for assistancemight have affected the differences seen between the men and the women in the elderly stroke patients for ADL performance and lifestyle. This study confirmed that elderly men stroke patients had lower F’IM scores than did elderly women patients for bathing, upper dressing, and lower dressing, and had lower FAI scores for household chores. The men were also more likely to continue to receive medical rehabilitative training at the hospital, though continuing hospitalization for social reasons, and to perform training voluntarily at home. Because no difference
GENDER
Table
DIFFERENCES
5: Scores Stroke
of the
IN DISABILITY
AND
FAI in Stroke
Patients
Patients Control
LIFESTYLE,
Hachisuka
and Control
Subjects
Subjects
Significance
Men (n = 68)
Women (n = 34)
Men (n = 30)
Women (n = 30)
0.3 i- 0.9
2.1 k 1.4
1.1 + 1.3
2.9 i
0.6 2 1.2 0.3 2 0.8
1.9 2 1.4 2.2 2 1.3
1.7 + 1.3 1.3 t 1.4
3.0 t 0.0 2.9 t 0.4
0.4 2 0.9
2.1 2 1.4
1.6 t
0.2
PC.05
0.5 i 1.0 0.6 + 1.0 1.6 + 1.1
1.5 t 1.5 2.0 ? 1.1 2.0 t 1.2
2.2 + 1.1 2.0 + 1.2 2.3 + 0.9
3.0 + 0.2 3.0 + 0.0 2.3 + 0.9
p<.o5 PC.05 NS
hobby
2.5 + 1.0 1.4 i 1.4
2.7 + 0.8 1.7 " 1.2
2.7 + 0.6 1.6 2 1.2
3.0 -c 0.2 2.5 i- 1.0
NS NS
Driving car/bus travel Travel outings/car rides Gardening
1.4 t 1.2 0.5 + 0.6 0.9 t 1.2
1.5 t 1.3 0.8 2 0.7 1.2 t 1.3
2.9 5 0.4 0.8 t 0.7 0.6 k 1.0
2.9 + 0.3 0.8 -c 0.6 1.221.2
Household/car
0.4 + 0.8
0.4 2 1.0
1.6 + 0.9
0.9 + 1.3
0.9 + 1.3
2.0 t
1.3
0.1 IT 0.2
0.1 + 0.5
2.2 k 1.2
0.9 2 1.2
Preparing
main
Washing Washing Light
meals
up clothes housework
Heavy housework Local shopping Social occasions Walking Actively
outside pursuing
Reading Gainful Total
books work
score
maintenance
12.0
2 7.3
23.1
i 9.6
1.3
26.8 2 8.0
1001
MS:FS
of Tukey Tests
MC:FC
MS:MC
FS:FC
p i .05
PC.05
PC.05
PC.05
PC.05 PC.05
PC.05 PC.05
PC.05 PC.05
pi.05 NS
PC.05
PC.05
PC.05
PC.05 PC.05 NS
PC.05 PC.05 PC.05
NS PC.05 NS
NS NS
NS NS
NS NS
NS -
NS -
PC.05 -
1.2 2 0.8
NS
NS
PC.05
PC.05
2.0 ? 1.3
NS
NS
p<.o5
PC.05
NS
PC.05
PC.05
PC.05
PC.05
PC.05
PC.05
pi.05
3.0 t
34.6
0.4
i 4.0
pi.05 -
Values reported as mean -+ SD. Tukey’s tests were performed for the items with significant difference on one-way ANOVA; not performed for “Travel . .‘I and “Gardening” because of lack of significant difference on one-way ANOVA. Abbreviations: MS:FS, men vs women stroke patients; MC:FC, men vs women control subjects; MS:MC, men stroke patients vs men control subjects; FS:FC, women stroke patients vs women control subjects; NS, not significant.
was found between the men and the women patients in the severity of hemiplegia or ADL capability, the difference would not derive from differences in the degree of impairment caused by stroke but rather from differences in their lifestyle. In a study conducted in the United Kingdom the prestroke FAI scores of women (34.2), and men (34.4) did not differ significantly and indicated similar prestroke levels of social activities.6 The FAI score of control subject women in our study was similar to that of women in the United Kingdom, but there was an obvious gender difference among the elderly stroke patients and among the controls in our study. The gender difference is probably a result of cultural roles: in the traditional pattern, men do not share in household chores at home but are employed outside, whereas women are exclusively involved with household chores. Although the lifestyle of the younger generation in Japan has been westernized and this division between men and women is certainly not as prevalent, people born before World War II tend to maintain traditional lifestyles with separate men’s and women’s roles and spheres of influence. As the FAI patterns of male and female elderly stroke patients were similar to those of the controls, the low scores for household chores in the elderly men stroke patients would derive from their continuing the traditional lifestyle before the stroke. The traditional lifestyle, which may be prominent in Japan as well as in Taiwan, can be regarded as a possible cause of deterioration of the ADL performance and social activities, especially for men stroke patients. The traditional lifestyle, moreover, may be amplified to cause more prominent differences in gender roles by stroke and then induce a discrepancy between capability and actual performance in the ADL. Women stroke patients are involved with household chores and can remain physically active without the degree of rehabilitative training received by men. If the men were also to share in housework, they might be able to maintain their physical activity in daily life without going to the hospital to receive rehabilitative training. The lifestyle of men stroke patients may be one factor decreasing ADL performance and increasing medical costs for hemiplegic patients in the chronic stage. A nationwide and cross-cultural survey of gender differences in
disability and lifestyle will be needed.
of elderly stroke patients living
at home
Acknowledgments: The authors thank the physical and occupational therapists of the Welfare Center for the Disabled in Kitakyushu City and the nurses at the Health Offices in Tobata, Kokura-Minami and Kokura-Kita wards for their cooperation, and Ms. Aya Katayama of the Department of Rehabilitation Medicine, University of Occupational and Environmental Health, for data collection. References 1. Health and Welfare Statistics Association. The movement of the population. J Health Welfare Stat 1996;43:397-445 2. Wade DT, Leigh-Smith J, Hewer RL. Social activities after stroke: measurement and natural history using the Frenchay Activities Index. Int Rehabil Med 1985;7:176-81. 3. Holbrook M, Skilbeck CE. An activities index for use with stroke patients. Age Aging 1983;12:166-70. 4. Schuling J, de-Haan R, Limburg M, Groenier KH. The Frenchay Activities Index: assessment of functional status in stroke patients. Stroke 1993;24: 1173-7. Chong DK. Measurement of instrumental activities of daily living in stroke. Stroke 1995;26: 1119-22. Wade DT, Hewer RL. Stroke: associations with age, sex, and side of weakness. Arch Phys Med Rehabil 1986;67:540-5. Hsieh R, Lein I, Lee W, Lee T. Disability among the elderly of Taiwan. Am J Phys Med Rehabil 1995;74:370-4. Tanaka S, Ogata H, Hachisuka K. Community rehabilitation system: studies on physical training for disabled in Kitakyushu. Sangyo lka Daigaku Zasshi 1990;12:369-72. 9. Hachisuka K, Ogata H, Ohkuma H, Tanaka S, Dozono K. Test-retest and inter-method reliability of the self-rating Barthel index. Clin Rehabil 1997;11:28-35. 10. Hachisuka K, Okazaki T, Ogata H. Self-rating Barthel index compatible with the original Barthel index and the Functional Independence Measure motor score. Sangyo Ika Daigaku Zashi 1997;19:107-21.
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Research. Guide for Use of the Uniform Data Set for Medical Rehabilitation. Chino N, translator. Tokyo: Keio University; 199 1. Cockburn J, Smith PT, Wade DT. Influence of cognitive function on social, domestic, and leisure activities of community-dwelling older people. Int Disabil Stud 1990;12:169-72. Clark MS, Bond MJ. The Adelaide Activities Profile: a measure of the life-style activities of elderly people. Aging Milan0 1995;7:17484. Bond MJ, Clark MS, Smith DS, Harris RD. Lifestyle activities of the elderly: composition and determinants. Disabil Rehabil 1995; 17:63-9. Health Plan Department. Outline of the Public Health Administration in Kitakyushu City. Kitakyushu City, Japan: The Health Plan Department, Public Health Bureau, Kitakyushu City Government; 1993
Suppliers a. model 650; Yamasa Tokei Co., l-5-7 Chuo-machi, Meguro-ku, Tokyo, 150-0012 Japan. b SPSS Japan Inc., 10F Ebisu Prime Square Tower, l-l-3 Hiroo, Shibuya-ku, Tokyo, 150-0012 Japan.
Gender Differences in Disability and Lifestyle Among Community-Dwelling Elderly Stroke Patients in Kitakyushu, Japan Kenji Hachisuka, MD, Yuka Tsutsui, MD, Kazunari Furusawa, MD, Hajime Ogata, MD ABSTRACT. Hachisuka K, Tsutsui Y, Furusawa K, Ogata H. Gender differences in disability and lifestyle among communitydwelling elderly stroke patients in Kitakyushu, Japan. Arch Phys Med Rehabil 1998;79:998-1002. Objective: To examine whether there were differences in lifestyle and performance of activities of daily living (ADL) between men and women in a population of elderly stroke patients. Design: Case-comparison study. Material and Methods: Sixty-eight men and 34 women who were elderly stroke patients living in the community with a spouse or family members were evaluated with the self-rating Barthel Index (SRBI), Frenchay Activities Index (FAI), Stroke Impairment Assessment Set (SIAS), Functional Independence Measure (FIM), and a pedometer for physical activity. Control subjects, 30 men and 30 women, were assessedwith the FAI. Results: Among the stroke subjects, there were no significant differences in age, SRBI, motor score of the SIAS, or physical activity between men and women; however, men had significantly lower values than did women for three FIM items and the total FIM score and for 6 FAI items and the total FAI score. Among control subjects, men had significantly lower values than did women for 7 FAI items and the total FAI score (Tukey’s test, p < .05). Conclusion: Among elderly stroke patients, men received more support from family members in ADL performance and had less active lifestyles than did women, possibly because of cultural gender roles. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
A
LTHOUGH MORTALITY from stroke has been decreasing, stroke was still the second most common cause of death in Japan in 1995.l Stroke survivors usually suffer from hemiplegia, cognitive disturbances, speech disturbances, and other conditions that, despite appropriate medical or surgical treatment and rehabilitative training, cause functional disability in daily life. Therefore, maintaining functional independence in
From the Department of Rehabilitation Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan. Dr. Furusawa is currently affiliated with Nagasaki Rosai Hospital. Submitted for publication December 8, 1997. Accepted in revised form March 23, 1998. Supported by grants from the Research Committee for Subacute Myelo-OpticoNeuropathy by the Ministly of Health and Welfare Japan, and Research Projects on Aging and Health by the Ministry of Health and Welfare Japan. No commercial party having a direct financial interest in the results of the research supporting this article hasor will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Kenji Hachisuka, MD, Department of Rehabilitation Medicine, University of Occupational and Environmental Health, Japan, l-l Iseigaoka, Yahatanishi, Kitakyushu, #X07, Japan. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7908-4752$3.00/O
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activities of daily living (ADL) and improving quality of life are important for stroke patients in the chronic stage. Among elderly stroke patients with mild or moderate disability seen at our rehabilitation clinic who live at home, men seem to need more help in daily life than do women. Although we notice no difference in ADL performance between men and women among elderly stroke patients while they are in the hospital, a difference seems to arise after discharge. There are few reports, however, on gender differences in ADL performance and lifestyle, that is, how stroke patients spend each day. Wade and colleagues2 reported that analysis of social activities after stroke measured with the Frenchay Activities Index3-5 (FAI) in the United Kingdom did not support a sex-based association and that younger women had more severe initial disability after stroke, but other associations with sex reflected the preponderance of women among older patients.6 However, Hsieh and associates7in Taiwan found that men were more disabled than women in terms of functional disability, a difference that may be due to gender roles in traditional Chinese culture. Therefore, to investigate whether a gender difference exists in ADL performance and lifestyle among community-dwelling elderly stroke patients in Kitakyushu, Japan, we examined the characteristics, functional disability, lifestyle, and physical activity of participants in a community-based rehabilitation program. MATERIALS AND METHODS Subjects were selected from among all registrants in a community-based rehabilitation program sponsored by the Public Health and Welfare Bureau, Kitakyushu City,8 from 1993 through 1996. Most of the registrants were stroke patients with slight disability who had already received medical or surgical treatment and medical rehabilitation during hospitalization. They were referred by a hospital social worker or a city health office nurse to the community-based rehabilitation program for training in functional independence in communitydwelling life and for improvement of their quality of life. The program was managed by a doctor, therapists of the Welfare Center for the Disabled, and city health office nurses, and sessions were held once a week at seven different locations in the city. The sessions included examination by the doctor, instructions for ADL, group training for health promotion, and recreational activities. Because a preliminary study found that ADL performance and lifestyle were affected by age, living conditions, and impairment and disability caused by stroke, the following inclusion criteria were used for this study: cerebral infarction or hemorrhage in the chronic stage (more than 1 year after the onset); older than 54 years but younger than 75 years; living at home with a spouse or other family members; self-rating Bat-the1 Indexg,lo (SRBI) score of 70 or above; no severe aphasia; and no dementia or depression. One hundred forty-six participants who fulfilled the first three inclusion criteria were selected by the therapists, who were not informed of the
GENDER
DIFFERENCES
IN DISABILITY
purpose of the study. When the participants attended the sessions,they were asked to complete the SRBI; there were 107 participants whose SRBI score was 70 or above. After five were excluded because of total aphasia, dementia, or depressive disorders according to the DSM-IV criteria,11 there were 102 participants, 68 men and 34 women. The SRBI is devised based on Granger’s modification12 of the Barthel Index13 and allows the evaluation of the basic ADL of many stroke patients. It consists of 13 main items and 2 supplementary items; possible scores range from 0 (cannot do any items) to 100 (can do all items). The validity, test-retest reliability, and intermethod reliability have been established.9v10 One of the characteristic features of the SRBI is a scale of ADL capability, although the original Barthel index13 and Wade’s modification14 examine ADLpe$ormance. In an interview we asked the subjects questions related to their characteristics. The severity of hemiplegia was evaluated by the doctor using the motor score of the Stroke Impairment Assessment Set (SIAS).16 The motor score consists of the knee-mouth, finger function, hip flexion, knee extension, and foot pat tests, each of which is rated on a 6-level scale from 0 (no voluntary movement) to 5 (as smoothly as on the unaffected side). The motor score ranges from 0 to 30, and its validity and reliability have been reported. l6 Actual ADL performance was evaluated by the doctor using the Functional Independence Measure (FIM).17-19The FIM consists of 18 ADL items with a 7-level scale from 1 (total dependence) to 7 (complete independence); its total score ranges from 18 to 126. Its validity and reliability have been established.17~18 Because the FIM measures performance rather than ADL capability, an ADL item was regarded as dependent when a subject could perform it independently but did not do so. While the stroke patients were in a waiting room, they were asked to complete a questionnaire of the FALzF4which was devised to measure activities reflecting a higher level of independence and social survival.5 The FAI consists of 15 items with a 4-level scale from 0 to 3 giving a total score from 0 (inactive) to 4.5 (highly active). In recent years the FAI has been used as a scale or prototype instrument for evaluating lifestyle in stroke patients.20-22 To examine physical activity in daily life, 70 consecutive stroke patients (49 men and 21 women) were asked to wear a pedometera at their waist belt above the hip joint on the noninvolved side, from the time of rising in the morning until retiring at night for 7 days. l5 The average number of steps per day was obtained as an index of physical activity in daily life. Control subjects for the FAI evaluation were 30 men and 30 women recruited from the database of the subacute myelooptico-neuropathy study (unpublished data). The database contained 1,000 elderly community residents who had been randomly selected from the electoral register as the controls. Inclusion criteria for the recruitment were: no serious diseases; no disability; and living at home with a spouse or other family members. To match the age distribution of the stroke subjects, 5 men and women aged 55 to 59 years, 20 men and women aged 60 to 69 years, and 5 men and women aged 70 to 74 years were randomly selected from among persons on the database who fulfilled the inclusion criteria. The FAI questionnaire was sent to the 60 control subjects by mail. Data are presented as means 2 standard deviations, and statistical analyses were performed with the SPSS 6.15 for Windows.b The two-tailed student’s t test, x2 test (or Fisher’s exact test if necessary), and Mann-Whitney U test were used to compare differences in data between men and women stroke patients. One-way analysis of variance (ANOVA) with Tukey test was used to compare differences in the age and FAI scores
AND
LIFESTYLE,
999
Hachisuka
among men and women stroke patients and controls. Differences with p < .05 were regarded as significant. RESULTS Profiles of the stroke group. Between the men and women in the elderly stroke patient group, there were no significant differences in age, years after the onset, or SRBI scores(t test or Mann-Whitney U test, p > .05), or in disease, side of hemiplegia, or disturbance of communication (x2 test, p > .05). More of the men lived with their spouses, whereas more women lived with other family members (x2 test, p < .OOl) (table 1). The mean ages of the elderly men and women stroke patients and the men and women control subjects were 64.4 ? 5.4, 65.1 + 4.3, 65.1 + 5.3 and 65.0 t 5.5 years, respectively, and there were no significant differences in age among the groups (one-way ANOVA, p > .05). Motor scores of the SZAS. There were no significant differences between the men and women stroke patients in the 5 motor scores or the total score of the SIAS (Mann-Whitney U test, p > .05) (table 2). Scores of ADL. Although no significant difference was found between men and women in the elderly stroke patient group for any SRBI item or for the total score of the SRBI (Mann-Whitney U test, p > .05) (table 3), the men had significantly lower values than did the women for three FIM items (bathing, upper dressing, and lower dressing) and for the total score of the FIM (Mann-Whitney’s U test, p < .05) (table 4). Scores of the FAZ in elderly stroke patients and controls. Among the elderly stroke patients, the scores of 6 FAI items (preparing main meals, washing up, washing clothes, light housework, heavy housework, and local shopping) and the total FAI score were significantly lower for the men (total FAI score, 12.0 -C7.3) than for the women (total FAI score, 23.1 t 9.6) (Tukey test, p < .05) (table 5). Among the control subjects, the scores of 7 items (preparing main meals, washing up, washing clothes, light housework, heavy housework, local shopping, and gainful work) and the total score were significantly lower Table
1: Characteristics
of Stroke Stroke
Patients
Men
Women
(n = 68)
Age (yrs), mean +- SD Years after onset, mean 2 SD
64.4
SRBI,
93.7
mean
Disease, no. infarction
cation, Yes No Living, With
8.6
65.1
14.3
7.9 i: 4.6 95.1
2 6.9
35
17
33
17
36
16
32
18
17 51
8 26
50
8
18
26
no.
P
Value NS* NS* NS+
NS
of communino.
NS
no. a spouse
With other members
i
(n = 34)
NS
Hemorrhage Side of hemiplegia, Right Left Disturbance
2 5.4
6.6 t 45.0
2 SD
Patients
1.001
family
Abbreviation: NS, not significant by the x2 test. * Not significant by the ttest; + not significant by the Mann-Whitney Utest.
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GENDER
Table
2: Motor
Scores
DIFFERENCES
Knee-mouth
test
Finger function Hip flexion test
test
Knee extension Foot pat test
test
Value
2.5 2 1.4
2.5 2 1.4
NS
2.0 t 1.7 3.7 + 1.0 3.3 i 1.1
1.8 t 1.6 3.5 + 0.6
NS NS
3.1 2 0.7 2.3 2 1.0
NS NS
13.3 -+ 4.6
NS
+ 6.0
Utest.
for the men (total score, 26.8 ? 8.0) than for the women (total score, 34.6 5 4.0) (Tukey’s test, p < .05). The scores of 11 items and the total score for men in the stroke patient group were significantly lower than those for control group men, and the scoresof 8 items and the total score for women in the stroke patient group were significantly lower than those for control group women (Tukey’s test, p < .05). Rehabilitative training and physical activity. Elderly men stroke patients received significantly more rehabilitative training than elderly women stroke patients, both at the hospital (frequency during the most recent 3 months, 7.8 2 12.4 and 3.4 i 5.1, t test, p < .05) and at home (minutes per day, 59.5 t 46.2 and 11.3 +- 16.4; t test, p < .OOl). However, there was no significant difference in physical activity in daily life between men and women elderly stroke patients (steps per day, 3,161 2 2,233 and 3,624 + 1,060, respectively; t test,p > .05). DISCUSSION Because gender difference, if present, may be subtle, it is necessary to sample patients whose characteristics and impairments are identical and to apply appropriate instruments for evaluation. The disabilities and handicaps caused by stroke are affected by age, severity of hemiplegia, complications, rehabilitative treatment, dementia, depression, and life conditions. To compare ADL performance and lifestyle, factors affecting disability and handicap should be controlled as much as possible. Moreover, ADL capability should also be identical in 3: Scores
of the
Stroke Men (n = 68)
SRBI
Group Women
(n = 34)
pValue
Drinking
4.0 2 0.0
4.0 t 0.0
-
Eating Upper
dressing
5.8 t 1.0 4.7 +- 0.9
5.9 2 0.4 4.9 L 0.3
NS NS
Lower dressing Grooming
6.3 t 1.7 4.9 t 0.9
6.8 + 1.2 5.0 + 0.0
NS NS
Bathing Bladder
5.0 + 2.2 8.4 I 2.9
5.4 t 1.7 8.2 + 2.7
NS NS
Bowel control Chair transfer Toilet transfer
9.2 rf- 2.0 14.7 + 1.3 5.9 k 0.5
9.3 t 1.8 14.8 t 1.4 5.9 t 0.5
NS NS NS
Bath transfer Gait Stairs
0.9 ? 0.3 14.7 2 0.6 9.4 + 2.2
0.9 t 0.4 14.6 t 1.4 9.6 t 2.0
NS NS NS
Total
93.7
95.1
NS
control
2 8.6
2 6.7
Values reported as mean t SD. “Drinking” pvalue not analyzed. data for the two supplementary items are not shown because were applied for testing of only a small number of subjects. Abbreviation: NS, not significant by the Mann-Whitney Utest.
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Men (n = 68)
P
(n = 34)
Values reported as mean + standard deviation. Abbreviation: NS, not significant by the Mann-Whitney
Table
4: Scores
of the FIM
Stroke
(n = 68)
13.8
Hachisuka
Table
Women
2.4 2 1.4
Total
LIFESTYLE,
Group
Mell Score on the SIAS
AND
of the SIAS
Stroke Motor
IN DISABILITY
The they
Eating
Group Women
pwue
(n = 34)
NS
6.7 2 0.6 6.8 t 0.7 5.0 2 2.5
6.9 2 0.6 6.8 L 1.0 6.2 k 1.6
NS c.01
dressing dressing
5.2 k 2.2
6.7 t
1.01
Toilet
5.2 + 2.1 6.6 i- 1.2
6.6 t 1.3 6.8 -t 1.0
<.OOl NS
Bladder control Bowel control
6.5 2 1.3 6.6 2 1.0
6.7 t 0.9 6.6 t 0.8
NS NS
Bed transfer Toilet transfer
6.4 t 0.6 6.4 t 0.6
6.3 t 0.6 6.2 t 0.6
NS NS
Bath transfer Walking
6.0 r 1.3 6.3 2 0.5
6.2 2 0.6 6.0 t 1.0
NS NS
Stairs Understanding
5.9 2 1.4 6.5 2 0.9
6.1 t 0.7 6.7 t 0.7
NS NS
Expression Social intercourse
6.2 ? 1.2 6.4 t 0.9
6.3 t 1.1 6.5 t 0.7
NS NS
Problem Memory
6.3 t 1.1 6.5 i: 1.1
6.6 t 0.8 6.7 t 0.8
NS NS
Grooming Bathing Upper Lower
Total
solving
112.1
Values reported as mean + SD. Abbreviation: NS, not significant
k 13.7
117.0
t
by the Mann-Whitney
1.2
11.7
1.05
Utest.
the two groups. Therefore, we used the inclusion criteria described above for the selection of stroke patients in this study. Because elderly men and women stroke patients did not differ in age, years after the onset, ADL capability evaluated with the SRBI, diseases, disturbance of communication, or side of hemiplegia, we could appropriately compare the degrees of the ADL performance and lifestyle in the two groups. The subjects in this study were registrants in communitybased rehabilitation programs administered by a municipal welfare office. The registrants were stroke patients living at home with slight disability in the chronic stage, and there were no biases toward geographic distribution of the patients’ homes or referring hospitals. Registrants living alone were excluded from the study, stroke patients with severe disability were not enrolled in this program, and patients in a hospital or nursing home were not included. However, we consider the subjects representative of community-dwelling elderly stroke patients with slight disability living at home with family members and we believe this sample was a good model for examining gender differences in ADL performance and lifestyle. Among the stroke patients in this study, the elderly men tended to live with their spouses and the elderly women with other family members. One possible reason for this difference is the shorter life expectancy of men (76.4 years in men and 82.8 years in womenl). For statistical analysis, the subjects were not divided into those living with their spouses and those living with other family members because no differences in the ADL performance and lifestyle were found. However, if persons living with their spouses tended to depend more easily on their spouses for assistance,the inclination for assistancemight have affected the differences seen between the men and the women in the elderly stroke patients for ADL performance and lifestyle. This study confirmed that elderly men stroke patients had lower F’IM scores than did elderly women patients for bathing, upper dressing, and lower dressing, and had lower FAI scores for household chores. The men were also more likely to continue to receive medical rehabilitative training at the hospital, though continuing hospitalization for social reasons, and to perform training voluntarily at home. Because no difference
GENDER
Table
DIFFERENCES
5: Scores Stroke
of the
IN DISABILITY
AND
FAI in Stroke
Patients
Patients Control
LIFESTYLE,
Hachisuka
and Control
Subjects
Subjects
Significance
Men (n = 68)
Women (n = 34)
Men (n = 30)
Women (n = 30)
0.3 i- 0.9
2.1 k 1.4
1.1 + 1.3
2.9 i
0.6 2 1.2 0.3 2 0.8
1.9 2 1.4 2.2 2 1.3
1.7 + 1.3 1.3 t 1.4
3.0 t 0.0 2.9 t 0.4
0.4 2 0.9
2.1 2 1.4
1.6 t
0.2
PC.05
0.5 i 1.0 0.6 + 1.0 1.6 + 1.1
1.5 t 1.5 2.0 ? 1.1 2.0 t 1.2
2.2 + 1.1 2.0 + 1.2 2.3 + 0.9
3.0 + 0.2 3.0 + 0.0 2.3 + 0.9
p<.o5 PC.05 NS
hobby
2.5 + 1.0 1.4 i 1.4
2.7 + 0.8 1.7 " 1.2
2.7 + 0.6 1.6 2 1.2
3.0 -c 0.2 2.5 i- 1.0
NS NS
Driving car/bus travel Travel outings/car rides Gardening
1.4 t 1.2 0.5 + 0.6 0.9 t 1.2
1.5 t 1.3 0.8 2 0.7 1.2 t 1.3
2.9 5 0.4 0.8 t 0.7 0.6 k 1.0
2.9 + 0.3 0.8 -c 0.6 1.221.2
Household/car
0.4 + 0.8
0.4 2 1.0
1.6 + 0.9
0.9 + 1.3
0.9 + 1.3
2.0 t
1.3
0.1 IT 0.2
0.1 + 0.5
2.2 k 1.2
0.9 2 1.2
Preparing
main
Washing Washing Light
meals
up clothes housework
Heavy housework Local shopping Social occasions Walking Actively
outside pursuing
Reading Gainful Total
books work
score
maintenance
12.0
2 7.3
23.1
i 9.6
1.3
26.8 2 8.0
1001
MS:FS
of Tukey Tests
MC:FC
MS:MC
FS:FC
p i .05
PC.05
PC.05
PC.05
PC.05 PC.05
PC.05 PC.05
PC.05 PC.05
pi.05 NS
PC.05
PC.05
PC.05
PC.05 PC.05 NS
PC.05 PC.05 PC.05
NS PC.05 NS
NS NS
NS NS
NS NS
NS -
NS -
PC.05 -
1.2 2 0.8
NS
NS
PC.05
PC.05
2.0 ? 1.3
NS
NS
p<.o5
PC.05
NS
PC.05
PC.05
PC.05
PC.05
PC.05
PC.05
pi.05
3.0 t
34.6
0.4
i 4.0
pi.05 -
Values reported as mean -+ SD. Tukey’s tests were performed for the items with significant difference on one-way ANOVA; not performed for “Travel . .‘I and “Gardening” because of lack of significant difference on one-way ANOVA. Abbreviations: MS:FS, men vs women stroke patients; MC:FC, men vs women control subjects; MS:MC, men stroke patients vs men control subjects; FS:FC, women stroke patients vs women control subjects; NS, not significant.
was found between the men and the women patients in the severity of hemiplegia or ADL capability, the difference would not derive from differences in the degree of impairment caused by stroke but rather from differences in their lifestyle. In a study conducted in the United Kingdom the prestroke FAI scores of women (34.2), and men (34.4) did not differ significantly and indicated similar prestroke levels of social activities.6 The FAI score of control subject women in our study was similar to that of women in the United Kingdom, but there was an obvious gender difference among the elderly stroke patients and among the controls in our study. The gender difference is probably a result of cultural roles: in the traditional pattern, men do not share in household chores at home but are employed outside, whereas women are exclusively involved with household chores. Although the lifestyle of the younger generation in Japan has been westernized and this division between men and women is certainly not as prevalent, people born before World War II tend to maintain traditional lifestyles with separate men’s and women’s roles and spheres of influence. As the FAI patterns of male and female elderly stroke patients were similar to those of the controls, the low scores for household chores in the elderly men stroke patients would derive from their continuing the traditional lifestyle before the stroke. The traditional lifestyle, which may be prominent in Japan as well as in Taiwan, can be regarded as a possible cause of deterioration of the ADL performance and social activities, especially for men stroke patients. The traditional lifestyle, moreover, may be amplified to cause more prominent differences in gender roles by stroke and then induce a discrepancy between capability and actual performance in the ADL. Women stroke patients are involved with household chores and can remain physically active without the degree of rehabilitative training received by men. If the men were also to share in housework, they might be able to maintain their physical activity in daily life without going to the hospital to receive rehabilitative training. The lifestyle of men stroke patients may be one factor decreasing ADL performance and increasing medical costs for hemiplegic patients in the chronic stage. A nationwide and cross-cultural survey of gender differences in
disability and lifestyle will be needed.
of elderly stroke patients living
at home
Acknowledgments: The authors thank the physical and occupational therapists of the Welfare Center for the Disabled in Kitakyushu City and the nurses at the Health Offices in Tobata, Kokura-Minami and Kokura-Kita wards for their cooperation, and Ms. Aya Katayama of the Department of Rehabilitation Medicine, University of Occupational and Environmental Health, for data collection. References 1. Health and Welfare Statistics Association. The movement of the population. J Health Welfare Stat 1996;43:397-445 2. Wade DT, Leigh-Smith J, Hewer RL. Social activities after stroke: measurement and natural history using the Frenchay Activities Index. Int Rehabil Med 1985;7:176-81. 3. Holbrook M, Skilbeck CE. An activities index for use with stroke patients. Age Aging 1983;12:166-70. 4. Schuling J, de-Haan R, Limburg M, Groenier KH. The Frenchay Activities Index: assessment of functional status in stroke patients. Stroke 1993;24: 1173-7. Chong DK. Measurement of instrumental activities of daily living in stroke. Stroke 1995;26: 1119-22. Wade DT, Hewer RL. Stroke: associations with age, sex, and side of weakness. Arch Phys Med Rehabil 1986;67:540-5. Hsieh R, Lein I, Lee W, Lee T. Disability among the elderly of Taiwan. Am J Phys Med Rehabil 1995;74:370-4. Tanaka S, Ogata H, Hachisuka K. Community rehabilitation system: studies on physical training for disabled in Kitakyushu. Sangyo lka Daigaku Zasshi 1990;12:369-72. 9. Hachisuka K, Ogata H, Ohkuma H, Tanaka S, Dozono K. Test-retest and inter-method reliability of the self-rating Barthel index. Clin Rehabil 1997;11:28-35. 10. Hachisuka K, Okazaki T, Ogata H. Self-rating Barthel index compatible with the original Barthel index and the Functional Independence Measure motor score. Sangyo Ika Daigaku Zashi 1997;19:107-21.
11. American Psychiatric Association. Quick reference to the Diagnostic Criteria from DSM-IV Washington (DC): American Psychiatric Association; 1994 12. Granger CV, Albrecht GL, Hamilton BB. Outcome of comprehensive medical rehabilitation: measurement by PULSES profile and the Barthel index. Arch Phys Med Rehabil 1979;60: 145-54. Arch
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13. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index. Md Med J 1965;14:61-5. 14. Wade DT, Langton Hewer R. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry 1987;50: 177-82. 15. Tanaka H, Ogata H, Hachisuka K, Kousi K, Maruyama I. Effect of daily activity on muscle strength and on the cross-sectional areas of thighs in middle-aged and elderly men [Japanese with English abstract]. Jpn J Rehabil Med 1990;27:459-63. 16. Chino N, Sonoda S, Domen K, Saitoh E, Kimura A. Stroke Impairment Assessment Set (SIAS). In: Chino N, Melvin JL, editors. Functional evaluation of stroke patients. Tokyo: SpringerVerlag; 1996. p. 19-31. 17. Hamilton BB, Granger CV, Sherwin FS, Zielezny M, Sherwin FS. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986;1:59-74. 18. Hamilton BB, Laughlin JA, Fiedler RC. Interrater reliability of the 7-level functional independence measure (FIM). Stand J Rehabil Med 1994;26:115-9. 19. Data Management Service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment
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AND
20. 21. 22. 23.
LIFESTYLE,
Hachisuka
Research. Guide for Use of the Uniform Data Set for Medical Rehabilitation. Chino N, translator. Tokyo: Keio University; 199 1. Cockburn J, Smith PT, Wade DT. Influence of cognitive function on social, domestic, and leisure activities of community-dwelling older people. Int Disabil Stud 1990;12:169-72. Clark MS, Bond MJ. The Adelaide Activities Profile: a measure of the life-style activities of elderly people. Aging Milan0 1995;7:17484. Bond MJ, Clark MS, Smith DS, Harris RD. Lifestyle activities of the elderly: composition and determinants. Disabil Rehabil 1995; 17:63-9. Health Plan Department. Outline of the Public Health Administration in Kitakyushu City. Kitakyushu City, Japan: The Health Plan Department, Public Health Bureau, Kitakyushu City Government; 1993
Suppliers a. model 650; Yamasa Tokei Co., l-5-7 Chuo-machi, Meguro-ku, Tokyo, 150-0012 Japan. b SPSS Japan Inc., 10F Ebisu Prime Square Tower, l-l-3 Hiroo, Shibuya-ku, Tokyo, 150-0012 Japan.