Introduction
Stroke is a leading cause of long-term disability, morbidity and mortality globally (1). Worldwide, stroke is the second leading cause of mortality (2,3), and has continued to increase in recent years. A major economic and social burden is the high prevalence of stroke because the psychological, social and physical consequences of strokes on patients are devastating (4). Stroke influences personal autonomy and quality of life (QOL). QOL is an important healthcare issue in patients with stroke which is influenced by various factors such as sex, age, comorbidity, mood and disability (5,6). In addition, patients with silent strokes remain poorly treated because the symptoms are clinically undetectable and difficult to discover (7-9).
The majority of stroke patients suffer from ischemic stroke and are older than 65 years. Post-stroke survivors are affected in multiple ways. First, motor impairment is the main factor that contributes to a decrease of social activities and gives rise to emotional and behavioural changes in post-stroke patients. Cognitive impairments are also important sequelae after stroke. Mental and emotional instability due to brain signalling pathway disruption early after stroke is a key factor that affects the post-stroke recovery and decreases QoL. However, long-term emotional and behavioural changes are challenging issues to be addressed (7-9).
In addition, post-stroke depression (PSD) is an important aspect to deal with in stroke survivors and their families. PSD is one of the main contributors to a diminished QoL after stroke and an increase in mortality (10,11). Notably, one third of post-stroke survivors are affected by PSD in the early stage after stroke but also, after several years after stroke onset.
Despite the research effort made in the field of strokes, clinical studies in the Romanian population are scarce. Management of stroke remains frequently limited by state of the art rehabilitation facilities and by financial considerations hindering access to thrombolytic therapy (12).
Coronavirus disease-19 (COVID-19) first occurred in Wuhan, China; it was declared a pandemic in March 2020 and subsequently became a major global health threat. Since 2021, over 100 million individuals from 210 countries have been confirmed to have been infected with the COVID-19 virus (13).
In Romania, the first case of infection with the new coronavirus was confirmed on February 26, 2020 and the first three deaths were recorded on March 22, 2020 reaching a maximum of 591 deaths per day on November 2, 2021. The virus is expected to remain active until 2024 even after adequate control measures, particularly with the emergence of numerous mutants called variants of concern, including B.1.1.7 (alpha), B.1.617.2 (delta), and B.1.1.529 (omicron) (14).
PSD is frequently under-detected and under-treated due to social stigma and cognitive deficits that mask the post-stroke depression symptoms. Mental and physical health assessments are crucial in the determination of post-stroke cognitive complications including PSD and long-term outcomes in stroke patients. The QoL indicator is useful to assess beneficial or detrimental changes in patients with stroke after treatment. However, the functional outcome after stroke depends on multiple factors. The hypothesis of the authors is that assessment of the Health-Related Quality of Life (HRQoL) is a powerful tool that can improve the diagnosis of post-stroke comorbidities, including PSD and predict the long-term outcome of stroke survivors (10,11).
However, an important factor that influences PSD development is the absence of family support. The incidence of post-stroke mental complications is increased in individuals without family support. On the other hand, the caregivers of stroke patients are often neglected. There is a lack of tools, that enable the investigation of the impact of stroke on the QoL of caregivers. Since, QoL of caregivers is directly associated with the long-term outcome of post-stroke survivors, there is an urgent need to correctly identify the effects of stroke from a social point of view. This gap of knowledge is even more deep regarding informal caregivers, which are the main support system in low and middle-income countries. This is due to limited access and limited resources in the transitional period from hospital to home-care services (10,11).
Since post-stroke recovery is strongly dependent by socio-cultural, genetic and personal factors, the aim of the present study was to identify socio-demographic key factors that play a role in the impairment of the HRQoL of patients or their caregivers, in the southern part of Romania. The findings of the present study may provide an improved understanding of the socio-cultural differences in stroke-related complications, and in the identification of the optimal specific interventions, in the multimodal approach therapy of post-stroke survivors. In addition, the present study may aid in attracting attention on the critically decreasing QoL of stroke-survivors and their caregivers, thus, leading to significant improvements through the development of adapted health policy strategies.
Discussion
The present study investigated for the first time, the impairment in QoL among patients who suffered stroke and their caregivers in a single center located in Romania during the COVID-19 pandemic, after a three-month post-stroke period, without any intervention to support the transition from hospital to home. For this purpose, demographic variables, the 15D assessment tool, TOAST, ADL, Barthel index and discharge mRS score, that were studied separately in the literature, were used, without comparative evaluation before and during the COVID-19 pandemic (20-23).
Muresanu et al highlighted the significant decrease in hospital discharges in Romania among patients who suffered stroke during the COVID-19 pandemic (21). The pandemic led to global chaos, particularly in the healthcare system where it caused sudden interruptions in the provision of healthcare to all patients across the country, induced by the relocation of workforces from healthcare facilities to treating patients with COVID-19(24) or by the panic instilled in the population that led to a decrease in trust in the medical act with a therapeutic (25) or preventive purpose such as vaccination (23). The number of non-COVID-19 acute emergency cases decreased, a fact reflected by the low number of emergency presentations and the number of CT scans performed (25,26). Moreover, a negative impact of COVID-19 was identified in patients who had risk factors for diseases or already suffered from life-threatening diseases such as stroke, with some hesitation from the patient to initially visit a doctor due to the associated risk of exposure to the virus (27,28).
The present study revealed that the HRQoL of survivors and their caregivers was decreased. The stroke survivors and their family proxies modestly agreed to undergo assessment of QoL following a stroke, as well as functionality assessment at 1 to 2 months post-stroke (29). In the present study, at baseline and after 3 months, the HRQoL of survivors was influenced by age, employment status, number of hospitalization days, ADL, Barthel index, and age as well as employment status of the caregiver. Younger survivors had improved QoL and the lack of employment decreased it. Obesity and TOAST influenced HRQoL after 3 months.
In addition, at baseline and after 3 months, the HRQoL of the caregiver was influenced by age, employment status, ADL, Barthel index, and their employment status. Life satisfaction of family caregivers was associated with feelings and emotions of the patients only. It was strongly linked with the four WHOQOL-BREF domains (physical health, psychological health, environment, and social relationships) of the caregiver (30). Strong psychological repercussions may be generated for both patients and family caregivers (31). The family proxy rated QoL worse than stroke survivors rated that domain, however, the rates were similar in more objective domains such as physical functioning but not analogous in more subjective domains such as mood. What is difficult to determine is whether the patient or the proxy is closer to the ‘truth’. For example, depressed patients report a lower HRQoL and these scores are more consistent with proxy HRQoL ratings, but whether the reported lower HRQoL of the patient is accurate or whether it is lower than their ‘actual’ HRQoL, resulting from the overlying depression, is not clear.
The findings of the present study are not consistent with those of a previous study regarding sex differences in HRQoL in patients who suffered stroke, where it was reported that females had a lower QoL than males (32). Worse HRQoL in female patients with stroke was not identified and the interventions including those increasing rehabilitation efforts could be assessed in the future regardless of sex in Romania.
A previous study identified differences in the levels HRQoL with regard to employment status. Unlike individuals at home with no activity and despite their handicap, stoke patients who are retired may have less stress or unhappiness and may maintain a social position/identity, which is based not only on age and social characteristics but also on the sense of self of the individual (33). As expected, it was demonstrated that, both at baseline and after 3 months of home post-stroke stay, the lack of employment decreased HRQoL.
In the present study, the length of hospitalization and mRS at discharge were negatively correlated with HRQoL and the tendency towards depressive mood was likely to influence the HRQoL, concurrently as the other assessed dimensions including mobility, usual activities, mental function, distress, or sexual activity. The same results were detected by Pedersen et al for post-stroke Scandinavian patients (33).
Following the pandemic period, significant changes in the QoL of patients were reported, including stroke survivors. In a previous study, a significant decrease in stroke hospitalization time was reported during and after Covid-19(34). This had a high impact on the outcome of the disease as well as on the QoL of patients and their caregivers.
During Covid-19, an increased number of cases with clinical signs of severe and moderate stroke were recorded. According to the American Heart Association, patients with Covid-19 are more exposed to stroke by a different mechanism than atherosclerosis (35). As a result, this can change the impact of the disease and requires further investigation in order to identify pre- and post-Covid 19 changes in the QoL-related stroke pattern. The delay of thrombolytic therapy for patients who have suffered a stroke has a high impact on post-stroke recovery and functional outcome. It is associated with long term disability and increased healthcare costs.
Notably, a recent study reported an increased risk of stroke in middle-aged individuals, independent of age (35). In the post-Covid-19 era, the consequences of the pandemic have to be carefully monitored (36). The QoL of caregivers is an important topic to be addressed. The post-Covid-19 public health policy has to be wary of the impact of Covid-19 on both stroke survivors and their caregivers.
The present study had several limitations. The statistical assessment of QoL in a relatively small population during the pandemic was extremely difficult, as outliers can alter the results. The trend that was identified in the present study, should be further validated on large cohorts in a multicentric clinical study. Thus, the results are consistent, but some other covariates could influence the QoL, including medication adherence or fatigue, assessed by evaluating post-stroke QoL (37). In order to quantify the HRQoL, a valid tool for the Romanian population is required, based on a precise and valid measurement algorithm for stroke patients. There is still a lack of tools for the assessment of HRQoL in stroke patients in Romania, and this difficulty must be resolved in the future.
The aim of the present study was to identify the multidimensional effects of post-stroke HRQoL among patients and caregivers, in order to propose and implement suitable intervention approaches, to support the transition from hospital to home after stroke, in Romania (36-38).
In conclusion, HRQoL is an important issue to be addressed in the multimodal management of stroke survivors following the acute period. As revealed in the present study, the HRQoL of post-stroke patients and their caregivers was decreased in a significant clinical percentage, in Romania. The aim of the present study was to raise awareness on this issue, identifying certain important key factors with direct consequences on the HRQoL of stroke survivors and their caregivers. The clinical reduction of the QoL of both patients and their caregivers was observed during the pandemic, and changes in health policies in Romania are warranted regarding this issue, particularly in a pandemic.