Ie pete for parsnal veto downed and ave ony an le and pint only one copy a Arte nat peri to make dione copes no permed to dt he lac copy ote aril tug 2 Stroke rehabilitation: availability of a family member as caregiver and discharge destination 5, TANWIR, K. MONTGOMERY, ¥, CHARI, S. Ni \THURAL Background. In today’s health care environment where resources are scarce discharge planning is an important component of resource allocation. Knowl- ‘edge of the factors that influence discharge disposi- tion is fundamental to such planning. Further, return ‘metric related to the ‘a caregiver at home wil of the patient discharged from a stroke rehabilitation unit are more likely to be discharged home given oth- ‘er predictive factors being the same. Design. Retrospective cohort study using bi gistic regression analysis with outcome as discharge home vs. discharge not home after in-patient stroke rehabilitation. Setting. Hamilton Health Sciences multidisciplinary integrated stroke program uni Population. During this period, 276 patients were admitted to the integrated stroke unit, of which 268 patients were living in the community prior to hospi- talization, The remaining eight patients were admitted from a care facility, such as a nursing home or as- sisted living facility. Since a sample size of eight is too ‘small, these patients were excluded from the analysis. As such, the analysis is based on the 268 patients who ‘were living at home prior to the onset of stroke. Methods. The data points collected during the study period were age, gender, days from stroke onset to rehabilitation unit admission, pre-stroke living ar- rangement (lived alone rs. lived with spouse, partner, or another family member), FIM™ at admission, type of stroke, laterality of impairment, and discharge des- tination (.c., private dwelling vs. nursing home, as- sisted living facility, or back t0 acute care). Corresponding author: 8, Tanoir, MD, Physical Medicine and Departinenit of Physical Medicine and Rebabilitation «al Hamilion Health Sciences and St. Joseph Hospital Dwviston of Physical Medicine and Rebabiluation Michael G: DeGiroote School of Medicine McMaster University; Hamilion, Ontario, Canada Results. As established by a number of previous stud: ies, the most significant predictors of home as charge destination was admission FIM™, However, the second most important predictive factor for home discharge was prestroke living arrangement (lived alone vs lived with spouse/partner/other family mem- er) as hypothesized by the authors. Conclusion. Literature is rich with studies showing functional independence to be the most important predictor of home as discharge disposition but our analysis shows that pre-stroke living arrangement, .e,, lived alone vs lived not alone is also an important predictor for patients to be discharged home after ‘stroke rehabilitation. Clinical rehabilitation impact, If current discharge planning relies on the availability of a caregiver at home after discharge from in-patient stroke reha- ilitation then it may be worthwhile to include these caregivers in the inpatient rehabilitation process, to prepare them for their loved one’s return home. Ad tionally, once the patient is discharged home more ‘sources should be made available to support caregiv- ers in the community. This may include more home healthcare personnel training and availability along with respite care. Key worDs: Stroke ~ Rehabilitation Community integration Patient discharge ~ “This document protected by nian eopyaght laws No adational epaducton is shorn 3 22% © habilitation, McMaster University, Hamilton Health Sciences, 711 2828 Concemon sire Haman, Ontario, LAV 1C3 Canad ccording to World Health Organization 2008 ue Fema sara iegmail.com Arner sheer suoke is the second lending cause of Sant gezi asus 55 ETE va so-nos HUNOPEAN JOURNAL OF PYSICAL AND REMABIEAION MEDICA 355 BEkEdeath in the world after ischemic heart disease.t Eve- ry 40 seconds, someone in the United States has a stroke.? The annual direct and indirect cost of stroke in the United States is estimated at $34.3 billion Each year, nearly 14,000 Canadians die from stroke; 300,000 Canadians are stroke survivors.3 In the year 2000, stroke cost the Canadian economy $3.6 bik lion in physician services, hospital costs, lost wages, and decreased productivity.* Given the high societal costs of stroke, optimizing stroke rehabilitation is an important healthcare goal. Successful rehabilitation afier stroke can maintain productivity, improve qual- of life, and potentially minimize the burden of disease for stroke survivors and their caregiver ‘The ultimate goal of rehabilitation after stroke is functional independence despite impairment lead- ing to successful reintegration into the community. ‘The literature is rich with studies that have evaluated the effectiveness of stroke rehabilitation using various functional independence measurement tools.*® These studies have consistently shown functional independ- ence to be an independent predictor of successful integration back into the community after stroke. Our analysis showed that the most important predictor of discharge home is functional capacity as measured by the Functional Independence Measure (FIM™) thus reinforcing findings of these previous studies.‘ An- other important predictor of home as discharge dispo~ sition compared with a care institution (eg., nul home) that our analysis showed was pre-stroke liv- ing arrangement as patients who lived with a spouse, partner, or another family member before the onset ‘of stroke were more likely to be discharged home. We hypothesized that these patients are more likely to be discharged home because these family members are available to act as caregivers once the patient is dis- charged. An extensive literature search revealed only a few good quality. studies that found the availability of a caregiver at home to be an independent preclic- tor of retum to homie after stroke.” We conducted this analysis to add to the growing literature that as- sents that availability of a caregiver at home is preclic- tive of return to home afier stroke rehabilitation, w: its healthcare resource allocation implications, Materials and methods Hamilton Health Sciences Integrated Stroke facil- ity is a 62-bed unit that manages the care of stroke 356 patients in acute care, in-patient rehabilitation, and ‘outpatient follow-up. A case manager is charged ‘with managing the movement of patients along this continuum of care. In Canada, the National Reha- bilitation Reporting System (NRS) at the Canadian Institute for Health Information (CIHD) requires all participating rehabilitation facilities to collect a uni- form set of data for all patients admitted for stroke rehabilitation.” The data set that we have used rep- resents all admissions to the Hamilton Health Sci ‘ences Integrated Stroke Program from March 1, 2011 to March 31, 2012, The data were-collected using standardized forms as mandated by the NRS. Dur- ing this period, 276 patients were admitted to the integrated stroke unit, of which 268 patients were living in the community prior to hospitalization. The remaining eight patients were admitted from a care ility, such as a nursing home or assisted living fa- ince a sample size of eight is too small these patients were excluded from the analysis. As such, the analysis is based on the 268 patients who were living at home prior to their stroke. The variables available for analysis were: age, gender, days from stroke onset to. rehabilitation unit admission, pre- stroke living arrangement (lived alone es. lived with spouse, parther, or another family member), FIM™ at admission, type of stroke, laterality of impairment, and discharge destination (ie., private dwelling «s. nursing home, assisted living facility, or back to acute ‘care). An extensive chart review was performed to determine the type of stroke. Ischemic stroke was placed into subcategories using the TOAST classifi- cation, while hemorthagie stroke was divided into intracerebral and subarachnoid hemorrhage. About the TOAST Classification The TOAST classification describes five subtypes of ischemic stroke: 1) lange-artery atherosclerosis, 2) cardioembolism, 3) small-vessel occlusion, 4) stroke of other determined etiology, and 5) stroke of unde~ termined etiology. The TOAST stroke subtype clas- sification system is easy to use and has good inter- ‘observer agreement. 19 As shown by Stineman et al..6 and Granger et al.!0 FIM™ instrument can be considered a measure of ‘two separate yet interrelated domains, namely motor function and cognitive function. In keeping with this distinction we divided aggregate admission FIM™ into two categories: aggregate admission cognitive‘lier. ts nol perro’ rettors cover own, concurs, Hck, r charg ay Copii noes ore use which ihe Puhr my poet on he Arse I's mt pried To tare or vse tara cimngens i are ery tara FIM™ score and aggregate admission motor FIM™. Following the format set by the NRS at the Canadian, Institute for Health Information in their reporting we placed cognitive FIM™ and motor FIM™ into three categories: low functioning, intermediate function- ing, and high functioning? Patient age and number of days from stroke onset to inpatient rehabilitation unit admission were also placed into categories to facilitate analysis (Table 1, Given that the outcome (dependent) variable of interest is categorical - dis- charge home es. not home- and the explanatory Gin- dependent) variables are a mix of categorical and continuous, the model best suited for the analysis is binary logistic regression analysis.1" About the FIM™ Instrument: ‘The Functional Independence Measure (FIM™) is a scale of disability and associated caregiver burden; it is composed of 18 items (13 motor and 5 cog tive) that are rated on a scale from independent (7) to dependent (1). Adding the ratings for these 18 items provides a Total Function Score, which has an ‘overall maximum of 126 (18 items x 7). The FIM™ strument is the result of extensive research and development, sponsored by the American Congress ‘of Rehabilitation Medicine and the American Acad- ‘emy of Physical Medicine and Rehabilitation, Results When compared with patients with a low-func- tioning motor FIM™, those. in the intermediate functioning category had. an adjusted odds ratio of “Taoue Variables available or analysis aiid thety categorization, 2.48 with P-value: 0.04 (Cl: 1.04-5.90) for discharge home. Similarly, compared with patients who had low-functioning motor FIM™, patients with a high- functioning aggregate motor FIM™ had an_adjust- ed odds ratio of 4.75 with P-value <0.01 (Cl: 2.14- 10.52) for discharge home. The next most important predictor for discharge home was pre-stroke living. ‘arrangement, Compared. with patients who lived alone, patients who lived with a spouse, partner or family member (including extended family) prior to troke had an adjusted odds ratio of 4.07 with P- value < 0.01 (Cl: 2.05-8.06) for discharge home after rehabilitation (Table D, Like motor FIM™, cognitive FIMP was also a pre- dictor for discharge hone. Compared with patients who had low-functioning cognitive FIM™, patients with intermediate-functioning cognitive FIM™ had an adjusted odds ratio of 2.88 with P-value <0.01 (Ck: 1.39-5,95) for discharge home. Similarly, com- pared with patients who had low-functioning cogni- tive FIMM™ patients with high-functioning cognitive FIMM had-and adjasted odds ratio of 3.02 with P- value; 0.03 (Ck. 1.13-8.05) for discharge home. In our analysis of patient age, we compared those younger than 65.and those 65 to 84 years with patients older than 85 at the time of stroke onset. ‘There was no statistically significant difference be- ‘tween patients older than 84 and those between the ages of 65.and 84. However, compared with patients 85 years or older, patients who were less than 65 years old at the onset of stroke had an adjusted odds ratio Of 2.80 with P-value: 0.03 (Cl: 1.09- 7.22) for discharge home. In our analysis gender, days from onset of stroke to admission to inpatient rehabilitation unit, hemi- Demographic taformation Age Gender Prestroke Hving sting Mal female ‘wa at home Prestroke living arangement ‘Aggregate FIN score at admission Motor The categories: younger than 65, 65 to 84, and 85 and older Due smal sample size, analysis rested to cases in Which pre-admission ving sexing “Two categories lived with spouse/partnr/family or tved alone ‘Admission FIMM« Mtor Seore—three groupings: 13-38 (low functioning), 39-50 CGntermesiste functioning), 51-91 {high fonctioning) Cognitive -Adinission FIM Cognitive Score «thre groupings 5:20 ow functioning), 21-29 ‘termediate functioning), 30-35 (hgh functioning) Lateraty of Impaiment [Number of days between stoke and admission to Three categories ‘inpatient rehabsation Left body involvement, right body involvement, bilateral, no paresis days or less, 5-21 days, 22 days oF more Woh 50-0. EUROPEAN JOURNAL OF PHYSICAL AND KEHABILITATION MEDICINE 357sphere of stroke, and etiology of stroke were not statistically significant predictors of return to home after stroke rehabilitation, Discussion A number of randomized controlled trials and population based studies have established the ef- fectiveness of intensive rehabilitation of stroke p: tients in an inpatient multidisciplinary rehabilita- tion unit245 Literature is rich with studies that have evaluated various factors that influence outcome after stroke. #1 Most commonly cited predictors in the literature are age at stroke onset, physical functional ability, cognitive functional ability, etiol- ogy of stroke, number of days from stroke onset to inpatient rehabilitation admission and communica- tion ability. 16.7 A few studies have also looked at socioeconomic status (SES) as a predictor of outcome after stroke but the evidence on this point is mixed. In a Dutch cohort, van den Bos et al..18 found that patients with low education level (used in the study as a surrogate for SES) were more likely to go to a nursing home afier stroke, Similarly, Kapral et al!? found) that, among a group of Canadian stroke patients, patients the lowest income quintile were less likely to be discharged home, In contrast, two studies from the UK found no relationship between SES and. return, to home after stroke.” 2! Our data set, however, did not include this important factor’ Certainly this is a question to be further investigated in the future studies, ‘Age has been previously shown to be a-good pfe- dictor of outcome after stroke? # The age ranges that have been studied as predictor of better patient ‘outcome after stroke rehabilitation. differ in various papers but the overall trend is consistent: the young- cr the patient, the more likely they are to return to home. Our analysis showed that age was a predictor ‘of return to home for patients under the age of 65 when compared to those 85 years and older. There was, however, no statistically significant difference in return to home between patients older than 84 and patients aged 65 to 84, Therefore, relationship of age with outcome defined as return to home needs further investigation. The increased number of co-morbidities and decreased functional reserve ‘common in older patients are possible reasons why 358 ‘older patients are less likely to be discharged home after stroke rehabilitation. Another factor that has been studied as predictive of outcome after stroke is patient's gender. Some studies have found no relationship between gender and stroke outcome; our study supports this find- ing? However, there are a few studies that have shown that women are more likely than men to be institutionalized upon discharge from hospital: Additionally, an analysis of European data showed that female gender is a significant predictor of dis- ability and handicap at 3-month follow-up. In their review of the Framingham data, Petrea et al. 7” pro- pose that stroke occurs-later, in life for women; therefore age and increased comorbidities may be important confounders for gender differences in stroke rehabilitation Stroke onset to) inpatient rehabilitation unit ad- mission interval is also often cited in the literature as predictive of stroke rehabilitation outcome with nost studies coming to the conclusion that earlier admission to inpatient rehabilitation unit leads to better functional outcome and higher probability of patients’ successful reintegeation into the society.2*3! Our study and that of Wilson D B er al. > found no relationship between functional outcome after stroke and onset'to admission interval. It is possi- ble that the sample size in our study was not large ‘enough to uncover the effect of this factor as a pre~ dictor of the final outcome for stroke patients. Given that our sample was 268, placing patients in.categories based on the etiology of stroke as de- fined by TOAST and intracerebral vs. subarachnoid hemorrhage resulted in too small a number to draw meaningful statistical conclusions about the effect, of each etiological variable on the stroke outcome. Previous studies have also evaluated hemispheric lateralization as a predictor of stroke outcome.*.3235 In our analysis hemispheric lateralization was not a statistically significant predictor of outcome after stroke, Many studies in the literature support this finding, concluding that laterality of stroke is not related to outcome;s 5% 3 however, other studies suggest right-sided ‘stroke is predictive of worse ‘outcome.*" 35 A number of studies have shown that unilateral spatial neglect sometimes associated with, right hemispheric stroke is a negative predictor for stroke outcome.% 3” Paolucci ef al. in their com- prehensive analysis showed that “Severity of stroke at admission and hemineglect were the strongestprognostic factors’ for stroke patients..* It is possi ble that unilateral spatial neglect sometimes found in patients with right hemisphere stroke, a variable not available to us for analysis, is a confounding, factor here leading to conflicting results in above mentioned studies. Of all the factors that have been shown to have prognostic value for outcome after stroke, admission aggregate FIMM has been the most consistent pre- dictor of discharge to the community. 1.15.32. 941 ‘Our analysis supports this finding as in this cohort of stroke patients we found that compared with patients who had low admission motor/cognitive FIM™, those with high or intermediate admission motot/cognitive FIM™ were more likely to be dis- charged home, The authors believe that return to home is an im- portant outcome metric that is distinct from func- tional status as it encompasses cognitive capacity, physical ability, and availability of psychosocial sup- port at home.’ Availability of a caregiver at home willing to provide this psychosocial support along. “Tanur IL—Results of liste regression analysts with support in patients’ ADLs and IADLs go a long sway in easing patients’ reintegration into the society. A number of previous studies have shown that fam- ily members of patients discharged home with re- sidual physical and/or cognitive deficits become de facto primary caregivers.*2-# It is estimated that ap- proximately one in eight adults provides some form of care for a family member living in the community with a serious health condition in most industrial- ised nations. The authors wanted to test the hypothesis that a patient is more likely to be discharge home if he/ she has a potential caregiver at home in the form ‘of a spouse, partner, or another family member. If this hypothesis is proved to be true it has numer- ‘ous healthcare resource allocation implications, Our analysis indicated this hypothesis to be true and showed that after controlling for other predictor variables available 16 us for analysis a patient living with a potential caregiver (spouse, partner, or other family member) had an odds ratio of 4.07 of being, discharged home (Table ID. 35h confidence tena dds fat PSalve tower Une [Age = Comparison Age Group: © 5 Years ‘Age <65 years 2a 0s, 09 Age: 65-4 Years 168 oat 074 Gener ~ Comparison gender male Female 175 ou ow 337 Prestroke living arangement = Compass arb ln ione Lived with Spouse/Partnee/Famuly 407 oo 205 065 Stroke onset to echab admission days comiparison group: 321 day Stoke t0-ehab- Days: $7 bas 082 4.06 Stoke to-ehab- Dass 7~ 20 050 061 278 -Agateite motor FIM ~ comparision: lft (13°38) TIntermesite Functioning (9-5 248 004 104 590 igh-Funcioning (51-91) 475 ool 24 ose Aggregate cognitive FINI comparison group lou functiontng (5-20) Tmermediate-functonig (21-29) 288 oo Le 595 High functioning (30-35) 02 003, Lis 05, Biology of stroke ~ comprson groups large artery atherosclerosis Cardioembolism 194 ous. o74 sa Small vessel oetusion 2 o7 030 5.23 Other determined etiology 135 074 024 723 Indeterminate evology 075 054 O31 186 Iniracerebral hemorrhage 124 on 038, 4.06 Subarachnoid hemordage 060 070 005, 72 Laterality of impairment ~ Comparison group et body (ight bemsphere) ‘ight body (left hemisphere) 155 020 on 304 Bilateral 234 029 oa na No paresis Osi 086. 019, 59 Woh 50-0. EUROPEAN JOURNAL OF PHYSICAL AND KEHABILITATION MEDICINE 359tener ‘lier. ts nol perro’ rettors cover own, concurs, Hck, r charg ay Copii noes ore use which ihe Puhr my poet on he Arse I's mt pried To tare or vse tara cimngens i are ery tara brother pop nrmation of Tue Hh —Variables and their frequency ‘arabe equeney (N=208) Vaile Toxl___Percente Gender Male 1B 56 Female Bi 1% Prestroke living arrangement Lived alone Ls 47% Lived with spouse, partner, or family 140 59% Laterality of impairment Let hemiparesis 138 52% Right hemiparesis m1 410% Bilateral paresis 3 3% No paresis, 6 2% ‘Azaregate motor FIM category Low functioning op 1% Intermediate functioning 50 igh functioning rrod Arzepate cognitive FIM category Low functioning 7 Intermediate fanetionir 1s High functioning 65 Days from stroke onset to rehabilitation unit admission Within 7 days 56 Berween day 8 - 21 iss After day 21 %6 “Type of stroke using TOAST classification Large artery atefoxelerosé 46 Cardioembolis ” small vessel occlusion 2 Other determined etiology 15 Undetermined exology %0 Intracerebral hemor 26 Subarachnold hemontage 5 Studies have shown that compared with non-car- egiver controls stroke caregivers have higheh preva- lence of depression.»® Another study, by. Schulz ef cal.” showed that compared with non-caregiver con- trols caregivers were more likely to die. If the system relies on-family:- members: asta egivers for discharge planning then these caregiv- cers need greater support to prevent caregiver burn- ‘out and negative patient outcomes, ‘To, remedy this requires, as suggested by-Palmet et aja para- digm shift from patient-centered to family-centered sttoke rehabilitation. Potential caregivers should be involved in the rehabilitation of the patient at the ‘outset and psychosocial care should be given to both the patient and potential caregivers from the beginning. Potential caregivers should also be given in-depth information about available community re- sources and the circumstances under which these resources should be accessed, The authors also believe that more research is needed to properly define caregiver needs and how best to implement changes required, 300 Limitations Previous studies have also shown_post-stroke depression,» unilateral spatial neglect,>! and apha- sia to be important prognostic factors for stroke rehabilitation, ‘These variables are not collected by the Canadian National Rehabilitation Reporting, System. As such, this analysis did not include these Conclusions ‘This study explores an essential question: does the current inpatient rehabilitation paradigm in terms of discharge planning relies on partner, spouse or an- other family member to act as caregivers in decid- ing patient discharge destination? If this is true then Ithcare resource allocation paradigm needs to be realigned. This may include having these future car- cegivers participate in the inpatient rehabilitation as much as practicable, more home healthcare profes-Publ ey pet on fe ci. nol pred wo fae oc farang bchetopes bo ecioe ay dont 636 no permit to dtibae a electors apy othe aril tough on rt andor tare i having syste elecoie meng or ay er ‘rears wmch ny ow access fo the Ale The ute ta rey Pa ol he Arie ry Gammel Use not permite. The cretion of eatva works tor ihe Ae nt permite The proaicton oferta peracna or commer use ‘the prota elation) he Arle fay pupoes i i i : 3 “Thi document protected byiniatona copyight laws No adatonal eprocuton sahara. parm fr personal use o downoad and save ry one earl pit ony ne copy of As. tno pai o mk sonal opis ‘ot germs Ii nt peated orerove, cover ovr cee, sock change ay Sopy Noes oes sei ‘or oter poprtary marmaton of he Pusch STROKE RENABILTATION sionals training and availability and availability of respite care once the patient is discharged home. Without these changes caregiver burnout and neg- ative patient outcomes will continue to lead to a greater burden on society. References ‘World Health Organization [Intemet) Available at hupy/www: ‘who in/mediacentre/factsheets/fs810/en/index.huml feted 2012 Sep 4) 2. The American Heart Association [Internet], Avallable at hup:// re ahajournalsong [cited 2012, Sep 4 4, Public Health Agency of Canada [internet Available at bp:// www phac-aspe ge ca/publicat/2009/cvd-ave/summary ‘esume-eng php [nline} 2009 [eed 2012, Sep 4 Baer RL Bieber PL, Basford JR, Haris MF score, FIM cificiency and’ discharge disposition folowing inpatient stroke tehabitation, Rehabil Nuts 2006;31:22-5 5, Wilson DB, Houle DM, Keith RA. Stoke echabiltation: a med predicting return home, West | Med 1991;154:587-90, 6, Sineman MG, Maslin G, Feiler KC. A Prediction Model for Functional Recovery in Soke, Stoke 1997;28'550.6 7. Jehkonen M. Ahonen’ F, Dastdar A, Kowvisto M, Laippala P. 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Stoke in patients aged over 75 years: Outcome and prediciors, Posigrad Med } 199308:35 g 38, Paoluccl S, Antonucci G, GlallorettL, Traballesi M, Lubich s, Prates eal. reciting Soke Inpatient Rehabiation Out come: The Prominent Role of Neuropsychological Disorders Bur Neweol 1990;36:385-90, 39. Amundson J. Brunner A, Ewers M. FIM Scores an Indicator Gf Length of Stay and Discharge Destination in CVA Patients: WN Retroactive Outcomes Study uwaxed [lntere) Available 2 Ini /murphy brary usa ed/digtal jr 2000/amunson- ‘pnanner ewer pal feted 2012, Sep A 40, Shelton F Volpe B, Reding M. Motor Impairment 3s a Pedice 361"eae shang syteme,loconi mango ary oer | | : mite. The ceston of rave works rom the Arle el permitad. Te pedito trp personal of Conmere ue is no permed to dt he lac copy ote aril tug 2 "The we ol al ray part othe Arie any Commercial Use ‘lperntied.tsnolprred ie rttors cover own, concurs, Hck r charg ay Copwightnoes ore ews which he Puhr my pet one Aries mt pried Io tare ose tara cinngens i are ey tar “Thi document protected byiniatona copyight laws No adatonal eprocuton sahara. parm fr personal use o downoad and save ry one earl pit ony ne copy of As. tno pai o mk sonal opis ‘rotor propria marmaton ofthe Pusch 4a 2. 4 45 46, «7. 362 tor of Functional Recovery and Guide 10 Rehabitation ‘Tea iment alter Soke" Neworchab Newell Rep 20011529. ES Harvey Rl, Roth E, Heinemann AW, Lovell LL, McGuire J Diaz 8 stoke rehabitation, clinical predictors of resource it ization. Arch Phys Med Rehabs 1958991399 ‘Wilkins Ry Park E ome care in Canada” Heath Repons Susie “Canada” nips publicatonsge ca ternal aval. able at htp/publcatonsgeca/cllctions/Collection 8 Setcan 82.003 Ris ann0882.005-KIEparpagersT fed 2012, Spi Int, Chumbler N, Roland K. Care coordination/hometele- Fealth Yor veterans ith stroke and tei caregivers: adres unmet need Top Sake Rehab SO0s4See Brereton Ly Nolan St “Seeking” 4 key activity for new family {ers of siuke survivors J Chin Nuts 2002112231 Granswice Canadas caregivers Canadian. Soc sours ian B, Haley W. Family Caregiving for Patents Wah Stoke ew and Anaya Soke 19 Schule Seat R Caregiving as a Rak Factor for Moray; The Girepivet Heath Eiects Sty JAMA 1999.282.22159, ‘Trends 48, Palmer S; Glass TA. Family function and stroke recovery: 4 rele Rehab Psych 20051825505, ‘Adams HP. Jf Bendixen BH, Kappelle 1, Bier J, Love BB, Bordon Dl, Mash EE, Classification of subsype of cite ikchemilc soke. Definitions Tor use in 2 multicenter clinical tal, TOAST. Tral of Ong 10172 in Acute Stoke Treatment Stroke 1998:26 35-41 50, Paolucc 8: Epidemiology and treatment of post-stwoke depres sion. Neuropsychiatr Dis Treat 2008:1:145.54 51, Gillen Ry Tennen Hl, MeKee Unilateral spatial neglect Tation so rehabilitation outcomes in patients with eight hemi sphere stoke. Arch Phys Med Rehabil 2005:86:763-7. 52, Holkind A. Functional Outcome Assessment of Aphasia Follow ing Lek Hemisphere Stroke: Semin Speceh Lang 19385 19:209-6 @. Conflicts of interest —the suthors ce tha there is no conflict of interest with any’ financial organization regarding the material discussed in the manuscript Received on October 25, 2012. ‘Accepted for publictdon On July 11, 2013 Epub ahead of print Febuary 11, 2014