The roles of daughters as caregivers compared with spouses, sons, daughters-in-law
are different.33 Stroke patients’ spouses, sons and their daughters-in-law might
probably share partial responsibility for caregiving but are less likely to be primary
caregivers, and therefore may have less influence on patients’ discharge distribution.
Some studies observed that spouses frequently became primary caregivers. However,
we observed that the patients’ spouses were elderlies themselves and might have less
capacity to take the caregiver responsibility alone. Sons sometimes serve as decision
makers for parent care but less often become household caregivers.18, 19, 34 Sons may
be unmarried. If they are married, their wives, the daughter-in-laws of stroke patients,
!can sometimes become household caregivers.34, 35 In modern urban areas in Taiwan,
sons and daughters-in-law commonly live separately from their parents and may be
less influential on patients’ discharge distribution than daughters.
We explained that daughters, being the younger female members in these families, are
more capable of providing physical aids to the patients than stroke patients’ spouses.
Some married daughters provide care for elderly parents and children simultaneously,
being recognized as the “Sandwich Generation”,36 while some unmarried daughters
live with their parents, having fewer obstacles to start caregiving. Besides caregiving,
some daughters in Taiwan can be decision makers and even sources of financial aids
for elderly parents’ care. We hypothesized that if any of patients’ daughters can take
such role, these stroke patients may have higher chances to return to home than those
without daughters and by this way, number of daughters is influential to parents’
chances to home discharge.
!5.6. Other predictors for failure of home discharge after post-acute inpatient
rehabilitation
The influence of self-care function on outcome
Stroke patients’ functional ability on admission to inpatient rehabilitation is proved to
be an important predictor.12, 13, 16, 17, 19-22 Pohl and colleagues reported that patients
with a FIM score lower than their population mean FIM score had an OR of 5.8 for
residential care discharge.19 Other studies using FIM presented ORs between 1 to 3
for the protecting effect of better self-care function against poor outcome of failure of
home discharge. The study by Pinedo reported that patients with BI scores between 0
and 20 had a 2.9 fold risk compared with those with higher BI scores to be discharge
to residential care.13 This study confirmed the influence of good patient function on
successful home discharge.
The tools of assessing self-care function
In this study, we used the BI to evaluate functional ability for basic activity of daily
life.29 The BI was the most frequently used tool and the FIM being the second.27 It has
strong psychometric properties and is more feasible from a practical standpoint.
!Therefore we chose the BI to measure patients’ functional ability in our study.
Despite that our study population in average had severe dependence on admission and
even after they finished the inpatient training, a 10-point BI gain we observed was
clinically important.31,37 This supported that our rehabilitation team in this study
setting provided post-acute stroke rehabilitation with desirable and comparable
effectiveness compared with other studies. Therefore, our study findings can be
reliably compared with the findings from previous studies.
The timing of assessing self-care function
Studies usually assessed patients’ function on their admissions since this assessment
can be performed in a package of other admission routines. Also an early acquisition
of functional information may help early prediction of rehabilitation outcomes.
Function at discharge is another popular choice, like we did in our study. It is not only
a convenient time point to assess in clinical practice but also a time point of greatest
relevance to discharge disposition. Function scores of the same individual measured
at different time points have high correlations, as we proved in this study. Therefore,
choosing function on admission or at discharge may probably yield similar results.
!Some studies tried to determine whether rehabilitation gain, which is the difference
between the function on admission and at discharge, predicts rehabilitation outcomes,
including discharge disposition.17, 23 This predictive value is not as established as
function on admission and at discharge.
The influence of age on outcome
An older age, in previous researches, is associated with higher risk of not discharging
to home.17-21 However, all reported ORs were around 1-1.5, except in the study by
Tanwir.20 In their study, stroke patients less than 65 years old had an OR of 2.8,
patients between 65 and 85 years old an OR of 1.7 for home discharge, compared
with patents older than 85 years old. In our study, however, an older age was related
with lower risk of failure of home discharge, although the OR was close to 1. One
possible explanation is that elderly disabled stroke patients and their family members
tend to set low goals for these patients’ future self-care abilities. These elder patients
also tend to have more prolonged cognitive confusion and more chance of depression
after stroke. When arranging for discharge disposition, their key decision makers may
choose to bring them home instead of arrange further hospitalization which requires
!complicated processes or arrange long-term care facilities admission which is not a
popular choice in Taiwan. On the contrary, young stroke survivors and their families
expect highly of the patient. So these young patients may tend to go for subsequent
inpatient rehabilitation in other hospitals.
The correlations between predicting factors
Functional ability is highly correlated with stroke severity, cognitive impairment,
aphasia and age in our study. Therefore, we only adjusted for age and functional
status into the proposed models and left the other factors out. Age and functional
status, remained statistically significant after adjusting for confounding factors.