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527
Psychosocial Function and
Life Satisfaction After Stroke
M. Astrom, MD; K. Asplund, MD; and T. Astrom, PhD
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Background and Purpose: This prospective study was designed to describe different aspects of
psychosocial function after stroke and the development of changes over time. A major aim has been to
identify mental, functional, and social factors associated with low life satisfaction late after stroke.
Methods: Social network, functional ability, leisure-time activities, experience of ill health, major
depression, and life satisfaction were assessed repeatedly over 3 years in a population-based sample of 50
long-term survivors of stroke (mean age 71.4 years).
Results: Compared with a general elderly population, patients 3 years poststroke had more psychiatric
symptoms, lower functional ability, and reduced life satisfaction. Contacts with children were maintained
over the 3-year follow-up period, whereas contacts with friends and neighbors declined early after stroke
and remained lower than in the general elderly population (p<0.05). When time dependency was
analyzed, activities of daily living and somatic/neurological symptoms were found to change little after 3
months, while psychiatric symptoms showed changes later. Between 3 and 12 months poststroke, the
prevalence of major depression decreased, leisure-time activities and social contacts were partly resumed,
and life satisfaction improved (p<0.01). Once good life satisfaction was restored it was maintained, and
poor life satisfaction at 1 year remained poor for the entire 3 years.
Conclusions: It is concluded that major depression early after stroke, functional disability, and an
impaired social network interact to reduce life satisfaction for the long-term survivors of stroke. (Stroke
1992;23:527-531)
KEY WORDS • cerebrovascular disorders • depression • stroke outcome
A
marked social deterioration often follows a
stroke. The important contributions of emotional and cognitive functioning, coping strategies, and social support to well-being late after a stroke
have been recognized.1-9 Quality of life (or life satisfaction) seems to be severely reduced as late as 2,1 4,2 and
5 3 years after the stroke. In these patients, social
functioning has previously been described during shortterm follow-up4 or in selected groups of patients undergoing active rehabilitation.5 In groups of elderly patients, no comparisons with other old people have been
made.
We have described important determinants of life
satisfaction before and at 3 months after the stroke in a
population-based cohort of stroke patients and compared them with a general elderly population. Even
before the stroke, the patients had more health problems, lower functional ability, more passive leisure time,
and lower global life satisfaction than the others of
similar age. Three months after the stroke, poor life
satisfaction was associated with major depression and
From the Departments of Psychiatry (M.A.) and Medicine
(K.A.), Umea University Hospital, and the Department of Social
Welfare (T.A.), University of Umea, Sweden.
Supported by grants from the Joint Committee of the North
Region, King Gustav V's 80th Anniversary Fund, the Swedish
Medical Research Council (27x-07192), King Gustaf V's and
Queen Victoria's Foundation, and the 1987 Stroke Fund.
Address for correspondence: Monica Astrom, MD, Department
of Psychiatry, University Hospital, S-90185 Umea, Sweden.
Received July 25, 1991; accepted November 22, 1991.
poor performance of the activities of daily living
(ADL).10 In the present study, we have followed longterm survivors after stroke and compared them with a
general population of similar age. Over 3 years we
repeatedly assessed their social network, functional
ability and dependence, physical and social activities,
subjective experience of ill health, major depression,
and global life satisfaction. A major aim of the study has
been to identify mental, functional, and social factors
associated with low life satisfaction late after stroke.
Subjects and Methods
A consecutive series of 98 patients admitted acutely
to the stroke unit of the Department of Medicine, Umea
University Hospital, were considered for the study.
Patients are admitted to the unit directly from the
emergency room in a manner that ensures that they are
representative of all patients admitted to the hospital
for acute stroke within a well-defined population in
northern Sweden.11 This hospital is the only one serving
this population.
During the 3-year follow-up, 37 patients died. Four
patients refused to participate, four were excluded because of recurrent stroke, two were excluded because
they were nonassessable (severe aphasia, mental retardation), and one had moved outside the hospital catchment area. The remaining 50 patients were included in
the study. The cohort included in the study was somewhat younger than the original sample of 98 stroke
patients (71.4±10.8 versus 73.9±10.9 years, mean±SD).
As shown in Table 1, the male-to-female distribution, the
528
Stroke Vol 23, No 4 April 1992
TABLE 1. Comparison of Basal Characteristics in Original
Series of 98 Consecutive Stroke Patients and 50 Patients Included
in Study
Variable
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Men: women
Married/cohabitant
Previous medical history
Stroke
Myocardial infarction
Angina pectoris
Heart failure
Diabetes
Stroke diagnosis
Intracerebral hemorrhage
Transient ischemic attack
Brain infarction
Unspecified
Consecutive
series
Present
study
60:40
51
66:34
54
23
13
24
30
21
12
10
18
22
14
7
10
82
1
6
12
82
0
72
28
90
10*
25
55
17
4
32
64
Level of consciousness at onset
Alert
Lowered
Extent of hemiparesis at onset
None
Slight to subtotal
Total
Data not available
ot
4
Values are %.
*tp<0.05 and /?<0.01, respectively, different from consecutive
series.
proportion of married/cohabitant, and the distribution of
stroke diagnoses were similar in the follow-up cohort and
the population-based group of stroke patients. The longterm survivors tended to have had fewer previous strokes
(difference not significant) and fewer concomitant cardiovascular disorders (difference not significant), and
they had significantly less severe symptoms at onset of the
stroke than the original series of patients (Table 1).
The data on the general population were derived
from two national sample surveys in Sweden. The first,
The Survey of Living Conditions (ULF),12 contained
measures of living conditions and health in a sample of
65-84-year-old people. As the reference group in the
present study, the 294 subjects from the four northernmost counties of Sweden (where Umea is located) were
selected. The second national sample survey, The Level
of Living Survey (LNU),13 also included a few questions
concerning life satisfaction. Mean age of the LNU
participants was 70 (range 65-76) years. This survey is
smaller than ULF and, therefore, data from the entire
national sample of elderly people («=828) were used.
Because there were more men than women in the stroke
group (Table 1) but the national samples had equal
numbers of both sexes, the reference group data have
been weighted (male :female=1.6:1).
Selected questions from ULF and LNU were used to
construct a questionnaire on living conditions and life
satisfaction (LL questionnaire) that was used in the
stroke patients.10 Interviews on conditions before the
stroke were performed 4-5 days after admission to the
hospital, and assessments were then done at 3 months,
1 year, 2 years, and 3 years after the stroke. In patients
who were not able to cooperate, a close relative or
friend replied. All interviews were performed by the
same psychiatrist.
Motor deficits and disorientation in the patient group
were assessed by a stroke unit physician, and the
procedures have been described previously.14 The
agreement between orientation score from two independent observers was 91%. Performance of the ADL
was recorded according to Katz et al.15 Major depression was diagnosed by an experienced psychiatrist according to DSM-III (except for the organic factor
criterion).16
Informed consent was obtained from all subjects
and/or their relatives, and the study was approved by the
Ethics Committee of Umea University.
For comparisons between the national samples and
the study group, 95% confidence intervals were calculated. Significant differences between the national samples and the study group are reported as /><0.05; NS
denotes p>0.05. For comparisons within the study
group, x1 t e s t s n a v e been used as follows. For 2x2
tables, in which data represent paired comparisons,
McNemar's test was used; otherwise Pearson's x2 or>
when appropriate, Fischer's exact test was used. Calculations were made using SYSTAT.17
Results
Table 2 shows prevalences of self-reported medical
problems over the 3-year follow-up period compared
with the general elderly population. High blood pressure, heart complaints, and diabetes tended to be more
frequent in the patients before the stroke (NS). One
year after the stroke and throughout the follow-up
period the patients reported significantly higher frequencies of heart complaints and diabetes than the
national sample (/?<0.05). In this population we have
previously demonstrated good agreement between selfreports and the presence of somatic disorders as documented by medical records.10
The frequencies of psychiatric symptoms before the
stroke did not differ significantly from those in the
national sample of the elderly (Table 2). After the
stroke there was a significant increase (/><0.05) in the
proportion of patients who reported dizziness, general
tiredness, sleeping problems, anxiety/nervousness, and
sadness. Dizziness remained as frequent at 3 years as at
3 months after the stroke, whereas the other symptoms
showed some improvement from 3 months to 1 year
after the stroke. Three years after the stroke, the
prevalences of dizziness, anxiety/nervousness, and sadness were still significantly higher than before the stroke
(p<0.05 by x2 test) and than in the general population
(p<0.05).
A major depressive syndrome was found in 25% of
the patients at discharge from the stroke unit; the
prevalence decreased significantly up to 1 year (12%,
p=0.01 by x2 t e s 0 but thereafter occurred more often,
so that at 3 years after the stroke 25% of the long-term
survivors were depressed (Figure 1). The presence of
sadness has previously been found to correlate closely
with major depression10; 6% of the general elderly
population reported sadness (Table 2). Disorientation
was not common. The proportion of patients dependent
Astrom et al
Psychosocial Function and Life Satisfaction After Stroke
529
TABLE 2. Self-Reported Prevalence of Disorders and Symptoms in National Sample of Elderly People and Long-Term
Survivors After Stroke
Variable
Stroke patients («=50)
After stroke
National
sample
(n=828)
Before stroke
3 mo
lyr
2yr
3yr
25
36
32
34
34
34
16
28
34*
34*
36*t
40*t
8
16
20
22*
22*
22*
20
14
40*f
44*t
36*t
40*t
25
38
54*f
44*
42*
44*
23
32
46*t
30
32
34
17
18
50*t
6
8
42*f
46*t
30*t
36*t
30*f
36*t
30*t
High blood pressure
Heart complaints
Diabetes
Dizziness
Tiredness
Sleeping problems
Anxiety
Sadness
Values are %.
*95% confidence interval not overlapping with that of national sample.
t/><0.05 by x2 test compared with before stroke.
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on others for their primary ADL was significantly larger
at 3 months than before the stroke (/7=0.02), with only
little change (NS) occurring over the rest of the 3-year
follow-up period (Figure 1).
Figure 2 shows ambulation outside the home and
secondary (instrumental) ADL. Significantly fewer patients could take a walk alone, did their own cooking, or
were cleaning the house before the stroke than in the
general elderly population. Three months after the
stroke, the proportion of patients who reported intact
function had declined significantly for all secondary
ADL (/7<0.01) and ambulation (/?<0.05) items. No
significant improvement was observed from 3 months
after the stroke.
Twenty-three items of leisure-time activities were
assessed. In Figure 2, illustrative examples from four
domains (physical activities, indoor activities at home,
attendance at religious services, and amusements) are
shown. Before the stroke, the same proportion of patients as in the reference population were active in most
leisure-time activities. Only for attendance at religious
services and sports events, holiday trips, visits to restaurants, and own sports activities was the proportion
significantly lower among the patients before the stroke.
SHOP
COOK
CLN
WALK
BUS
per
cent
80-
\
60-
•
40-
20
0PA123
REPS
PA123
SEW
PA123
BOOK
PA123
PA123
REL
TRIP
W
v-
Major depression
ADL dependence
PA123
Disorientation
2
3
FIGURE 1. Prevalence (percent) of major depression, dependence in activities of daily living (ADL), and disorientation in
long-term survivors after stroke (n=50). P, prestroke; D, at
discharge; A, at 3 months; 1, 2, and 3, at 1, 2, and 3 years of
follow-up.
PA123
vPA123
PA123
PA123
FIGURE 2. Secondary activities of daily living and ambulation outside home (proportion who are able to independently
undertake specific tasks) and leisure-time activities (proportion participating in specific activity at least once a quarter) in
national sample of elderly (fine line, n=294) and in long-term
survivors after stroke (bold line, n=50). P, prestroke; A, at 3
months; 1, 2, and 3, at 1, 2, and 3 years of follow-up; SHOP,
shopping; COOK, cooking; CLN, cleaning house; WALK,
walking; BUS, boarding bus; REPS, house/car repairs; SEW,
sewing/knitting; BOOK, reading books; REL, visiting religious services; TRIP, taking holiday trip.
530
Stroke
TABLE 3.
Vol 23, No 4 April 1992
Social Network in National Sample of Elderly People and Long-Term Survivors After Stroke
Stroke patients (n=50)
Contact at least weekly with
Children (n=46, patients with
children)
Neighbors («=45, patients
living at home before stroke)
Other relatives/friends
National
sample
(n=294)
Before stroke
3 mo
lyr
2yr
3yr
59
76*
76*
78*
78*
78*
55
44
69
44
51t
47f
30f
47t
44f
28*t
28*t
After stroke
22*t
Values are %.
*95% confidence interval not overlapping with that of national sample.
tp<0.05 by x2 test compared with before stroke.
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Before the stroke, the patients did not differ significantly from the general population for a variety of
activities such as fishing, taking walks, gardening, do-ityourself activities, reading books, visiting the library/
cinema, and others (data not shown). After the stroke
there was a reduction in physical leisure-time activities
most marked at 3 months. By 1 year, many patients were
again engaged in do-it-yourself activities (like house
repairs, sewing/knitting) or taking a holiday trip. After
1 year, the pattern of leisure-time activities remained
essentially unchanged. Patients who had not resumed
physical activities like gardening and hiking by 3 months
did not do so later (data not shown).
As shown in Table 3, the patients had had closer
contact with their children before the stroke than the
general elderly population. In other aspects, the social
network before the stroke was similar to that in the
general elderly population. At 3 months after the
stroke, the proportion of patients who had contacts with
neighbors, friends, and relatives other than a spouse or
children was significantly reduced (p<0.05), whereas
the ties with children seemed to remain quantitatively
unchanged. At the 1-year follow-up, social contacts with
friends were partly improved (NS); there was essentially
no further change over time, so that 3 years after the
stroke fewer patients still had contact with people other
than their children (p<0.05).
Global life satisfaction was assessed by completing
the following: "We have asked you many questions
about various aspects of your living conditions. Overall,
do you think life is . . . " and then the three alternatives
"good," "fair," and "poor" were presented. The results
are shown in Figure 3. Even before the stroke, a
somewhat lower proportion of the patient group found
life to be good (84% versus 93% in the general elderly
population; NS). Stroke involved a very marked reduction in global life satisfaction, being lowest at 3 months
after the stroke, when only 32% of the patients reported
their life as being good. This proportion increased
significantly to 52% at 1 year (p=0.01); thereafter the
proportion was essentially unchanged. Six of the 13
patients reporting their life as fair at 1 year had
deteriorated to poor life satisfaction at 3 years after the
stroke.
All 10 patients (20%) who rated their life satisfaction
as poor at 1 year also reported poor life satisfaction
through the remainder of the follow-up period. These
patients differed from the rest of the stroke group in
that they were older, had significantly lower secondary
ADL ability and a more passive leisure time, reported
general tiredness and anxiety, lived alone, and had
fewer contacts with friends and neighbors (p<0.05)
than the others. The frequency of clinically significant
depression did not differ at 1 year, but early after stroke
these patients with low life satisfaction had a significantly higher frequency of major depression than the
rest of the stroke group (p=0.01).
Discussion
The long-term outcome in unselected patients surviving a stroke is usually described in terms of survival,
neurological deficits, and functional dependency. The
present prospective data provide supplementary information on the global situation in a population-based
sample of long-term survivors of stroke, as well as
information on the development of changes over time.
Compared with a general elderly population, at 3
years after a stroke the patients had more psychiatric
symptoms, lower functional ability, and a pronounced
reduction in life satisfaction. Contacts with close family
members were maintained over the 3-year follow-up
period, whereas contact with other relatives, friends,
and neighbors declined early after stroke and remained
lower than in the general elderly population. Decreased
socializing outside the home in half of the physically
restored long-term stroke survivors has been reported.6
Other researchers have demonstrated how social support decreases the risk of poor psychosocial adjustment
in patients examined 2-24 months after stroke.9 Viitanen et al3 found a social integrative handicap in
Stroke pat ent
100I
HI Poor
• Fair
E2Good
FIGURE 3. Global life satisfaction in national sample of
elderly (Gen. pop., n=828) and in long-term survivors after
stroke (n=50). P, prestroke; A, at 3 months; 1, 2, and 3, at 1,
2, and 3 years of follow-up.
Astrom et al
Psychosocial Function and Life Satisfaction After Stroke
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34% of long-term survivors after stroke. Social disintegration was significantly associated with reduction in
global life satisfaction. Failure to maintain or reestablish social ties except for those with close family members, as shown by our results, probably is an important
determinant of poor life satisfaction late after stroke.
Our results concerning the social network agree with
and extend those of Belanger et al,18 who reported a
higher frequency of contacts with children and a lower
frequency of contacts with friends at 6 months after a
stroke in patients than in a general population. Psychological well-being was associated with the social integration of an individual outside the immediate family.
Examining the changes over time gives further information about these relationships. ADL functions as well
as most somatic/neurological symptoms changed little
after 3 months while psychiatric symptoms continued to
change. Thus, symptoms of anxiety were gradually
reduced over time while sleeping problems and the
prevalence of major depression decreased significantly
during the interval from 3 months to 1 year after the
stroke. During this period, social contacts and leisuretime activities were partly resumed and life satisfaction
improved. Patients with restored good life satisfaction
retained it up to 3 years after the stroke. Almost half of
the patients with poor life satisfaction at 3 months had
changed for the better by 1 year, whereas poor life
satisfaction at 1 year remained poor for the entire 3
years. Stroke victims with permanently reduced life
satisfaction were older, felt more tired and anxious,
were dependent on others in secondary ADL, had a
passive leisure time and fewer social contacts, and early
after stroke had a higher frequency of major depression.
Numerous studies, recently summarized,19'20 have
demonstrated that depressive disorder is a frequent
sequela of stroke although information on the nature,
etiology, and frequency of the disorder are still equivocal. Feibel and Springer21 found that depression was
significantly correlated with failure to resume social
activities after stroke. The importance of early recognition and treatment of poststroke mood disorders has
been emphasized.22-23 Starkstein and Robinson,20 in a
summary of their findings, claimed that impaired
social functioning probably does not cause poststroke
depression but that once depression occurs it —together with physical and intellectual impairment —can
reduce the patient's future social functioning. Our
data support these findings. Other common psychiatric
sequelae after stroke, including anxiety symptoms and
tiredness —which may occur independently or coexist
with major depression —also constitute mental barriers24 for resuming social activities early after stroke.
The patient's social network is apparently as good as
in the general elderly population before the stroke,
but this important resource for well-being deteriorates
after a stroke. This may leave the spouse and/or
children with an excessive supportive burden. It seems
that psychosocial intervention and support early after
stroke and throughout the following years are impor-
531
tant to prevent a permanent reduction in life satisfaction for stroke victims and their families.
Acknowledgment
The authors wish to thank Rolf Adolfsson, MD, for constructive criticism of the manuscript.
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Psychosocial function and life satisfaction after stroke.
M Aström, K Asplund and T Aström
Stroke. 1992;23:527-531
doi: 10.1161/01.STR.23.4.527
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