To Evaluate the Level of Awareness and Assess the Risk of Falls in Stroke Patients

Introduction

Stroke is defined as the sudden loss of neurological function caused by an interruption in the blood flow to the brain.¹ Two types of brain strokes are hemorrhagic and ischemic. Hemorrhagic stroke, which is due to blood vessel rupture, accounts for 20% of cerebrovascular accidents (CVA). Ischemic stroke due to brain vessels occlusion and blockage constitutes 80% of strokes.²

The incidence of strokes worldwide is around 17 million and it is the second leading cause of death.³ Global burden of stroke is rapidly increasing. Worldwide, one person suffers stroke every second, and a stroke-related death occurs every six seconds. Due to increase in the ageing population worldwide, it has been estimated that by 2020, stroke will be the leading cause of healthy lifeyears lost to disability.⁴

Patients with stroke have a 15 times higher risk of recurrence and this risk is further increased in the presence of cerebrovascular risk factors (CVRF). These risk factors include systemic arterial hypertension, myocardial infarction, atrial fibrillation, diabetes mellitus, high cholesterol levels, carotid artery disease, smoking, alcohol use, etc. Awareness and knowledge have an important role in suboptimal post stroke management.⁵

Stroke patients have multiple risk factors for falling including slow and abnormal gait, impaired dynamic balance, cognitive impairment; all of these make them inherently vulnerable to fall, over after a stroke.⁶ The high fall risk among individuals with stroke in acute phase has been reported that 14%-65% of stroke patients falls during their hospitalization and 37%-73% fall at home within the first 6 months after being discharged. Higher risk of falling remains a considerable health concern throughout the post stroke life span and this rate is 36% in chronic patients.⁷

Falls may have severe consequences, both physically and psychosocially. Individuals with stroke have an increased risk of hip fractures, and after such a fracture, they less often regain independent mobility.⁸ Falling is a leading cause of fractures in 23-50% of stroke patients.

Therefore, understanding the factors associated with a higher risk of falling is necessary to prevent dependence for activities of daily living (ADL) and secondary injuries.⁹

The knowledge and awareness of people about symptoms, warning signs and risk factors of stroke is crucial to prevent stroke by reducing the number of patients who are at a higher risk of suffering a stroke and to help patients to seek immediate medical care and receive timely diagnosis and life-saving treatment by the rapid detection of those at a higher risk of developing neurovascular events.¹⁰

To conduct a detailed study on the risk of falls in stroke patients, tools such as fall efficacy scale (FES) and Berg balance scale (BBS) are used. This study was a descriptive study where a questionnaire was used for collecting data. The patients were asked to answer a set of oral and written questions. Questionnaires are one of the most practical ways to gather quantitative data. And it also allows you to gather information from a large audience in which respondents can take their time to complete the list of questions.¹¹ Therefore, it is important for a stroke survivor to know about their disability, and the factors associated with the risk of falling.¹²

Methods

This was a cross-sectional questionnaire-based study with a sample size of 100 subjects. The questions focusing on awareness of stroke were prepared under the guidance of a neurophysician. The questionnaire is divided into 2 parts; Part I: socio demographic data (questions) and; Part II: awareness of risk of falls (questions) in stroke patients. All the collected data were analyzed using SPSS 18.0.

Questionnaires

Part: I (Socio-demographic characteristics)

1. Name

2. Age

3. Gender

4. Religion Hinduism/Islam/Christian/Jainism/Sikhism Buddhism

5. Educational status Literate/Illiterate

5.a. If literate, what is your level of education

5.b. Informal education, primary level, secondary level, higher secondary level and above

6. Occupation Farmer, housewife, labor, service, business, others (please specify)

Part: II (Awareness associated with risk of falls in stroke patients)

1.1. Will you be able to sit without hand support? Yes/No

1.2. Will you be able to sit for a minimum 2 minutes without any assistance? Yes/No

1.3. Will you be able to sit for a longer time without support? Yes/No

1.4. Will you be able to feed yourself independently or need any assistance? Yes/No

1.5. Will you be able to dress yourself? Yes/No

1.6. Will you be able to use toilet independently? Yes/No

1.7. Will you be able to take bath independently? Yes/No

1.8. Will you be able to transfer from bed to chair and back, without any assistance? Yes/No

1.9. Will you be able to stand without support? Yes/No

1.10. Will you be able to stand without support for more than 3 seconds with closed eyes? Yes/No

1.11. Will you be able to place feet together independently and stand for 1 minute safely without holding? Yes/No

1.12. Will you be able to turn sideways while maintaining balance without any support? Yes/No

1.13. Will you be able to place feet together independently and stand for 2 minutes safely without any support? Yes/No

1.14. Will you be able to look behind from both the sides with weight shifting? Yes /No

1.15. Will you be able to lift leg independently and hold for more than 10 seconds? Yes/No

1.16. When you are standing without support, Will you be able to do hand movement (reach out task) without losing your balance? Yes/No

1.17. Will you be able to take back steps without the feeling of falling? Yes/No

1.18. Will you be able to take atleast 3-5 steps forward without the fear of falling? Yes/No

1.19. Will you be able to climb the stairs independently or need any help (physical aid)? Yes/No

1.20. Have you heard about stroke? Yes/No

1.21. Has anybody in your family suffered stroke? Yes/No

1.22. Have you had a fall before stroke? Yes/No

1.23. What should be done to prevent falling while walking?

a. Restrict walking

b. hazard assessment at home

c. use comfortable shoes

d. advice to walk slowly e. use of assistive devices

1.24. Do you know the consequences or result of stroke? Yes/No

Results

A questionnaire-based study was conducted among 100 participants with stroke. In the study there were 38 females (38%) and 62 males (62%) who were between the age group 40 and 60 years. Most of the participants had completed higher secondary and above level of education, were mostly housewives or involved in service and business. None of the participants reported good awareness, 3% reported average awareness, and about 97% reported poor awareness. The mean±standard deviation awareness score was 2.88±1.955, with a median of 3. All participants expressed fear of falling, and the Berg balance score of these participants was between 0 and 20 (wheelchair bound). All participants were at a higher risk of falling and the fall efficacy score of these participants was >70.

Discussion

Stroke is the sudden loss of neurological function caused by the interruption of blood flow to the brain.1 There are interventions and management strategies for falls in stroke but not many studies on awareness of risk of fall in stroke has been conducted. The purpose of this study is designed to assess awareness and to assess the risk of fall in stroke patients.

A cross-sectional study conducted by Cho K, Yu J (2015) with an aim to investigate a comprehensive understanding of factors associated with falls in stroke patients. Stroke patients (22 men and 26 women) participated in this study. The study concluded that ADL performance was the primary explanatory variable of fall efficacy. These results may be used as supportive data to develop rehabilitation programs to prevent falls in stroke patients. In the present study, 3 male participants were found to have average awareness and 59 (men) and 38 (women) had poor awareness.¹³

Hyndman, Ashburn, Stack conducted a crosssectional study with the aim to describe frequency and circumstances of falls among people with stroke and to compare the characteristics of people who fall and those who don’t. A total of 41 people with stroke, i.e., 26 men and 15 women within the average age range between 69.7 and 11.6 years were recruited, of which 23 had right hemispheric infarction and 16 had left hemispheric infarction. Study concluded that there is a high risk of falling among people with stroke.¹⁴

A study was conducted by Berman, and Thomas (1999) with the aim to examine effectiveness of community education program on increasing the knowledge of stroke risk factors, stroke warning signs and action needed when stroke warning signs occur. The study conclude that the education program was effective in increasing knowledge of stroke risk factors, warning signs and necessary actions in subjects of varying ages and education.¹⁵

Haines, Hill, Bennell, Osborne (2006) conducted a study to evaluate the effectiveness of a patient education programme in preventing falls in the subacute period. Participants in both the control and intervention groups after the education programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Thus, patient education is an important part of a multiple intervention falls prevention approach in the subacute period.¹⁶

Observation based on awareness score in 100 participants, we found that none of the participants expressed good awareness. Of these patients, 3% had average awareness, and about 97% had poor awareness.

Limitations

Multiple-choice questions were asked to the respondents of which only limited options are available to study participants and he/she was allowed to guess the answer, unlike open-ended questions. Follow-up was not taken into consideration to assess knowledge level in patients. The number of days of hospital stay was not considered which allows patients to learn via observation. Knowledge of stroke and risk of fall in stroke through participant’s family members, relatives or friends was not considered.

Recommendations

Follow-up of patients should be considered to assess awareness in patients. Further large-scale study with in-depth analysis of individual care-item may reveal better understanding of patient’s knowledge. A stroke awareness program must be effectively organized to instill awareness in family members.

Conclusions

High fall risk among individuals with stroke is not only present in theacute phase but it remains a considerable health concern throughout the post stroke lifespan. It is reported that 14%-65% of stroke patients fall during their hospitalization and 37%-73% fall at home within the first 6 months after being discharged, and this rate is 36% in chronic patients.

The purpose of this study was to investigate the knowledge of stroke patient’s regarding their risk of fall and assessment of risk of falls and fear of falls with outcome measures such as Berg balance scale and fall efficacy scale.

This study demonstrated a poor level of awareness among majority of stroke patients interviewed in different areas of the questionnaire related to awareness. Berg balance scale (BBS) score range was between 0 and 20 among 100 participants, who were wheelchairbound. Along with it a fall efficacy scale (FES) score amongst 100 participants, where a score <70 was scored 1, while score of <70 was scored as 2.

Both the scales indicated that none of the participants were aware of the risk of fall but, 100% participants had a higher risk of falling.

Hence, we conclude that all participants were expressed fearing of falling. Poor level of knowledge is extracted via the following procedure. Respondents were asked questions and each correct response was given “1” score and wrong answer “0” score. The level of awareness was then classified into 3 categories: (0%) good awareness, (3%) average awareness, (97%) poor awareness. All the collected data were analyzed using SPSS 18.0.

Educational and awareness programs at the community level involving campaigns, informal education using mass media, at school, universities and governmental agencies is essential in order to improve stroke awareness.

Conflicts of interest

Authors declare that there is no conflict of interest.