Living in a Poor Neighborhood May Impede Stroke Recovery

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Living in a Poor Neighborhood May Impede Stroke Recovery

The chances that a stroke patient will have a good recovery after leaving the hospital may depend on where they live, according to a new study of stroke patients in Texas.

At 90 days post-stroke, patients who lived in lower socioeconomic neighborhoods had more disability, and more depressive symptoms compared with stroke survivors whose neighborhoods had a higher socioeconomic status.

Prior studies have reported that living in low socioeconomic neighborhoods is associated with an increased risk for stroke and stroke mortality, and now the new study, published online April 28 in Neurology, suggests it may be a barrier to stroke recovery as well.

“A lot of care planning goes into [working with] stroke survivors,” said study coauthor Lynda Lisabeth, PhD, professor of epidemiology at the University of Michigan School of Public Health. Dr. Lisabeth said she hoped the findings would help stroke care providers “to really understand not just what the person's deficits might be at discharge, but what their neighborhood environment looks like.”

Relevant factors, for instance, could be whether the stroke survivor has friends or family nearby for support or whether their home is hard to navigate with a cane or walker; whether they have access to parks, green spaces, places to walk, sidewalks, and community centers, and a sense of social connection in the neighborhood.

The authors noted that there is a “growing body of literature suggesting neighborhood context significantly influences post-stroke outcomes beyond individual-level factors.”

While the study did not delve into specific factors, it noted that lower neighborhood SES (nSES) “environments have lower levels of perceived safety, fewer physical activity facilities, poorer walking environments, and lower social cohesion. These neighborhood factors are likely relevant in the recovery process following a sudden and dramatic change in life state that occurs following a stroke.”

The study authors noted that the prevalence of stroke in the US is expected to double by 2050 as the population gets older. More people also are surviving stroke, making it even more critical to understand the factors that can affect recovery, much of which occurs outside the hospital, Dr. Lisabeth said.

Texas-Based Study

The study involved participants from the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a population-based surveillance study among persons 45 and older in a bi-ethnic community in Nueces County, TX. The study, which identified stroke patients between 2010 and 2015 included people with primary stroke (hemorrhagic or ischemic) who identified as non-Hispanic White or Mexican American, were living in a non-institutionalized setting prior to stroke. They had agreed to participate in the interview portion of the BASIC project and survived through 90 days after stroke.

The current analysis included 776 stroke survivors, of whom 53 percent were men, 62 percent were Mexican American, and 53 percent were 64 or older.

To capture socioeconomic status at the neighborhood level, the researchers determined a “nSES” for each participant based where they lived at the time of stroke. nSES, a standardized composite, was calculated from six census tract variables representing wealth/income, education, and occupation, including median household income; median value of owner-occupied housing units; proportion of households receiving interest, dividend or net rental income; proportion of adults 25 or older with a high school diploma; proportion of adults in that age group with a college degree; and proportion of people employed in executive, managerial, or professional occupations. Those living in neighborhoods with worse nSES indexes were more likely to be Mexican American, have less education, and have more comorbidities.

The researchers determined the stroke survivor's functional status at 90 days by averaging the score of a 22-item questionnaire designed to assess seven activities of daily living and 15 instrumental activities of daily living. Participants self-reported their level of difficulty with each item using an ordered scale with a range of one (no difficulty) to four (can only do with help).

They assessed self-reported psychosocial health by using results of the 12-item Stroke Specific Quality of Life Scale (SS-QOL). Participants also self-reported depressive symptoms using the Patient Health Questionnaire Eight (PHQ-8). The researchers also considered the severity of stroke.

“If you are not doing well (mentally) then maybe you are not motivated to take your medicines, or follow-up with doctor appointments or do rehab.”—DR. VIRGINIA HOWARD

“Residence in areas with higher nSES (the 75th percentile versus the 25th percentile) was associated with significantly better post-stroke functional status and biopsychosocial health when analyzing all stroke survivors as one group,” the study found, though the association was stronger for participants with a moderate-to-severe stroke. “Higher nSES was associated with significantly less post-stroke depressive symptoms in those with moderate-to-severe stroke but not in those with mild stroke.”

“Our results suggest that those living in lower nSES neighborhoods and with moderate-to-severe strokes were most susceptible to poor outcomes,” the study reported.

Dr. Lisabeth said that the home/neighborhood environment may play a less critical role for patients with mild stroke because their “distance” to recovery is less and they might be able, for instance, to drive themselves or be mobile enough to get to places for physical or social activity. Less than 20 percent of those in the study went to an inpatient rehabilitation facility.

“Integrating information on a patient's neighborhood context within the demographic information on the medical chart would assist with hospital discharge and deposition planning,” the researchers said. They said the findings also have public policy implications.

Dr. Lisabeth said she and her colleagues hope to use the data from the BASIC Project to identify specific aspects of lower socioeconomic neighborhoods that might contribute to worse post-stroke outcomes.

A study limitation is that it was done in one community, the Corpus Christi area, an urban area with mostly non-Hispanic Whites and Mexican-Americans. Whether the findings apply to other settings or groups, such as rural America or the Black community, is not known.

Stages of Stroke Care

Jeremy Ader, MD, MBA, a neurologist and researcher at Columbia University, said the new study is noteworthy. “We know that socioeconomic status has an impact on stroke before people get to the hospital, but this study is very interesting because it identifies the fact that SES impacts people's outcomes after they leave the hospital,” he said.

Dr. Ader said more attention has been paid recently to heightening public awareness of stroke symptoms and the need to get to the hospital quickly to potentially qualify for treatment with tissue plasminogen activator (tPA), but he said those messages need to be reinforced in the most vulnerable communities.

Dr. Ader coauthored a study published in August 2019 in Neurology that found that lower patient SES was associated with longer onset-to-treatment time and in-hospital mortality from stroke. SES did not seem to play a role in onset-to-arrival time (at a hospital) or whether the stroke patient was given tPA, according to the study's data derived from American Heart Association GWTG-Stroke, a voluntary national registry.

Dr. Ader said stroke discharge planning is often focused largely on safety issues (such as having to navigate steps, for instance), which he said is different than assessing whether the person is returning to an environment that provides nearby social connections or a park to which they can walk. Dr. Ader said a significant amount of functional recovery can occur in the several months following stroke, even for patients in bad shape at two weeks.

“Certainly not everyone has to go to a rehabilitation center,” Dr. Ader said, though “we often have a strong focus on rehabilitation after patients leave the hospital to take advantage of early neuroplasticity after stroke.”

Gustavo Saposnik, MD, MPH, PhD, associate professor of neurology and director of the Outcomes Research & Decision Neuroscience Unit at St. Michael's Hospital at the University of Toronto, said he thought the findings on the association between nSES and stroke recovery are not particularly surprising given previous stroke outcomes research. But he said the paper could still have impact if it helps “increase public and policymakers' awareness of what happens after stroke.”

He said putting in place standard out-of-hospital programs for stroke recovery would likely be more difficult in the US, with its multipayer insurance system, compared to Canada, where there is a single-payer system where care is organized at the provincial level. He said his patients benefit from a case-manager, community-based approach to post-stroke care that incorporates not just a physical rehabilitation plan and other medical components but also non-medical assistance such as house cleaning.

Virginia Howard, PhD, FSCT, FAHA, Distinguished Professor of Epidemiology at the School of Public Health at the University of Alabama at Birmingham, said the new study on stroke recovery illustrates what's been made clear by the COVID-19 pandemic—that lower socioeconomic condition is associated with poorer outcomes.

She said one particularly concerning finding in the stroke recovery study was that people with moderate-to-severe stroke who lived in lower SES neighborhoods reported more depression after being discharged from the hospital.

“If you are not doing well (mentally) then maybe you are not motivated to take your medicines, or follow-up with doctor appointments or do rehab,” which could impede recovery and increase the risk for another stroke, said Dr. Howard, one of the lead epidemiologists for the REGARDS (REasons for Geographic and Racial Differences in Stroke) study.

She said that in general low SES status and all the factors that go along with it means there is “less opportunity to protect yourself,” whether it's from COVID or chronic conditions such as stroke.

Disclosures

Drs. Lisabeth and Ader had no disclosures. Dr. Saposnik disclosed receiving unrestricted grants from Roche and CME compensation from Servier Canada and Roche, which have no relationship with the current publication.