Background: The main purpose of this study was to place a virtual reality (VR) system, designed to assess and to promote motor performance in the affected upper extremity in subjects after stroke, in a nonhospital environment. We also wanted to investigate if playing computer games resulted in improved motor function in persons with prior stroke. Methods: The intervention involved 11 patients after stroke who received extra rehabilitation by training on a computer 3 times a week during a 4-week period. The control group involved 11 patients after stroke who continued their previous rehabilitation (no extra computer training) during this period. The mean age of all was 68 years (range = 47–85) and the average time after stroke 66 months (range = 15–140). The VR training consisted of challenging games, which provided a range of difficulty levels that allow practice to be fun and motivating. An additional group of 11 right-handed aged matched individuals without history of neurological or psychiatric illnesses served as reference subjects. Results: All the participants reported that they were novel computer game players. After an initial introduction they learned to use the VR system quickly. The treatment group demonstrated improvements in motor outcome for the trained upper extremity, but this was not detected in real-life activities. Conclusions: The results of this research suggest the usefulness of computer games in training motor performance. VR can be used beneficially not only by younger participants but also by older persons to enhance their motor performance after stroke.

Background and Purpose: The economic burden of stroke is substantial and is likely to increase with an increasing number of elderly individuals in the population. There is thus a need for information on the use of health care resources and costs among these elderly stroke patients. We examined the impact of the cognitive impairments on the ability to perform activities of daily living (ADL) and utilization and costs of health care in a cohort of elderly stroke patients. Methods: One hundred and forty-nine patients aged ≧70 years with acute stroke were included. The patients were assessed regarding their ability to carry out ADL and health resource utilization and cost during the first year after stroke. Cognitive impairments were assessed 18 months after the index stroke. Results: Stroke severity in acute stroke andcognitive impairment at 18 months after stroke onset was associated with impairment in ADL and increased costs for utilisation of care during the first year. Patients with cognitive impairment were more dependent on personal assistance in ADL. Costs per patient during the study were three times higher for patients with cognitive impairment. Hospital care, institutional living and different kinds of support from society accounted forthe highest costs. Conclusions: Costs of care utilisation during the first year after stroke were associated with cognitive impairments, stroke severity and dependence in ADL. The results should be interpreted cautiously as the assessment of cognitive function was made 18 months after stroke onset and costs were estimated for the first year after stroke.

Background and Purpose-The aim of the present study was to examine resource utilization during a 12-month period after acute stroke in elderly patients randomized to care in an acute stroke unit integrated with a care continuum compared with conventional care in general medical wards. A secondary aim was to describe costs related to the severity of stroke. Methods-Two hundred forty-nine consecutive patients aged Ն70 years with acute stroke within 7 days before admission, living in their own homes in Göteborg, Sweden, without recognized need of care were randomized to 2 groups: 166 patients were assigned to nonintensive stroke unit care with a care continuum, and 83 patients were assigned to conventional care. There was no difference in mortality or the proportion of patients living at home after 1 year. Main outcomes were costs from inpatient care, outpatient care, and informal care. Results-Mean annual cost per patient was 170 000 Swedish crowns (SEK) (equivalent to $25 373) and 191 000 SEK ($28 507) in the stroke unit and the general medical ward groups, respectively (PϭNS). Seventy percent of the total cost was for inpatient care, and 30% was for outpatient and informal care. For patients with mild, moderate, and severe stroke, the mean annual costs per patient were 107 000 SEK ($15 970), 263 000 SEK ($39 254), and 220 000 SEK ($32 836), respectively (PϽ0.001). There was no statistical difference in age or nonstroke diagnosis. Conclusions-The total costs the first year did not differ significantly between the treatment groups in this prospective study. The total annual cost per patient showed a very large variation, which was related to stroke severity at onset and not to age or nonstroke diagnoses. Costs other than those for hospital care constituted a substantial fraction of total costs and must be taken into account when organizing the management of stroke patients. The high variability in costs necessitates a larger study to assess long-term cost effectiveness.

Background and Purpose-The aim of the study was to compare the effect of conventional treatment with the effect of acute stroke unit care integrated with geriatric stroke unit care continuum. Methods-A 1-year study was undertaken with 2:1 randomization to stroke unit care or conventional care, with assessment by an independent team. The study was composed of 249 elderly patients (aged Ն70 years) hospitalized for acute stroke, without previous cerebral lesion and without recognized need of care. Main outcome measures were patients at home after 1 year, ability in daily living activities, health-related quality of life score according to questionnaire, death or institutional care, and death or dependence. Results-One hundred two patients (61%) in the stroke unit and 49 patients (59%) in the general ward group were alive and at home after 1 year (95% CI Ϫ10% to 16%). There were no significant differences in daily life activities or quality of life. In patients with concomitant cardiac disease, there was a reduction in death or institutional care after 3 months in the stroke unit group compared with the group receiving conventional care (28% versus 49%, respectively; 95% CI Ϫ40% to Ϫ3%). This effect did not remain after 1 year. Patients seeking care after 24 hours often had mild stroke and lived alone. Conclusions-There was no effect on the number of patients living at home after 1 year, but after 3 months of stroke unit care, a beneficial effect was found on mortality and the need for institutional care among those with concomitant heart disease. This study involved patients who were considerably older than those investigated in previous randomized studies of acute stroke unit care; thus, these findings will contribute to the specialized register of controlled trials in stroke. (Stroke. 2000;31:2578-2584.)

The aim was to learn how frail elderly people experienced becoming assistive device users and how assistive devices affected their independence in daily activities. Focus-group methodology was used, including people 80 and older with multiple health problems. Five group discussions were conducted with a total of 18 people including 14 women and four men. Each group met once, for 90-120 minutes, and all discussions were audiotaped. Two themes emerged: Confidence in knowledge and experience and getting used to assistive devices in daily activities. Confidence in knowledge and experience was formed by two categories of experiences from the prescription procedure: trust the expert and trust yourself, and to have confidence in having the right information about assistive devices. Getting used to assistive devices in daily activities was formed by five categories of ambivalent experiences when using assistive devices in daily activities: creates opportunities and limitations; provides security but also raises concerns; the need is seen as transient or permanent; the social environment both encourages and restricts; the physical environment both facilitates and complicates, with less extreme experiences in between. This study indicates that frail elderly people need specifically developed support in the process of becoming assistive device users.

Reduced levels of participation in IADL persist many years after stroke onset and indicate a need to adapt a long-term perspective on stroke rehabilitation.

Background With an upward trend in the number of people who return home to independent living after stroke, the ability to perform more complex activities is becoming an increasingly important long-term outcome after stroke. Although associations between Instrumental Activities of Daily Living (IADL) and cognitive dysfunction, emotional problems, and fatigue have been reported, less is known about the long-term impact of these stroke consequences on the performance of everyday activities in young and middle-aged stroke survivors. Objective To explore the impact of cognitive dysfunction, emotional problems, and fatigue on long-term performance of instrumental activities of daily living in young and middle-aged stroke survivors Method Data on stroke survivors, aged 18–69 at index stroke, were collected from the Sahlgrenska Academy Study on Ischaemic Stroke. IADL outcome was assessed using the Frenchay Activities Index (FAI), and the impact of chosen variables was assessed using Spearman´s rank-order correlation and logistic regression. Results Seven years after index stroke, 296 stroke survivors (median age of 64) were included in this study. Cognitive dysfunction showed the strongest correlations with FAI outcome and independently explained worse outcome on FAI summary score and the domain of work/leisure activities. Fatigue was independently explanatory of worse outcome on FAI summary score and domestic chores, while depressive symptoms independently explained worse outcome on work/leisure activities. In a subgroup with only those participants who had no or minimal residual neurological deficits at follow-up (NIHSS score 0), cognitive dysfunction independently explained worse outcome on FAI summary score and work/leisure activities. Depressive symptoms independently explained worse outcome on FAI summary score and domestic chores. Conclusion Our results show that in young and middle-aged stroke survivors, cognitive dysfunction, depressive symptoms, and fatigue negatively impact performance of IADL even at seven years post stroke onset. Further, we have shown that an impact of both cognitive dysfunction and depressive symptoms can be found also among stroke survivors with mild or no remaining neurological deficits.

Background and Purpose: Readmissions after acute stroke vary over time and with age and comorbidity. Knowledge of the reasons for readmissions and characteristics of readmitted patients is sparse. This 1-year prospective study examined whether readmissions were related to severity of the index stroke or to comorbidity and explored outcomes in readmitted patients with respect to daily life activities and health-related quality of life. Methods: The study included 216 elderly patients (aged ≧70 years) discharged to their homes or a nursing home after index stroke. The main outcomes were readmission rates and reported diagnoses, performance of daily life activities and health-related quality of life. Results: Nearly half (45%) of the patients were readmitted to the hospital after being discharged to their homes. One readmission was most common, and stroke-related diagnoses were most frequently reported as the reason for readmission. Different forms of heart disease were the next most common reason. The readmitted patients were significantly more dependent in daily life activities, and health-related quality of life was significantly lower among this group. Conclusions: Recurrent stroke and sequelae after stroke were major factors behind readmissions, followed by heart disease in elderly stroke patients. The readmitted patients were more dependent in daily life activities and reported a lower health-related quality of life compared with not readmitted patients.