Four million Americans are living with the effects of stroke, a major cause of disability. Survivors of stroke are often left with devastating physical, psychosocial and cognitive disabilities that affect independence in personal activities of daily living, instrumental activities of daily living, and decision-making. The majority of stroke survivors returns home after initial hospitalization and is assisted in the recovery process by a primary family caregiver, usually the spouse. There are approximately 570,000 new stroke survivors each year; the cost of treating stroke survivors is approximately $30 billion annually. Also caregivers may experience prolonged stress in their care-giving role, which may result in negative psychological and physical health outcomes, including depression and immune imbalances. This proposed 5-year randomized intervention study uses an advanced practice nurse, with the assistance of an interdisciplinary rehabilitation team, to provide education, support, skill training, and counseling to stroke survivors and their spouses for 6 months post-hospital discharge. The intervention will be delivered using previously tested protocol guidelines that are consistent with the AHCPR Clinical Practice Guidelines, Post Stroke Rehabilitation. Stroke survivors (n=100) and their spousal caregivers (n=100) will be assessed to determine whether or not the intervention is successful in (1) improving the stroke survivor's function, quality of life and perceived health and decreasing depression, (2) decreasing unplanned emergency room visits and admissions to hospitals, nursing homes (3) decreasing depression, burden, stress and improving health of spousal caregivers, and (4) decreasing cytokine imbalances related to the chronic stress of care giving among spouses. Assessments will be made at baseline and 3, 6, 9, and 12 months post-discharge on the stroke survivor and on the spousal caregiver by a nurse who is masked to the group assignment at discharge. To determine the effect of the intervention on cytokine imbalance, the researchers will 1) generate cytokines from cell cultures (mitogen induced and antigen specific t-cell lines and 2) analyze culture supernatants and plasma samples for their immunoregulatory cytokine content. The laboratory technician and immunologist will be masked to the intervention group. All covariates (SES, severity of stroke, dyadic relationships, family functioning, comorbid health) will be evaluated to determine which are significantly related to outcomes and only those will be included in the model. Hierarchical Linear Models (HLM) will be used to model change over time for individual participants using a polynomial form. Depending on the nature of the change function, individual parameter estimates of the intercept, slope, and if necessary, curvature will be compared across groups.
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