Effect of Self-Management Support for Elderly People Post-Stroke: A Systematic Review

A systematic review was undertaken to determine the efficacy of self-management interventions for people with stroke over the age of 65 in relation to psychosocial outcomes. PubMed, Embase, and PsycInfo were searched for randomized controlled clinical trials. Studies were eligible if the included people with stroke had a mean age ≥65 years in both the intervention and control group. Data on psychosocial measurements were extracted and an assessment of methodological quality was undertaken. Due to heterogeneity across the studies, the results were synthesized narratively. Eleven studies were identified. They included different self-management interventions in terms of theoretical rationales, delivery, and content. Seven psychosocial outcomes were identified: i) self-management, ii) self-efficacy, iii) quality of life, iv) depression, v) activities of daily living, vi) active lifestyle, and vii) other measures. Self-management interventions for people with stroke over the age of 65 may be beneficial for self-management, self-efficacy, quality of life, activity of daily living, and other psychosocial outcomes. However, low study quality and heterogeneity of interventions, as well as variation in time of follow-up and outcome measures, limit the possibility of making robust conclusions.


Rationale
3 Describe the rationale for the review in the context of what is already known.

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Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
4 Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

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Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

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Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated. Table S2 Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).
6 Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. 6 Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

Risk of bias in individual studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.       No information about blinding, however it is assumed that blinding was not possible. Furthermore, little time was devoted to addressing health or psychosocial issues as intended No information about blinding, however it is assumed that blinding was not No information about blinding, however it is assumed that blinding was not possible. No information about whether deviations arose because of the trial context Part 2: Questions 2.6 and 2.7 2.6 Appropriate analysis?

Allen et al. (2002) NI PN Some concern
Missing information about analysis used to estimate the effect of assignment to intervention Low 'Some concerns' in either Part 1 OR in Part 2, AND NOT 'High' risk in either part Some concern 'High' risk of bias in in either Part 1 OR in Part 2 High Y/PY = 'Yes' or 'Probably yes'; N/PN = 'No' or 'Probably no'; NI = 'No information' Does not differentiate between the dropout rate in the two groups. Total dropout = 16% (stroke individuals) and 22% (caregivers). No flowchart. No information about methods correcting for missing outcome data.

Glass et al. (2004) Y ---------Low
Dropouts: 8% (interventions group) and 10% (control group). The reasons for dropout are similar in the two groups. Sensitivity analyses was made for Barthel Index. It is assumed that this also applies to the other outcomes. Uneven dropout: 11% (intervention group), 22% (control group). Sensitivity analyses was not performed Y/PY = 'Yes' or 'Probably yes'; N/PN = 'No' or 'Probably no'; NI = 'No information' * The other signalling questions were also assessed as they seem to be important in relation to the judgement The investigator-generated questionnaire measuring present activity may not be sufficiently sensitive and validated. Participant-reported outcomes = the outcome assessor was not blinded, as it was impossible to blind the participants to group assignment Bishop et al. (2015) N PN PY PY PN Some concern Participant-reported outcomes = the outcome assessor was not blinded, as it was impossible to blind the participants to group assignment Fu et al. (2020)  Participant-reported outcomes = the outcome assessor was not blinded, as it was impossible to blind the participants to group assignment Y/PY = 'Yes' or 'Probably yes'; N/PN = 'No' or 'Probably no'; NI = 'No information' **One of three psychosocial measurements may not be sufficiently sensitive and validated *** Not all psychosocial measurements were subject to uncertainty regarding sensitivity and validity, which is why the other signalling questions also were assessed No information about pre-specified analysis intentions. However, it is a feasibility study and could be perceived as a pre-study No information about pre-specified analysis intentions. Quality of life is overreported in relation to selfefficacy, and the different areas of quality of life is unevenly reported Lo et al. (2018) N NI NI Some concern Insufficient information about pre-specified analysis intentions. Do not report health-related quality of life, depressive symptoms and community reintegration as mentioned in the protocol Sit et al. (2016) NI N N Some concern Insufficient information about prespecified analysis intentions Y/PY = 'Yes' or 'Probably yes'; N/PN = 'No' or 'Probably no'; NI = 'No information'