Original Articles
Return to work among elderly patients with acquired brain injuries
2022 Volume 4 Issue 1 Article ID: 2021-0024-OA
Details
2022 Volume 4 Issue 1 Article ID: 2021-0024-OA
Objectives: Generally, it is difficult for elderly patients with acquired brain injuries (ABI) to return to work (RTW). To assess whether elderly patients with ABI can return to their workplace, like working-age patients, we investigated medical and support records and compared the rates of RTW between the working-age and elderly groups. Methods: A prospective cohort study on RTW among inpatients with ABI was conducted. We collected the clinical data of inpatients who were admitted to the Department of Neurosurgery for acute treatment and participation in a health and employment support program; follow-ups were conducted after discharge. Participants with almost independent activities of daily living (ADL) were enrolled. A χ2 test was used to examine factors influencing RTW and successful RTW by groups stratified by white-collar and blue-collar occupations and hemiplegia. The Kaplan-Meier method was used to calculate the RTW proportion curves. Results: The RTW rates were 74% for the working-age group and 89% for the elderly group (χ2 test, p=0.149); age was not a significant factor. Occupation type was the only significant factor for RTW (χ2 test, p=0.014). The RTW proportion curves of both the working age and elderly groups showed early RTW, and the elderly group had a significantly higher RTW profile than the working-age group (log-rank test, p<0.039). Almost all elderly participants were engaged in white-collar or less physical jobs, to which it is easy to return. Conclusions: In participants with almost independent ADL, the elderly group had a higher RTW rate than the working-age group.
In the United States, the prevalence of stroke increases with advancing age in both men and women1); an estimated 7 million Americans ≥20 years of age have reportedly had a stroke, which is a leading cause of long-term disability. Patients may suffer from cognitive, emotional, and physical impairments after a stroke and potentially face difficulties in returning to work. The ability to return to work (RTW) is one of the primary goals of treatment and rehabilitation in patients who have had a stroke, with the rates of RTW after stroke ranging between 11% and 85%2). Previous studies on RTW have focused on working-age patients <65 years of age3,4,5,6,7). Moreover, one of the positive factors related to RTW is age <65 years6).
However, with aging of the global population, the employment situation among the elderly is changing. The Organisation of Economic Co-operation and Development indicated that member countries had an average labor force participation rate of 16.0% among individuals aged ≥65 years (rate of the labor force aged ≥65 years within the same age group) in 2019, which was accompanied by an increase of 3.4% in the past 10 years. In the United States and Japan, these rates were 20.2% and 25.3%, respectively, accompanied by an increase of 3.0% and 5.2%, respectively8). Understanding how to cope with the employment of elderly individuals is important, and it warrants careful consideration of RTW among the elderly.
Based on these circumstances, we addressed the issue of RTW among elderly and working-age patients with acquired brain injuries who participated in a project for the promotion of health and employment support sponsored by the Japan Organization of Occupational Health and Safety. Acquired brain injuries included stroke, traumatic brain injury, and postoperative benign brain tumor. Based on our experience of treating elderly patients who suffered a stroke9), we hypothesized that patients with acquired brain injuries may be able to return to the workplace regardless of age. In this study, we investigated health and employment support in both working-age and elderly patients with acquired brain injuries and compared the rates of RTW between the two groups.
A prospective cohort study on RTW among inpatients with acquired brain injuries was conducted at Moji Medical Center, Kitakyushu, Japan. The study protocol was approved by the Institutional Review Board of Moji Medical Center (31-1), and its registration period was from April 2017 to March 2020. All participants were informed of the purpose and risks associated with the study before they provided written informed consent; this study was conducted in accordance with the principles of the Declaration of Helsinki.
The participants were patients who were admitted to the Department of Neurosurgery for acute treatment of acquired brain injuries, including stroke, traumatic brain injury, and postoperative benign brain tumor. Participants in this study met the following inclusion criteria: 1) ≥20 years of age; 2) first-ever stroke (subarachnoid hemorrhage [International Classification of Diseases-10th revision {ICD-10} code I60], cerebral hemorrhage [I61], cerebral infarction [I63]), first-ever traumatic brain injury (intracranial injury [S06]) confirmed by magnetic resonance imaging, or first-ever surgery for a benign brain tumor (cerebral meninges [D32.0], brain, supratentorial [D33.0]) confirmed by a pathological examination; 3) almost independent in activities of daily living 2 weeks after the onset or day of operation (Barthel Index score ≥80); 4) full-time, part-time, or self-employed just before admission; and 5) willing to join the health and employment support program and participate in this cohort study. Participants who suffered from any multimorbidity requiring prompt treatment or hospital transfer were excluded from this study. Finally, 62 participants who provided written informed consent within 14 days of admission were enrolled in this study and were assigned to the working-age group (<65 years of age) or the elderly group (≥65 years of age) (Figure 1).
Flowchart of the study process.
The participants who had a mild physical disability underwent acute medical treatment and stroke rehabilitation during their hospital stay, receiving health and employment support. After discharge to home, we were allowed to observe their entire recovery and RTW in the outpatient settings. Participants who succeeded in RTW were followed up until the month of RTW, and the others were followed up to 12 months after discharge.
We collected the demographic and clinical data of the participants from their medical and support records, which included age, sex, years of education (6 years of elementary school, 3 years of junior high school, 3 years of high school, and 4 years of college or university), occupation type (white-collar or blue-collar), employment status (full-time, part-time, or self-employed; students and housewives were not included), living conditions (alone or with family), alcohol or drug addiction, primary disease diagnosis (stroke, non-stroke [traumatic brain injury, benign brain tumor]), mental function (evaluated using the Mini-Mental State Examination10)), neurological findings (including the severity of hemiplegia evaluated using the Brunnstrom recovery stage11)), and neuropsychological deficits (ideomotor apraxia, constructional apraxia, unilateral spatial neglect, and aphasia).
The endpoint of this study was the participants’ RTW, which was defined as the resumption of any full- or part-time paid work, inclusive of self-employment, in a regular or modified capacity12); medical social workers confirmed the participants’ RTW via personal or telephonic interview.
Health and employment support programThe health and employment support program, which was based on the guidelines for the dual support of treatment and work-life of stroke patients published by the Ministry of Health, Labour and Welfare in 2016, included medical treatments by brain surgeons; stroke rehabilitation by physiatrists, physical therapists, occupational therapists, and speech therapists; counseling, management, and support by medical social workers; and management and support in the workplace by occupational physicians, occupational health nurses, and/or the office staff in charge of RTW. The specific feature of this health and employment support program was a dual support coordinator who had taken a 1-day course sponsored by the Japan Organization of Occupational Health and Safety13). Many of the dual support coordinators were medical social workers who played roles in the exchange of information between the patient’s hospital and workplace, promotion of cooperation, and adjustment of the RTW plan.
Statistical analysesAll statistical analyses were performed using GraphPad Prism version 7 (GraphPad Software, La Jolla, CA, USA). Successful and unsuccessful RTW for each factor were examined using a χ2 test to compare within-factor differences. Successful and unsuccessful RTW were compared between groups using the χ2 test, concerning factors (occupational types and hemiplegia) possibly associated with RTW. The Kaplan-Meier method was used to calculate the curves of the RTW rates to examine the differences in RTW rates between the two groups. A log-rank test was used to confirm the difference in the curves between the groups. Statistical significance was set at p<0.05.
The working-age group consisted of 35 participants (26 men and nine women), with an average age of 54.5 years, and the elderly group consisted of 27 participants (20 men and five women), with an average age of 72.9 years (Figure 1). The causes of brain injury were stroke in 41 participants and non-stroke in 21 participants.
Concerning age, the elderly group succeeded in RTW (89%) more than the working-age group (74%), but the difference was not significant (Table 1, χ2 test, p=0.149). In the factor of occupation types, there was a significant difference in RTW between white-collar and blue-collar participants (χ2 test, p=0.014). The other factors showed no significant differences in RTW (χ2 test, p>0.05), but participants without hemiplegia showed a tendency to succeed in RTW more than those with hemiplegia (χ2 test, p=0.072).
| Factor | No. | Successful return to work | Unsuccessful return to work | p-value |
|---|---|---|---|---|
| Age, years | ||||
| <65 (Working-age group) | 35 | 26 (74%) | 9 (26%) | 0.149 |
| ≥65 (Elderly group) | 27 | 24 (89%) | 3 (11%) | |
| Sex | ||||
| Male | 48 | 38 (79%) | 10 (21%) | 0.585 |
| Female | 14 | 12 (86%) | 2 (14%) | |
| Education, years | ||||
| 9–12 | 35 | 28 (80%) | 7 (20%) | 0.345 |
| 13–16 | 27 | 24 (69%) | 3 (31%) | |
| Occupation types | ||||
| White-collar jobs | 30 | 28 (93%) | 2 (7%) | 0.014 |
| Blue-collar jobs | 32 | 22 (69%) | 10 (31%) | |
| Employment status | ||||
| Full-time employment | 39 | 31 (79%) | 8 (21%) | 0.920 |
| Part-time employment | 13 | 11 (85%) | 2 (15%) | |
| Self-employment | 10 | 8 (80%) | 2 (20%) | |
| Living conditions | ||||
| Alone | 16 | 11 (69%) | 5 (31%) | 0.162 |
| With family | 46 | 39 (85%) | 7 (15%) | |
| Alcohol or drug addiction | ||||
| Yes | 0 | ― | ― | n/a |
| No | 62 | 50 (81%) | 12 (19%) | |
| Diagnosis | ||||
| Stroke | 41 | 32 (78%) | 9 (22%) | 0.470 |
| Non-stroke | 21 | 18 (86%) | 3 (14%) | |
| Traumatic brain injury | 14 (88%) | 2 (12%) | ||
| Benign brain tumor | 4 (80%) | 1 (20%) | ||
| Mental function | ||||
| Normal (MMSE ≥24) | 62 | 50 (81%) | 12 (19%) | n/a |
| Decreased (MMSE <24) | 0 | ― | ― | |
| Neurological findings | ||||
| Hemiplegia | ||||
| Yes * | 27 | 19 (70%) | 8 (30%) | 0.072 |
| No | 35 | 31 (89%) | 4 (11%) | |
| Other physical symptoms | ||||
| Yes † | 13 | 11 (85%) | 2 (15%) | 0.684 |
| No | 49 | 39 (80%) | 10 (20%) | |
| Neuropsychological deficits | ||||
| Yes ‡ | 13 | 11 (85%) | 2 (15%) | 0.684 |
| No | 49 | 39 (80%) | 10 (20%) |
n/a, not applicable; MMSE, Mini-Mental State Examination.
The χ2 test was applied to determine the differences in return to work by each factor.
Among the factors of interest, white-collar and blue-collar employments and hemiplegia, there were no significant differences in RTW between the working-age and elderly groups (Table 2, χ2 test, p>0.05). However, participants with hemiplegia in the elderly group showed a tendency to succeed in RTW more than those in the working-age group (χ2 test, p=0.070).
| No. | Successful return to work | Unsuccessful return to work | p-value | |
|---|---|---|---|---|
| Occupation type, White-collar | ||||
| Working-age group | 13 | 12 (92%) | 1 (8%) | 0.843 |
| Elderly group | 17 | 16 (94%) | 1 (6%) | |
| Occupation type, Blue-collar | ||||
| Working-age group | 22 | 14 (64%) | 8 (36%) | 0.179 |
| Elderly group | 10 | 8 (80) | 2 (20%) | |
| Hemiplegia, Yes | ||||
| Working-age group | 13 | 7 (54%) | 6 (46%) | 0.070 |
| Elderly group | 14 | 12 (86%) | 2 (14%) |
The χ2 test was applied to determine the differences in RTW between both groups concerning white-collar and blue-collar jobs and hemiplegia.
Table 3 shows specific contents of the white-collar and blue-collar occupations and successful RTW. White-collar workers had engaged in “administrative/managerial, clerical, sales, or professional/technical” work, and more than 90% of white-collar workers in each group succeeded in RTW. On the other hand, although blue-collar workers had engaged in “production, construction/laborer, transportation, or guard/others” work, nobody in the elderly group had chosen “production” but more than twice as many elderly blue-collar workers had engaged in “guard/others”.
| Successful return to work Working-age group | Elderly group | |
|---|---|---|
| White-collar occupations | 12/13 (92%)* | 16/17 (94%) |
| Administrative/managerial | 1/1 | 5/5 |
| Clerical | 4/4 | 4/5 |
| Sales | 4/5 | 5/5 |
| Professional/technical | 3/3 | 2/2 |
| Blue-collar occupations | 14/22 (64%) | 8/10 (80%) |
| Production | 6/7 | 0/0 |
| Construction/laborer | 3/6 | 1/2 |
| Transportation | 4/7 | 3/3 |
| Guard/others† | 1/2 | 4/5 |
Three and two participants worked at large companies with an employee size of ≥100 in the working-age and elderly groups, respectively. The rest of the participants worked at small or medium-sized companies.
Three elderly participants, who engaged in clerical, construction, and other work (cook), could not return to their workplace because of depression, physical disability due to hemiplegia, and altered sense of smell, respectively. On the other hand, nine working-age participants who engaged in sales (one), production (one), construction (three), transportation (three), and guard (one), could not return to their workplace. A white-collar worker (sales) could not return to the workplace because of a physical disability due to construction apraxia and left spatial neglect. Eight blue-collar workers could not return to their workplaces because of physical disabilities due to hemiplegia and work-side problems. Construction and transportation include working at a high place and driving large trucks, respectively. These types of work require high physical ability. Therefore, it was difficult for participants, even with mild hemiplegia, to return to their workplace. The work of a guard includes night duty; the participant (guard) could not endure long-time night occupation.
Figure 2 shows the RTW proportion curves of the working-age and elderly groups obtained using the Kaplan-Meier method. The RTW proportion curves had a steep slope in an early term after discharge from the hospital, and the proportion curve of the elderly group was significantly higher than that of the working-age group (log-rank test, p<0.039).
Return to work proportion curves of the working-age and elderly groups obtained using the Kaplan-Meier method. Blue line: working-age group; green line: elderly group. The elderly group has a significantly higher RTW profile than that of the working-age group (log-rank test, p=0.039).
The elderly participants attained successful RTW more than the working-age participants, but the difference was not statistically significant. However, the RTW proportion curve of the elderly group was significantly higher than that of the working-age group. These results suggest that more elderly patients with acquired brain injuries can return to their workplace than working-age patients.
RTW is generally considered unfavorable in elderly patients. Some researchers have reported that younger patients seem to have a better neurological and functional recovery, better adjustment to residual disability, higher motivation to work, and a greater willingness of the employer to take them back14), while other researchers have stated that age may be a negative predictor of RTW4,15). In a comprehensive review of stroke rehabilitation for RTW, it was noted that the factors positively associated with RTW were age <65 years, high education level, and white-collar employment; the severity of stroke was a negative predictor6). However, age has not been observed to be a significant predictor of RTW among different age groups <65 years3). Based on the present results, we believe age is not a negative predictor for RTW in the circumstance where the elderly persons worked without any trouble before the onset of acquired brain injuries.
In our analysis of factors related to RTW, occupation type was found to be the only significant factor influencing successful RTW (Table 1); that is, white-collar participants attained RTW more frequently than blue-collar participants. On the other hand, the RTW rates of the white-collar participants were almost the same in the working-age and elderly groups. Therefore, one of the reasons the RTW rate of the elderly group (89%) was higher than that of the working-age group (74%) was probably because the elderly group included more white-collar participants and fewer blue-collar participants, whose RTW rates were lower than the white-collar participants. The other reason was that blue-collar participants in the elderly group had a slightly higher RTW rate than those in the working-age group, along with a lower tendency to choose physical labor, such as that required in the production or construction industry, and a higher tendency to choose guard/others. Therefore, RTW of the elderly group may have been facilitated, to some degree, by the above-mentioned differences between white-collar and blue-collar employments and choice of work contents.
On the other hand, there were three elderly participants (one each in clerical, construction, and guard occupations) who could not return to work. Their neurological dysfunctions were mild hemiplegia, and activities of daily living were preserved. Their ability to work was improved by admission. However, they could not continue to work for sufficient time, and one participant had depression induced by disability. Therefore, at the workplace, it is important to support the mental condition of patients who RTW.
The severity of stroke6,15), including the function of the hemiplegic hand5), was a robust negative predictor for RTW, but hemiplegia in our study was not a significant factor influencing successful RTW (Table 1). The reasons for it not being a significant factor for RTW are as follows: first, the sample size was small; second, the severity of hemiplegia was null or mild because activities of daily living were defined as almost independent (Barthel Index score ≥80) 2 weeks after onset, so the effect of severity of hemiplegia was limited. However, in our study, even with mild hemiplegia, working-age participants found it difficult to return to their workplaces, such as working at high places (construction), driving large trucks (transportation), and night duty (guard), which required high physical ability and physical endurance. Therefore, at the workplace, redeployment to less demanding physical work is also important. However, it depends on the company’s situation.
Saeki et al. noted that independence in performing activities of daily living was the most important aspect in ensuring an early discharge from hospital5). The RTW proportion curve had two steep slopes: once during the first 6 months after admission and once between 12 and 18 months16). The first steep slope was defined as early RTW, and 50% of the patients who returned to work attained it at approximately 100 days from onset5,17). Toyota also reported that approximately 50% of 1,959 patients with stroke aged between 30 and 60 years recovered to modified Rankin scale 0 or 1 at 3 months after onset, of which levels were regarded as possible for RTW13).
In our study, participants of the working-age and elderly groups showed the RTW proportion curves with a steep slope within 3 months from admission, which was not accompanied by a second steep slope. The features of these RTW proportion curves, showing many of the participants attained early RTW, indicated that the participants were almost independent in activities of daily living and that their severity of hemiplegia was mild. Furthermore, the log-rank test revealed that the elderly group succeeded in RTW at a significantly higher rate than the working-age group in these circumstances.
Sickness benefits, disability pensions, and other funding sources may seem like complicated options, especially for patients who have not retired or elderly patients who are considering RTW. Saeki et al. reported that Japanese workers preferred to receive longer sickness benefits unless patients returned to work during an earlier period following a stroke16). Further, Treger et al. noted that several long-term sick-listed individuals moved from vocational rehabilitation to disability pensions, rather than reaching the goal of RTW6). Although sickness benefits and disability pensions are unavoidable issues in the management of RTW, we rarely confronted these issues in this study because the participants attained early RTW.
According to the Ministry of Internal Affairs and Communication, Japan, older workers comprised 53.1% of non-executive employees, 33.8% of self-employed workers, and 13.1% of executives; three-quarters of older employees are employed part-time, with reasons such as “wanting to work at a favorable day and time” in 30.5% of men and 37.2% of women, and “wanting to supplement the family budget” in 17.5% of men and 26.5% of women18). Therefore, elderly patients who had been working comfortably to supplement the family budget, and had already adapted to their work environment, had few barriers to RTW after recovering from their brain injury.
Finally, what we learned in this study was as follows: medical staff should not limit employment support only to working-age patients at work, and elderly patients at work also require employment support. In contrast, staff in charge of the workplace should provide occupation types (white-collar or blue-collar jobs), employment arrangements (full- or part-time), and work contents that are comfortable for elderly workers.
This study had several limitations. First, this study was performed in an acute-care hospital in a large city that has an aging rate of 36.8%. We did not confirm whether our results reflect the national trend in Japan. Second, the sample size of our study was small, and our results may not represent the nationwide trend of RTW; therefore, we should confirm whether elderly patients attain RTW as well as working-age patients in a large sample size and multi-institutional study. Third, this study only considered aspects of patient factors and did not include evaluation from a workplace perspective. Finally, we limited the participants to those with mild disabilities and did not include patients with moderate or severe disabilities.
In conclusion, the elderly group had a higher RTW rate than the working-age group in this study. We believe the elderly patients with acquired brain injuries could return to the workplace, at least as well as the working-age patients.
The authors thank the following members of the Health and Employment Support Team: Tomoaki Yuhi, Hirohisa Kondo, Hirotsugu Ohta, Hiroshi Miyachi, Souhei Nohara, Noboru Wada, Koji Tanigashira, Satoshi Masago, Yukiko Kamimura, Tametou Kenichiro, Takumi Momoda, Shinji Wasai, Asuka Hayata, Minami Ohnishi, Yousuke Nagano, Takeshi Fukuda, Shiho Watanabe, Natsuki Iwami, Taeko Uchiyama, Yoko Katsuragawa, and Chika Maehara.
This study was supported by research funds provided to promote hospital functions by the Japan Organization of Occupational Health and Safety.
All authors contributed to planning the design of this study. TU and KH explained the design of this study to participants and collected the workplace data. TU, KH, and SS analyzed the data. TU and KH prepared the manuscript. All authors critically revised the manuscript and approved the manuscript.
The authors declare that there are no conflicts of interest.
None.
