Adult Care after Stroke: Recommendations from Professional Associations

Care for stroke patients begins in the hospital and continues in the community, where recovery, reintegration, and maintenance of health take place over the years.

Primary care physicians provide most of this long-term care. The needs of these patients may be complex depending on the temporal phase of their disease, the cause and severity of their stroke, and other factors, including chronic comorbidities.

Approximately 50% to 80% will have hypertension; 20% to 30%, diabetes, and 10% to 30%, heart disease or atrial fibrillation.

Lung disease, depression, anxiety, kidney disease, and arthritis are also common. Caring for patients with chronic diseases and multiple comorbidities is a special expertise of primary care physicians.

When primary care practices achieve their defining functions (disease prevention, management of acute symptoms and chronic diseases), provide easy access and continuous, comprehensive and coordinated care, they must also advocate for patients when specialized care is needed, and ensure that different specialists and subspecialists work together.

Although there is vast clinical science to guide physicians in the care of patients after a stroke, it is dispersed in numerous original publications and professional guides. The purpose of this scientific statement is to summarize this literature and provide a practical system of goal-directed care for all patient needs throughout the lifespan. The authors emphasize strategies to prevent recurrent strokes, recognize and manage their complications, and maximize function.

Primary care, like all medical specialties, needs to close the evidence-practice gap and ensure that every patient receives the care recommended by the guidelines.

One year after stroke, 97% of eligible patients continue to take antiplatelet agents, but only 50% to 70% achieve blood pressure <140/90 mm Hg, 79% remain on statins, 84% continue in a non-smoking state and, 48% exercise according to recommendations and only 17% reach a healthy weight (body mass index <25 kg/m2)

Unmet needs for physical rehabilitation , activities of daily living (ADL), mobility, pain management, and communication remain prevalent. Many factors beyond primary care physician control contribute to deficiencies in post-stroke care, including social factors (health insurance, lack of access to care for other reasons, social isolation, structural racism), lack of perceived therapeutic benefits or fear of side effects of treatments.

However, effective communication by primary care physicians can improve adherence with effective care by boosting motivation with accurate and stimulating information, and overcoming linguistic, cultural literacy, and health barriers. Primary care is essential to improve the level of population health.

Post-stroke care is an iterative process of assessment, treatment and feedback that, over time, adapts to the patient’s changing needs.

To operationalize this process, the authors propose a template for primary care visits that is based on current notions of chronic care management, to help clinicians achieve 5 goals that are generally accepted for postcare care. Stroke: 1) provide patient-centered care, 2) prevent recurrent brain injury, 3) maximize function, 4) prevent late complications, and, 5) optimize quality of life.

Patient-centered care is a philosophy that guides physicians toward the health outcomes most valued by patients. Emphasizes relief from pain, fear and anxiety. Emphasizes patient autonomy and communication to identify patient values ​​and preferences underlying autonomous decisions.

A 6-point strategy is proposed to be applied by primary care physicians, in order to achieve the 5 general objectives. All components can be covered during most office visits.

The first post-stroke visit should occur shortly after discharge from the intensive care unit or rehabilitation hospital, usually within 3 weeks. An early visit can reduce readmission and treat conditions undetected during your care, which may exacerbate the high risk of recurrence in the first 3 months after hospital discharge. The current average interval for the first post-stroke medical visit is 27 days.

First, you need to know the patient’s experience, their understanding of what happened to them, and their concerns. These will shape much of the care that is about to begin, with understanding the cerebrovascular event in sufficient detail to classify the pathogenesis, which is not always established during hospitalization.

Carotid imaging, when indicated, is usually performed in the hospital, but prolonged carotid monitoring is usually deferred until after discharge. Almost 10% of ischemic strokes are related to carotid stenosis.

In almost 9% of patients, prolonged heart rhythm monitoring (e.g., every 30 days) will detect occult atrial fibrillation.

Some cause-specific treatments are compelling, particularly carotid revascularization, which, in most patients, should be performed within 2 weeks. Primary care physicians should note whether any part of the cause assessment was deferred to be completed in the outpatient setting.

Dual antiplatelet therapy is started in the hospital and can reduce early recurrence by 25%, but in many patients it must be stopped after 21 to 30 days to reduce the risk of bleeding.

Intracranial stenosis may benefit from extended dual antiplatelet therapy for up to 90 days. Patients eligible for dual antiplatelet therapy are those who have had a minor acute ischemic stroke or a high-risk transient ischemic attack within the previous 12 to 24 hours, and are not candidates for thrombolysis, endovascular therapy, endarterectomy or anticoagulation.

At the first visit, the patient and doctor should work to identify and remedy precursors that may have contributed to the stroke. Was your blood pressure not optimally controlled? Was anticoagulation inadvertently discontinued? What can be done differently in the future to reduce the risk of a stroke recurrence?

Because there are important and complex decisions that must be addressed early after a stroke, close collaboration between the primary care physician and the neurologist is required.

After the first visit, it is helpful to document a brief patient narrative about their stroke to plan specific care for future visits. Useful information includes pre-stroke risk factors, symptoms, diagnostic results, evaluation, anatomical location of stroke, pre-stroke therapy (if any), hospital course, suspected pathogenesis (including unrecognized or untreated risk factors). incomplete form) and the subsequent evolution in rehabilitation.

This narrative can be updated in future visits, even if the primary care physician has been for years, a stroke can alter the goals and interconnected components of the picture. The emergence of new physical and medical conditions requires care and preventive treatments that the patient may not have valued in the past and that, in this context, become more urgent, just as the consequences of a brain injury can alter a patient’s relationships. , social roles and sense of self.

Staying abreast of the patient and their new situation becomes the foundation for almost everything a primary care doctor can do. Therefore, essential work for each visit includes monitoring the consequences of the stroke and updating the medical and social history.

Approximately 60% of stroke survivors have some neurological symptoms, and 5% to 50% have moderate disability, requiring assistance with ADLs.

The social history considers the patient’s social past, circumstances, premorbid roles, family circumstances, and how any of these may have changed due to the stroke. Ultimately, the physician’s knowledge of his or her patient allows him or her to work with the patient, the family, and the multidisciplinary care team to address the social, emotional, and physical aspects of the patient’s health.

Patient-centered care is enhanced by a welcoming space where patients can express their values, aspirations, questions, fears and needs. With patient consent, caregivers can help identify patient and family needs and opportunities to improve satisfaction for all. Family and caregiver collaboration improves management of risk factors and outcomes.

Post-stroke complications include anxiety, bone fracture, cognitive impairment, contractures, depression, falls, fatigue, hemiplegic shoulder pain, osteoporosis, pressure ulcers, seizures, spasticity, and thromboembolism. Some complications can be prevented; others can be managed to reduce morbidity.

Most readmissions within 30 days, moreover, are due to medical rather than neurological causes, and can be reduced by care interventions.

Depression is very prevalent in the months after a stroke, but after 2 years it continues to affect up to 25% of patients. The main professional guidelines include a recommendation to detect post-stroke depression, whenever resources for treatment exist. Treatment is identical to that of depression in patients without stroke.

Unmet needs are remediable gaps between what the patient would like to be able to do or experience and what he or she is currently doing or experiencing. Estimates of the prevalence of unmet needs in the months and years after hospital discharge range from 20% to 75%.

In addition to asking patients and caregivers about unmet needs, there are screening tools. Even in the subacute or chronic phase of stroke, many patients can benefit from speech or occupational therapy. Patients in need can often be identified by asking: "Would this patient benefit from a referral to a disability care service?"

At post-stroke visits there are 2 important questions to ask:

1. "What caused this patient’s stroke?"
2. "Is everything being done to prevent recurrent stroke?

The answer to the latter begins with characterizing the control of stroke risk factors for which treatment provides proven benefit. The most prevalent important risk factors are: hypertension, atrial fibrillation, carotid stenosis and dyslipidemia. For each of these, specific treatment reduces the risk of recurrence. It is important to identify diabetes and intracranial atherosclerotic stenosis, for which treatments exist, although with less evidence of their effects.

Because patients often skip or prematurely discontinue active medication therapy, monitoring adherence is important and may reveal the cause of not achieving therapeutic goals. Medication nonadherence often responds to concerns about the risks of adverse effects, particularly among low-income people or historically disadvantaged groups. In addition to medical conditions that affect stroke prognosis, there are several socioeconomic factors that are associated with poor outcomes.

Designing care to accommodate poverty, food insecurity, low educational attainment, lack of access to care, lack of transportation, and other social determinants of health are challenging, but are a critical mission in primary care. . This concept requires asking patients about their social determinants of health, identifying community resources and connecting patients with those resources.

The integration of a social worker into the health team is crucial . On the other hand, the authors mention the characteristics of these inequities that exist in the United States and express that, “beyond socioeconomic factors, there are races (black) and ethnicities (Hispanics) that have been associated with quality of care. lower after stroke and higher risk of recurrence, compared to white people.

Inequity has been attributed to institutional, cultural and interpersonal racism. “Primary care physicians can potentially mitigate this inequity through strategies such as those advocated by the American Academy of Family Physicians and training themselves and their staff to correct implicit bias.”

The best plans in primary care arise from collaboration between the patient and the doctor. The plans are based on a list of problems, such as high blood pressure or a painful shoulder. When patients are invited to define those problems, doctors may be surprised by the result. Family responsibilities, for example, may top a list that includes obesity, inactivity, blood pressure or diabetes.

It is necessary to know the problems identified by the patient in order to then deal with other problems.

There are two related concepts that must be adapted, through the application of clinical guidelines directed to the patient’s specific circumstances and goals, to ultimately sequence or prioritize care. Upon discharge from the hospital, patients, especially those with significant neurological deficits, may be overwhelmed by new medications and attention in rehabilitation services.

Together, patients and their physicians must negotiate a plan of care through which certain clinical problems are prioritized and arrangements are made for timely follow-up to address deferred issues. Once problems are identified, action plans can be created based on things the patient wants to achieve and that they are confident they can do.

Setting realistic goals helps avoid failure. The typical office visit concludes with plans to reinforce successful behavior, address unmet needs, and close gaps between goals and achievements.

When patients leave the office, they and their caregivers must be able to manage themselves. Therefore, the basis of chronic disease management is support for self-management.

This support begins with the problems, goals and plans that arise from collaborative care and continues with education for patient and caregiver knowledge (about health, illness, prognosis, therapy, when to call emergencies) and skills in monitoring, resolution of problems and decision making. Self-management for blood pressure, diabetes, and weight management is now part of professional guidelines.

Self-monitoring provides feedback that can be combined with self-management to achieve better risk control. Emerging evidence suggests that team-based care involving nurses or pharmacists can improve chronic disease management, although most studies do not integrate these professionals into primary care practice.

For many goals of care, community nursing, pharmacy, social work, physiatry, physical therapy, speech therapy, occupational therapy, and each of the medical specialties can play a role in patient follow-up. post stroke. Visit intervals should be scheduled taking into account the patient’s condition, stability of risk factors, and risk of not meeting goals.

The risk of recurrence approaches 8% in the first year after ischemic stroke. After the first year, the risk is approximately 2%, which is still 4 times higher than the risk in a person without prior stroke.

In addition to clinically evident recurrences, 30% of patients with acute stroke have clinically inapparent disease on brain imaging and increased risk of future inapparent events, including small vessel disease, which can accelerate cognitive and physical decline. Fortunately, the authors say, surgical interventions are very effective in preventing recurrent cerebral ischemia.

A first step in outpatient primary care is to confirm the cause of the stroke, because the pathogenesis guides specific preventive treatment.

When the patient returns to the community, diagnostic tests that have not yet been completed should be prioritized, especially carotid imaging and heart rate monitoring.

Although the cause of stroke in most patients is due to 1 of 3 mechanisms (cardioembolism, large vessel disease, or small vessel disease), it is important to consider other causes (arterial dissection, vasculitis, patent foramen ovale, sickle cell disease). , Moyamoya, hypercoagulable states, carotid membrane and fibromuscular dysplasia) that may require high specialization and have effective treatments. Despite careful search, the cause of stroke in almost 30% of patients remains uncertain.

It is proven in clinical trials that carotid revascularization for carotid stenosis, anticoagulation in atrial fibrillation, lowering blood pressure, and treatment with statins and antiplatelet agents prevent the recurrence of vascular events. Improving lifestyle, diabetes control, and weight optimization are also important. However, it is necessary to have higher quality evidence.

Management of hypertension is particularly important because 50% to 80% of patients have hypertension, and treatment is very effective. The 2021 AHA/American Stroke Association guideline cites moderate-quality evidence and emphasizes the recommendation to set a blood pressure goal <130/80 mm Hg after ischemic stroke for most patients.

To select drugs, treatment tolerance, drug safety and patient characteristics must be taken into account. Research on strategies to prevent recurrent stroke or transient ischemic attack has been dominated by studies of surgical and pharmaceutical interventions.

Recently, there has been research on interventions that address so-called lifestyle factors, including diet quality, physical activity, obesity, smoking, and substance use disorders.

Lifestyle interventions can improve risk factors, but have not yet been shown to prevent clinical vascular events after stroke or transient ischemic attack (TIA).

The authors anticipate that approximately 800,000 American adults will suffer a new stroke each year, and 10% will die within 30 days.

At the time of stroke, almost 5% of patients <55 years and 40% >85 years have moderate premorbid disability. Within 90 days of a stroke, 10% of young adults and 30% of those >65 years of age develop a new disability related to the event, of moderate to severe severity. The cumulative burden of premorbid and new disability is believed to exceed 10% in young adults and 50% in older adults.

Indirect effects of life change include depression, loss of income, and social isolation. The US Centers for Disease Control estimated in 2009 that 1,076,000 adults >18 years (2.4% of the population) had at least moderate disability as a result of a stroke (i.e., required a mobility assistive device, assistance needed for ADLs or instrumental activities of daily living (IADLs), or were living limited in their ability to work at home or work).

Recovery begins early after stroke and can take years for a patient to achieve maximum restoration of function. With disability, motor strength and limb mobility improve rapidly in the first 30 days and maximum recovery can be achieved in approximately 4 months.

Restoration of the ability to participate in physical activities extends beyond this time, due to brain remodeling (the healthy brain takes over the functions of the infarcted brain), adaptation of compensatory strategies, reinforcement of confidence and the use of adaptive equipment.

There are effective rehabilitation therapies not only for motor disorders but also for cognition (memory, orientation, attention and language), communication, incontinence, pain, dysphagia, sensory impairment, spasticity, balance and mobility.

Improvements in each of these domains follow the same course as motor recovery, with rapid early recovery followed by more time for maximum restoration of function. Stroke recovery can fluctuate over time, depending on many factors: caregiver support, chronic comorbidities, episodic acute events, access to care, devices, joint flexibility, spasticity, pain, and degree of intact motor function.

All stroke patients should have their ADL and IADL capacity, communication skills, and functional mobility evaluated. This evaluation determines the need for rehabilitation services. Assessment is initiated during hospitalization, rehabilitation center, or nursing facility, and again as part of discharge planning, but must be repeated in the office.

Rehabilitation abilities and needs may change over time. In this evaluation 3 questions can be useful:

1) What could the patient do before the stroke that you can’t do now?

2) What does the patient want to be able to do?

3) Has the patient reached his or her full potential?

Sometimes the answers to these questions are evident from observation while the patient is in the office: mobility, speech, balance, gait, and mood. Other times, answers may come from direct questioning of patients and caregivers.

Direct questioning is essential for classifying the ability to perform ADLs and IADLs, and can uncover other gaps between what a patient did before the stroke and what they would like to be able to do now. Common questions include: "Can you still buy groceries?" and "Can you prepare and eat your favorite foods at home?"

Structured instruments for functional assessment and determination of rehabilitation needs may be useful in primary care, but some may be useful in special circumstances, particularly to identify fall risk. The balance scale and the Morse scale classify the risk of falls.

The timed up and go test and the 10-meter walk test classify mobility status. Assessment of cognitive impairment after stroke can be done using a brief instrument (e.g., Mini Mental State Examination or Montreal Cognitive Assessment Test).

The guidelines emphasize routine screening before hospital discharge, during the first year, and possibly thereafter. Case finding is justified when cognitive impairment is suspected based on clinical observation or the report of the patient or acquaintances of the patient. Neuropsychological tests such as the Patient Health Questionnaire-9 (PHQ-9) are rarely needed to screen for depression.

Once the functional status is classified and the rehabilitation is not satisfactory, the next step is to link the patient with the appropriate rehabilitation resources. When available, these interventions should be offered to eligible patients.

In addition to motor problems, which are easy to refer to rehabilitation services, resources such as otorhinolaryngology, clinics with speech therapy programs, are also needed; neuro-ophthalmologists; orthopedists; driver evaluation programs (e.g., a local motor vehicle department); a neurologist or physiatrist who can provide botulinum therapy; a vascular neurologist to determine the cause and, occupational and speech therapy programs; and psychology.

Aerobic exercise is important for all post-stroke patients, regardless of specific rehabilitation needs. Exercise improves functional capacity, walking endurance, balance, cardiovascular health, and secondary stroke prevention.

Primary care physicians can improve their patients’ participation in physical activity through structured assessment, counseling, and referral practices. Linking patients to exercise programs that exist in the community is particularly effective.

The process begins by asking patients about their physical activity. There are simple tools for this, such as the "Exercise Vital Signs", which includes 2 questions to find out how many days and minutes per week of moderate to vigorous activity the patient performs. The minimum amount of physical activity necessary to achieve a benefit has not yet been established.

However, 150 minutes per week of moderate activity (e.g., brisk walking) or 75 minutes per week of vigorous activity (e.g., jogging, running, carrying heavy packs, strenuous exercise) is recommended. If stroke patients can achieve these goals, it would be reasonable to support their efforts.

Quality improvement begins when clinicians identify an aspect of care to improve; For example, the doctor may set a goal of improving blood pressure control for hypertensive patients. Key features of quality improvement include:

1) An iterative process of continuous planning, implementation of changes, studies, tests and redesigns.

2) An agreed upon methodology (e.g., Lean Six Sigma is a method that examines repetitive processes to achieve better quality).

3) Empowerment of frontline workers and service users.

4) Data to inform and monitor the process (e.g. audit and feedback).

Specifically, quality improvement goes beyond an audit to include changes in ongoing practice, through human engagement in setting objectives, reflecting, evaluating, and planning to achieve the goal.

Magic bullets for quality are sometimes invented to meet the unique needs of a professional or health system, but often they are adapted from research discoveries in health services sciences, a field within services research. health that seeks to improve the use of evidence-based research by doctors and governments.  

Effective interventions relevant to stroke care include the use of pharmacists in practice to improve medication adherence and achieve better control of hypertension and diabetes, as well as patient self-management with or without self-management, to improve Control of blood pressure. In the field of stroke care, health services research has uncovered effective interventions for post-stroke care, often addressing the critical post-discharge transition.

An overall conclusion from this research is that hospital- or system-based collaborative care and case management can help patients improve risk factor control.

Effective models include improving the practice of primary care physicians or being in close communication with primary care teams, personally interviewing patients, and having prescribing authority.

However, the benefit of case management may be reduced in circumstances of high-quality primary care. Interventions aimed at patient education or behavior alone are not effective.