Early Identification, Intervention and Management of Post-stroke Spasticity: Expert Consensus Recommendations

Stroke patients with spasticity usually require long-lasting care and interventions but frequently report that outpatient and community treatment is limited, reflecting a significant unmet need in health and social care provision. Rehabilitation and spasticity management services are essential for patient recovery, with improvements in both activity and participation reducing the burden on patients, family and society. Current clinical guidance provides scope for improvements in both post-stroke management and spasticity prevention. However, access to specialist services can be limited and the patient journey does not always match national recommendations. Identification of spasticity and its predictors and lack of subsequent referral to rehabilitation or specialist spasticity services are key issues in the management of post-stroke spasticity. Implementation of a traffic light classification system prioritises patients at an increased risk of spasticity and promotes early and consistent management across the spectrum of primary and secondary care. The proposed system is based on clinical evidence, expert consensus and recent clinical guidelines. It provides simple and straightforward criteria for management, multidisciplinary consultation and referral to specialist spasticity services, with patients allocated by monitoring requirements and a low (green/periodic monitoring), medium (amber/routine referral) or high risk (red/urgent referral) of spasticity.

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Telehealth Use in a Home-Based Dementia Care-Coordination Program

Innovation in Aging ◽

10.1093/geroni/igaa057.633 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 195-196

Author(s):

Deirdre Johnston ◽

Melissa Reuland ◽

Kelly Marshall ◽

Inga Antonsdottir ◽

Morgan Bunting ◽

...

Keyword(s):

Clinical Supervision ◽

Unmet Need ◽

Dementia Care ◽

Care Plan ◽

Home Setting ◽

Home Team ◽

Individualized Care ◽

Home Based ◽

Increased Risk ◽

At Home

Abstract In the coming decades, greater numbers of people will either have Alzheimer’s Disease or a related dementia or will take care of a family member with dementia. The dementia syndromes are associated with increased risk of medical, social, and behavioral complications in both the person with dementia (PWD) and the caregiver (CG), many of which are preventable. These complications, and the dementia itself, can impede access to care and ultimately hasten residential care placement, which can be both undesirable and costly. A nearly universal unmet need in PWD/CG dyads is dementia-specific education. Therefore, it is vital we find ways to support and provide education to CG/PWD dyads to manage dementia in the community and home setting. MIND at Home is a dementia-care model developed and tested at Johns Hopkins University School of Medicine to minimize dementia complications and delay institutionalization by training non-clinical Memory Care Coordinators (MCCs) working under clinical supervision to support and guide PWD/CG dyads in the community. MCCs collaborate with CGs and PWDs in the community using an individualized care plan structured around the dyads’ specific dementia-related needs. This presentation will describe how the MIND at Home team used handheld tablets to connect MCCs to clinicians from participants’ homes, and will report on challenges encountered, strategies to address them, and participant and caregiver satisfaction with the telehealth experience.

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Abstract P305: Post-Stroke Aphasia as a Predictor of 30-Day Readmission Associated With Infection: A Retrospective Chart Review

Stroke ◽

10.1161/str.52.suppl_1.p305 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Emma M Loebel ◽

Mary Rojas ◽

Connor Mensching ◽

Danielle Wheelwright ◽

Laura K Stein

Keyword(s):

Chart Review ◽

Retrospective Chart Review ◽

Mount Sinai Hospital ◽

Index Admission ◽

Negative Consequences ◽

Medical Comorbidities ◽

Post Stroke ◽

Increased Risk ◽

Adjusted Model ◽

The Impact

Introduction: Studies have demonstrated that aphasia may negatively impact morbidity and mortality among ischemic stroke (IS) patients. However, the association between post-stroke aphasia and readmission with infection (RI) is poorly understood. We sought to assess the impact of aphasia on post-stroke RI. We hypothesized that aphasic patients are at increased risk of infection in the 30-day post-stroke period. Methods: We performed retrospective chart review of the Mount Sinai Hospital IS patients with 30-day all cause readmission from January 2016 - December 2019. All variables were abstracted from the index admission (IA) electronic medical records except for aspects related to the readmission (RA). Aphasia was present if a neurologist diagnosed the patient with acquired language dysfunction during IA. We performed chi square and logistic regression analyses to compare readmitted patients with and without aphasia at IA. Our fully adjusted model controlled for age, sex, medical comorbidities, NIHSS ≥ 8, IA LOS > 7, IA infection, discharge to facility. We completed all analyses with SPSS. Results: During IA, 36% (n=42) were diagnosed with aphasia. At IA, there were no significant differences in age (dichotomized at 65), sex, or medical comorbidities between aphasic and non-aphasic cohorts. However, more aphasic patients had admission NIHSS ≥ 8 (89% vs 35%, p<0.0001), LOS > 7 (76% vs 42%, p=0.0004), discharge to facility (79% vs 49%, p=0.0016), and RI (52% vs 19%, p=0.002). The presence of aphasia predicted RI in both unadjusted (OR=4.6, p<0.001) and adjusted (OR= 3.3, p=0.014) multivariate analyses. The Kappa inter-reliability ranged from 0.7-1.0 for the key variables included in our adjusted model. Conclusions: The adjusted odds of 30-day readmission with infection were significantly greater in those with diagnosis of aphasia at the time of index admission compared to those without. Our study provides preliminary evidence that the presence of aphasia may have negative consequences on a patient’s health beyond the language disturbance. Further study is needed to better understand the reasons and risk reduction strategies in this vulnerable population.

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Post-stroke memory deficits and barriers to seeking help: views of patients and carers

Family Practice ◽

10.1093/fampra/cmy109 ◽

2018 ◽

Vol 36 (4) ◽

pp. 506-510 ◽

Cited By ~ 3

Author(s):

Eugene Y H Tang ◽

Christopher Price ◽

Blossom C M Stephan ◽

Louise Robinson ◽

Catherine Exley

Keyword(s):

Health Professionals ◽

Health Care Professionals ◽

Organizational Level ◽

Stroke Survivors ◽

Ageing Population ◽

Family Carers ◽

Post Stroke ◽

North East ◽

Increased Risk ◽

Seeking Help

Abstract Background Memory and cognitive deficits post stroke are common and associated with increased risk of future dementia. Rehabilitation tends to focus on physical recovery; however, once in the community, it is unclear what happens in the longer term to the stroke-survivor with new memory difficulties. Objective The aim of this qualitative study was to examine in stroke-survivors what factors influence contact with health professionals. Method Semi-structured interviews were conducted with stroke-survivors and their family carers where memory difficulties were reported at 6 months post stroke. A topic guide was used which sought to critically examine participants care experience following their stroke diagnosis. All participants were interviewed at baseline (around 6 months post stroke) and offered an interview at around 12 months post stroke. All interviews were conducted in the North East of England. All transcripts were coded and thematically analysed. Results Ten stroke-survivors (age range 72–84 years) were interviewed alongside five carers at baseline; eight stroke-survivors and four carers agreed to a follow-up interview. Three main barriers were identified: (i) fear of a dementia diagnosis; (ii) denial or minimization of symptoms leading to adaptation and (iii) obstacles to seeking help in the community. Conclusions With an ageing population and increase in stroke-survival, the burden of post-stroke cognitive impairment and dementia will only increase. Stroke-survivors and their family carers in this study have identified issues that may hinder their presentation to health care professionals at a personal and organizational level. Health professionals need to be aware of these potential issues when planning services for stroke-survivors.

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Potential Prognostic Impact of Dopamine Receptor D1 (rs4532) Polymorphism in Post-stroke Outcome in the Elderly

Frontiers in Neurology ◽

10.3389/fneur.2021.675060 ◽

2021 ◽

Vol 12 ◽

Author(s):

Hae-Yeon Park ◽

Youngkook Kim ◽

Hyun Mi Oh ◽

Tae-Woo Kim ◽

Geun-Young Park ◽

...

Keyword(s):

Dopamine Receptor ◽

Statistical Significance ◽

The Elderly ◽

Minor Allele ◽

Prognostic Impact ◽

Nucleotide Polymorphisms ◽

Unique Identifier ◽

Clinical Trial Registration ◽

Post Stroke ◽

Increased Risk

Background: Single-nucleotide polymorphisms (SNPs) may affect post-stroke motor recovery, and some SNPs have been implicated in swallowing disturbances after stroke. Certain SNPs may also have altered influences according to different age.Objective: This post-hoc study investigated whether SNPs have different effects on dysphagia recovery between the elderly vs. young stroke patients.Methods: Analysis was conducted from a previous study including 218 stroke subjects with dysphagia. They were stratified into two groups, aged <65 and aged ≥65 years. The primary outcome was persistence of nil per mouth (NPM) at 3 months post-stroke onset. Association between outcome and nine different SNPs were investigated.Results: The elderly group (50%, n = 103) showed poorer swallowing outcomes than the young group. The minor allele of the dopamine receptor D1 (DRD1, rs4532) polymorphism showed potential association (p = 0.022) with an increased risk of NPM at 12 weeks post-stroke in the elderly, both in the additive (OR, 2.94; 95% CI, 1.17–7.37) and dominant models (OR, 2.93; 95% CI, 1.04–8.23) but did not reach statistical significance after Bonferonni correction. Logistic regression analysis showed that in those aged ≥65 years, models including the minor allele of rs4532 predicted the risk of the poor outcome with good accuracies even after adjustment of clinical factors, such as previous pneumonia episodes (AUROC, 0.86; 95% CI, 0.79–0.93) or the National Institutes of Health Stroke Scale (AUROC, 0.82; 95% CI, 0.67–0.92). In contrast, those aged <65 years seemed not to be affected by the presence of the rs4532 polymorphism, and models that included intubation history (AUROC, 0.81; 95% CI, 0.73–0.90) or previous pneumonia episodes (AUROC, 0.77; 95% CI, 0.68–0.87) showed modest levels of accuracies in predicting NPM at 12 weeks poststroke.Conclusions: Our study suggests a possible association between the rs4532 and post-stroke swallowing recovery, primarily in those aged ≥65 years. Certain SNPs may lead to less favorable outcomes in the elderly. The gene–age interaction should be considered in post-stroke swallowing recovery.Clinical Trial Registration:https://www.clinicaltrials.gov, Unique identifier [NCT03577444].

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The Return Home Program: integrated health and social care for post-stroke patients

International Journal of Integrated Care ◽

10.5334/ijic.3029 ◽

2016 ◽

Vol 16 (6) ◽

pp. 219

Author(s):

Aina Plaza ◽

Marta Fabà ◽

Marco Inzitari ◽

Mercè Salvat ◽

Patricio Hernández ◽

...

Keyword(s):

Social Care ◽

Stroke Patients ◽

Home Program ◽

Post Stroke ◽

Health And Social Care ◽

Integrated Health ◽

Return Home

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Longer-term health and social care strategies for stroke survivors and their carers: the LoTS2Care research programme including cluster feasibility RCT

Programme Grants for Applied Research ◽

10.3310/pgfar09030 ◽

2021 ◽

Vol 9 (3) ◽

pp. 1-268

Author(s):

Anne Forster ◽

Seline Ozer ◽

Thomas F Crocker ◽

Allan House ◽

Jenny Hewison ◽

...

Keyword(s):

Usual Care ◽

Unmet Needs ◽

Social Care ◽

Feasibility Trial ◽

Stroke Survivors ◽

Post Stroke ◽

Cluster Randomised ◽

Health And Social Care ◽

Stroke Services ◽

Randomised Controlled

Background It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified. Objectives The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations). Design Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales. Setting The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales. Participants Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services. Data sources Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified. Intervention Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks. Results A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains. Conclusions We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation. Future work Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation. Trial registration Current Controlled Trials ISRCTN38920246. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

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Risk of Stroke in Nasopharyngeal Cancer Survivors: A National Registry-Based Population Cohort Study

Neurology ◽

10.1212/wnl.0000000000013058 ◽

2021 ◽

pp. 10.1212/WNL.0000000000013058

Author(s):

Teng Hwee Tan ◽

Huili Zheng ◽

Timothy Cheo ◽

Jeremy Tey ◽

Yu Yang Soon

Keyword(s):

Cohort Study ◽

General Population ◽

Nasopharyngeal Cancer ◽

Reference Population ◽

National Registry ◽

Age Group ◽

Post Stroke ◽

Risk Of Death ◽

Increased Risk ◽

Stage 1

BackgroundWe aim to determine the risk of stroke and death within 30 days post stroke in nasopharyngeal cancer (NPC) survivors.MethodsWe conducted a population-based cohort study of patients diagnosed with NPC from Jan 1, 2005 to Dec 31, 2017. Using the cancer and stroke disease registries and the Singapore general population as the reference population, we report the age-standardized incidence rate differences (SIRDs) ratios (SIRs) and the cumulative incidence of stroke and the standardized mortality rate differences (SMRDs) and ratios (SMRs) for all causes of death within 30 days post stroke for NPC survivors.FindingsAt a median follow up of 48.4 months (IQR 19.8 – 92.9) for 3849 patients diagnosed with NPC, 96 patients developed stroke. The overall SIRD and SIR for stroke was 3.12 (95% CI 2.09 – 4.15) and 2.54 (95% CI 2.08 – 3.10) respectively. The SIRD was highest for the age group 70 – 79 years old (8.84 cases per 1000 person-years (PY); 0.46 – 17.21) while the SIR was highest for the age group 30 – 39 years old (16.41; 6.01 – 35.82). The SIRD and SIR for stage 1 disease was (6.96 cases per 1000 PY; 2.16 – 11.77) and (4.15; 2.46 – 7.00) respectively. The SMRD and SMR for all cause deaths within 30 days of stroke was (3.20 cases per 100 persons; -3.87 – 10.28) and (1.34; 0.76 – 2.37) respectively.InterpretationThe overall risk of stroke was markedly elevated in survivors of NPC, especially in Stage 1 disease when compared to the general population. The risk of death within 30 days of stroke was not significantly higher for NPC survivors.Classification of EvidenceThis study provides Class II evidence of the increased risk of stroke in survivors of nasopharyngeal cancer compared to general population.

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Cardiovascular care of the oncology patient during COVID-19: An expert consensus document from the ACC Cardio-Oncology and Imaging Councils

JNCI Journal of the National Cancer Institute ◽

10.1093/jnci/djaa177 ◽

2020 ◽

Author(s):

Lauren A Baldassarre ◽

Eric H Yang ◽

Richard K Cheng ◽

Jeanne M DeCara ◽

Susan Dent ◽

...

Keyword(s):

Multimodality Imaging ◽

Cardiovascular Complications ◽

Expert Consensus ◽

Oncology Patients ◽

Oncology Patient ◽

Cancer History ◽

Patients With Cancer ◽

Consensus Document ◽

Increased Risk ◽

Cardiovascular Care

Abstract In response to the coronavirus disease 2019 (COVID-19) pandemic, The Cardio-Oncology and Imaging Councils of the American College of Cardiology offers recommendations to clinicians regarding the cardiovascular care of cardio-oncology patients in this expert consensus statement. Cardio-oncology patients–individuals with an active or prior cancer history, and with or at risk of cardiovascular disease–are a rapidly growing population, who are both at increased risk of infection by COVID-19 and experiencing severe and/or lethal complications. Recommendations for optimizing screening and monitoring visits to detect cardiac dysfunction are discussed. In addition, judicious use of multimodality imaging and biomarkers are proposed to identify myocardial, valvular, vascular, pericardial involvement in cancer patients. The difficulties of diagnosing the etiology of cardiovascular complications in patients with cancer and COVID-19 are outlined, along with weighing the advantages against risks of exposure, with the modification of existing cardiovascular treatments and cardiotoxicity surveillance in patients with cancer during the COVID-19 pandemic.

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The views of public and clinician stakeholders on risk assessment tools for post-stroke dementia: a qualitative study

BMJ Open ◽

10.1136/bmjopen-2018-025586 ◽

2019 ◽

Vol 9 (3) ◽

pp. e025586 ◽

Cited By ~ 2

Author(s):

Eugene Tang ◽

Catherine Exley ◽

Christopher Price ◽

Blossom Stephan ◽

Louise Robinson

Keyword(s):

Risk Assessment ◽

Qualitative Study ◽

Secondary Care ◽

Assessment Tools ◽

Stroke Patients ◽

Post Stroke ◽

North East ◽

Increased Risk ◽

Diagnosis Of Dementia

ObjectiveStroke-survivors are at increased risk of future dementia. Assessment to identify those at high risk of developing a disease using predictive scores has been utilised in different areas of medicine. A number of risk assessment scores for dementia have been developed but none has been recommended for use clinically. The aim of this qualitative study was to assess the acceptability and feasibility of using a risk assessment tool to predict post-stroke dementia.DesignQualitative semi-structured interviews were conducted and analysed thematically. The patients and carers were offered interviews at around 6 (baseline) and 12 (follow-up) months post-stroke; clinicians were interviewed once.SettingThe study was conducted in the North-East of England with stroke patients, family carers and healthcare professionals in primary and secondary care.ParticipantsThirty-nine interviews were conducted (17 clinicians and 15 stroke patients and their carers at baseline. Twelve stroke patients and their carers were interviewed at follow-up, some interviews were conducted in pairs).ResultsBarriers and facilitators to risk assessment were discussed. For the patients and carers the focus for facilitators were based on the outcomes of risk assessment for example assistance with preparation, diagnosis and for reassurance. For clinicians, facilitators were focused on the process that is, familiarity in primary care, resource availability in secondary care and collaborative care. For barriers, both groups focused on the outcome including for example, the anxiety generated from a potential diagnosis of dementia. For the patients/carers a further barrier included concerns about how it may affect their recovery. For clinicians there were concerns about limited interventions and how it would be different from standard care.ConclusionsRisk assessment for dementia post-stroke presents challenges given the ramifications of a potential diagnosis of dementia. Attention needs to be given to how information is communicated and strategies developed to support the patients and carers if risk assessment is used.

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Association of Prior Atherosclerotic Cardiovascular Disease with Dementia After Stroke: A Retrospective Cohort Study

Journal of Alzheimer s Disease ◽

10.3233/jad-200536 ◽

2020 ◽

Vol 77 (3) ◽

pp. 1157-1167

Author(s):

Zhirong Yang ◽

Duncan Edwards ◽

Stephen Burgess ◽

Carol Brayne ◽

Jonathan Mant

Keyword(s):

Cardiovascular Disease ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Clinical Practice Research Datalink ◽

Atherosclerotic Cardiovascular Disease ◽

Stroke Patients ◽

Post Stroke ◽

Increased Risk ◽

The Impact

Background: Prior atherosclerotic cardiovascular disease (ASCVD), including coronary heart disease (CHD) and peripheral artery disease (PAD), are common among patients with stroke, a known risk factor for dementia. However, whether these conditions further increase the risk of post-stroke dementia remains uncertain. Objective: To examine whether prior ASCVD is associated with increased risk of dementia among stroke patients. Methods: A retrospective cohort study was conducted using the Clinical Practice Research Datalink with linkage to hospital data. Patients with first-ever stroke between 2006 and 2017 were followed up to 10 years. We used multi-variable Cox regression models to examine the associations of prior ASCVD with dementia and the impact of prior ASCVD onset and duration. Results: Among 63,959 patients, 7,265 cases (11.4%) developed post-stroke dementia during a median of 3.6-year follow-up. The hazard ratio (HR) of dementia adjusted for demographics and lifestyle was 1.18 (95% CI: 1.12–1.25) for ASCVD, 1.16 (1.10–1.23) for CHD, and 1.25 (1.13–1.37) for PAD. The HRs additionally adjusted for multimorbidity and medications were 1.07 (1.00–1.13), 1.04 (0.98–1.11), and 1.11 (1.00–1.22), respectively. Based on the fully adjusted estimates, there was no linear relationship between the age of ASCVD onset and post-stroke dementia (all p-trend >0.05). The adjusted risk of dementia was not increased with the duration of pre-stroke ASCVD (all p-trend >0.05). Conclusion: Stroke patients with prior ASCVD are more likely to develop subsequent dementia. After full adjustment for confounding, however, the risk of post-stroke dementia is attenuated, with only a slight increase with prior ASCVD.

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