Research trials in the older stroke patient

‘Research trials in the older stroke patient’ examines the challenges of research in older people, the phenomenon of ageism, the impact of frailty, trials of acute treatments like intravenous thrombolysis and endovascular therapy, acute lowering of blood pressure, and decompressive hemicraniectomy. Trials looking at secondary prevention, including cardioembolism, role of the newer oral anticoagulants (DOACs), carotid endarterectomy, lipid lowering, antihypertensive therapy, are examined. The broader issue of difficulties in recruiting older people to stroke trials and the potential solutions are discussed. Until recently most participants in clinical trials of stroke have been relatively young with little or no comorbidity. With a group growing more than any other, it becomes a priority to understand the challenges in recruiting and retaining older patients into clinical trials. Barriers to recruitment relate to both researchers and participants; solutions include good communication, logistical support, and innovative study design and sampling. Further research will hopefully narrow the gap to those seen in real-world clinical practice.

Discharge from hospital and early supported discharge

‘Discharge from hospital and early supported discharge’ provides some useful guidance and outlines the issues that we encounter in facilitating effective discharge from hospital following a stroke. Hospital discharge is an important milestone in a stroke patient’s journey. It marks the end of the acute hospital episode, and the start of a new life living with and adjusting to their stroke and its sequelae. It can be a stressful time for patients and their carers, but careful and thorough discharge planning can help to ease the transition from hospital to home. The chapter explores the timing of discharge, models of care after discharge, early supported discharge, the evidence from SSNAP (Sentinel Stroke National Audit Programme) in the United Kingdom, the initiative of CLAHRC (Collaborative for Leadership in Applied Health Research and Care), guidance from the National Institute for Health and Care Excellence (NICE), institutionalization, role of capacity, role of IMCA (independent mental capacity advocate), communication with primary care, and follow-up after discharge from hospital.

Early and late complications of stroke

‘Early and late complications of stroke’ refers to the medical complications of acute stroke and the importance of these in the context of the outcome, morbidity, dependency, and mortality in these individuals. It explores the temporal profile of these complications. Infections, neurological, cardiac, pulmonary, gastrointestinal urinary, thrombotic, spasticity, sexual, and perceptual complications are described. A quarter of all stroke patients suffer at least one serious medical complication (defined as prolonged, immediately life-threatening, or resulting in hospitalization or death). Approximately 85% of patients suffered from a medical complication during their hospital stay. Depression, emotionalism, and anxiety are the common psychological syndromes encountered. Long-term complications are related to patient dependency and duration after stroke. Medical complications account for approximately half of stroke mortality.

Stroke mimics: Transient focal neurological events

‘Stroke mimics: Transient focal neurological events’ explores the important stroke-like symptoms that are due to non-cerebrovascular causes. Stroke mimics account for up to 31% of code stroke presentations, and up to 60% of potential TIAs. The most common stroke mimics are seizures, migrainous auras, and functional neurological disorders. Making an astute clinical decision based on the history and examination is particularly important as imaging cannot definitely rule out stroke. The chapter includes interesting case vignettes and discusses differential diagnoses like migraine, seizures, transient global amnesia, vertigo, functional neurological disorders, neuromuscular disorders, tumours, syncope, primary ophthalmic problems, and some other rare conditions.

Transient ischaemic attack (TIA) in the older person

‘Transient ischaemic attack (TIA) in the older person’ explores the new definitions of TIA (transient ischaemic attack) especially in the context of modern imaging methods, epidemiology of this common condition and its implications for everyone, the pathophysiology, common and less common clinical presentations, the differential diagnoses (including transient mono-ocular blindness, transient global amnesia, migraine, amyloid spells, and others), the risk factors (modifiable and non-modifiable), prognosis, risk scoring (ABCD2, ABCD2i, ABCD3i), investigation methods, and various pharmacological, non-pharmacological, and surgical methods of treatment. Lastly, this chapter discusses issues about TIA in the real world and the issues facing various stroke services around the world.

Presentation of stroke in the older person

‘Presentation of stroke in the older person’ outlines the varied patterns of clinical presentation of stroke in the older person, looking at common and the less common syndromes. Symptoms and signs in older people can be very subtle, often difficult to diagnose, and challenge even the most astute of clinicians. Most stroke presentations in older patients are similar to those in younger patients with respect to Oxford Community Stroke Project classification. However, atypical presentations can lead to diagnostic challenges in older patients due to the interaction between age-related cerebral and circulatory changes and comorbidities. The presentation of ischaemic stroke with its different vascular patterns, is discussed. Cerebral haemorrhage is explored in the context of its presentation patterns.

Epidemiology and aetiopathogenesis

Stroke is a common disabling condition associated with a high mortality, especially in the elderly. Subsequent social and monetary costs are high and despite a decreasing incidence of stroke in developed countries in recent years, prevalence has not declined due to an ageing population. Chapter 2 deals with ‘Epidemiology and aetiopathogenesis’ and examines the definitions of stroke and its pathological subtypes; epidemiology on a worldwide basis; age-specific data; mortality rates; cerebral blood flow and its relationship with ischaemic thresholds; and macroscopic and microscopic changes in the brain with increasing age and their relationship with ischaemic and haemorrhagic strokes. Changes related to large vessel disease, cardioembolism, small vessel disease, inflammatory arteriopathies, spontaneous intracerebral haemorrhage and cerebral amyloid angiopathy, are also described.

What does it mean to have a stroke?

‘What does it mean to have a stroke’ is the first chapter of the book. It is written by a ‘Stroke Conqueror’, someone who suffered a stroke more than 20 years ago and is now attempting to impart a little of the flavour, drama, and trauma a stroke event brings, not only to the person suffering the stroke, but also to everyone in that persons family and beyond. Nothing is ever the same again, stroke is for life. The fundamental issue is that everyone on this planet of ours should, if required, have the same opportunity and access to the best possible stroke care services should such an event occur to them. The chapter explores the lessons learned, the consequences, and the perspective of the patient and the carers.

Post-stroke cognitive impairment

‘Post-stroke cognitive impairment’ explores in great depth the burden of post-stroke cognitive impairment, its pathological substrates and clinical characteristics, the causes of these impairments, post-stroke dementia, and the risk factors implicated. The chapter examines common definitions (vascular cognitive impairment, vascular dementia, post-stroke cognitive impairment), the DSM-5 criteria (Diagnostic and Statistical Manual of Mental Disorders-5), ICD-10 criteria (International Classification of Diseases), NINDS-AIREN criteria (National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l’Enseignement en Neurosciences) for vascular dementia, and vascular mild cognitive impairment. The VASCOG (vascular cognitive disorder) criteria are also described. A pragmatic approach to investigations and various assessment scales, a description of important clinical trials, and the management of these disorders are also included.

Fatigue and the older stroke patient

‘Fatigue and the older stroke patient’ explores with the help of a case vignette and a conceptual model, the complex field of fatigue after stroke. It looks at the definition of fatigue, assessment of fatigue in older stroke patients, mechanisms of fatigue, medical management, and psychological treatment of post-stroke fatigue. While fatigue is common after stroke, research into its management is in its infancy. With respect to the older person there is in particular a deficiency in research not only into fatigue management but also its nature and origins in this age group. Older people often have multiple medical comorbidities that can also cause fatigue and these need to be addressed appropriately. Nonetheless, clinically both psychological and medical management offer treatments that at the individual level may be worthwhile. Further rigorous empirical research particularly considering older people after stroke might assist in refining understanding and treatment of fatigue in this population.