Critères de choix des filières de soins dans la rééducation de l'hémiplégie vasculaire

Nombre de lits dédiés à la pathologie vasculaire cérébrale en soins de suite et de réadaptation. Les recommandations nationales sont-elles pertinentes ?

OBJECTIVE

We sought to determine the number of beds necessary for stroke patients in postacute care units and to measure the relevance of the national guidelines on required number of beds.

METHODOLOGY

We conducted an epidemiological follow-up of a cohort, what allowed for evaluating stroke care under real-life conditions. We applied the French guidelines for transfer of patients to postacute care wards.

RESULTS

Of the 605 stroke patients hospitalised, 156 with a mean age of 72 years were included. A total of 64 (41%) could return home directly from the acute care wards and 73 (47%) were referred to postacute care wards. Among the latter patients, 31 (43%) were transferred to a physical medicine and rehabilitation (PMR) unit and 42 (57%) to a geriatric unit. The 19 remaining patients died in acute care. Of the 137 surviving patients, 46.7% returned directly home and 53.2% were referred to postacute care wards. Of patients older than 80 years, 74% were transferred to a geriatric unit, whereas 76% of the patients less than 80 years were transferred to a PMR unit.

DISCUSSION-CONCLUSION

The national guidelines are based on a rate of discharge of about 24% of stroke patients to postacute care wards. In our study, we found that 47% were transferred to such wards. If the guidelines are applied, 19 beds dedicated to stroke patients would be necessary for postacute stroke care on a national level, or double that (36) on a regional level. Of these 36 beds, 16 to 24 should be PMR beds. The calculation of the number of beds necessary often rests on a simple transposition of the results of the studies and not on an objective evaluation according to the local context. Studies of longitudinal follow-up of cohorts such as this seem essential to evaluate needs and measure the relevance of the national guidelines.

L'âge très élevé constitue-t-il un facteur pronostique du devenir après un premier accident vasculaire cérébral ?

AIM

To determine whether very old age, older than 80 years, after a stroke is a significant predictor of mortality, orientation to a specific care pathway after the acute phase and functional status at 6 months after the stroke.

PATIENTS

A sample of 112 consecutive patients admitted to the emergency department because of a first stroke, with hemiplegia and/or aphasia over 6 months, who satisfied strict inclusion/exclusion criteria. Forty-seven patients were older than 80.

METHOD

After initial diagnosis and enrolment in the study, follow-up assessments were conducted at 48 hours, 15 days and 6 months. Demographic, medical, and radiographic data were collected, and patients were evaluated on the NIHSS, MMSE, Barthel Index, FIM(TM) and FAM scales. Descriptive statistics were generated, as were uni- and multivariate between group comparisons.

RESULTS

Our study shows that after a first stroke, old age is significantly associated with a high rate of death, a low rate of orientation to a physical medicine and rehabilitation unit and return to home but not poorer functional outcome.

CONCLUSION

Old age is therefore a determinant of post stroke management. Further studies are needed to evaluate whether in patient rehabilitation would result in significant functional benefit, considering the high cost of care, high risk of recurrent stroke, and high rate of death.

[Hemiplegia and return to domicile]

OBJECTIVE

We have studied the outcome after a stroke on being discharged from a department of physical medicine and rehabilitation in patients with hemiplegia, and the factors influencing the choice of the orientation.

MATERIAL AND METHOD

This prospective study was based on 93 patients. The mode of discharged was patient's domicile, institution, the number of death was also noted. The potentially influential factors studied were age, the side with hemiplegia, the aetiology of the hemiplegia, co-morbidity, the delay in starting rehabilitation, the neurological damage evaluated by the Orgogozo score, the initial functional damage evaluated by Functional Independence Measure (FIM) and by the functional score carried out within the framework PMSI(1) (computerised programme of medical care), the existence of aphasia, the existence of a depressive syndrome, presence of hemineglect, presence of superficial or profound sensory disorders, incontinence at the start of rehabilitation and at one month after the stroke, the existence of cognitive or psychiatric disorders. The tests used were the non-parametric test of Mann and Whitney, the chi(2) test and the correlation test. The threshold of significance used was 0.05.

RESULTS

Based on 93 patients (47 women and 46 men, average age 64.8) 81 have gone back to their previous domicile, 11 were oriented toward an institution. One patient died. The predictive factors or those linked to an absence of return to the previous domicile were the age, social situation, the delay in starting rehabilitation, presence of aphasia, the initial and final functional damage, the impossibility to walk, the presence of a depressive syndrome, urinary incontinence.

CONCLUSION

The authors stress the importance of familial environment and of functional independence in establishing a prognosis for return to the domicile.