How do stroke patients fare when discharged straight to their homes? A controlled study on the significance of hospital follow-up after one month

Feasibility of an integrated multidisciplinary geriatric rehabilitation programme for older stroke patients: a process evaluation

Background

Almost half of the stroke patients admitted to geriatric rehabilitation has persisting problems after discharge. Currently, there is no evidence based geriatric rehabilitation programme available for older stroke patients, combining inpatient rehabilitation with adequate aftercare aimed at reducing the impact of persisting problems after discharge from a geriatric rehabilitation unit. Therefore, we developed an integrated multidisciplinary rehabilitation programme consisting of inpatient neurorehabilitation treatment using goal attainment scaling, home based self-management training, and group based stroke education for patients and informal caregivers. We performed a process evaluation to assess to what extent this programme was performed according to protocol. Furthermore, we assessed the participation of the patients in the programme, and the opinion of patients, informal caregivers and care professionals on the programme.

Methods

In this multimethod study, process data were collected by means of interviews, questionnaires, and registration forms among 97 older stroke patients, 89 informal caregivers, and 103 care professionals involved in the programme.

Results

A part of patients and informal caregivers did not receive all key elements of the programme. Almost all patients formulated rehabilitation goals, but among two thirds of the patients the goal attainment scaling method was used. Furthermore, the self-management training was considered rather complex and difficult to apply for frail elderly persons with stroke, and the percentage of therapy sessions performed in the patients’ home environment was lower than planned. In addition, about a quarter of the patients and informal caregivers attended the education sessions. However, a majority of patients, informal caregivers and care professionals indicated the beneficial aspects of the programme.

Conclusion

This study revealed that although the programme in general is perceived to be beneficial by patients, and informal and formal caregivers, the feasibility of the programme needs further attention. Because of persisting cognitive deficits and specific care needs in our frail and multimorbid target population, some widely used methods such as goal attainment scaling, and self-management training seemed not feasible in their current form. To optimize feasibility of the programme, it is recommended to tailor these elements more optimally to the population of frail older patients.

Post-acute hospital healthcare services for people with mild stroke: a scoping review

BACKGROUND

People with mild stroke comprise a significant proportion of the overall stroke population. Previously this population has been viewed as having limited impairments, receiving minimal services following hospital discharge. Recent findings demonstrate that the implications of mild stroke are more significant than originally comprehended, warranting further services.

OBJECTIVES

To identify the evidence-base regarding services for people with mild stroke, post-acute hospital discharge, that target secondary prevention and/or changes following stroke.

METHODS

Scoping review utilizing the five-stage framework proposed by Arksey and O'Malley, with revisions by Levac, Colquhuon, and O'Brien. Framework stages included: identification of a research question and relevant studies, study selection, charting of data, and collating, summarizing, and reporting. A critical appraisal using the Downs and Black Checklist was added to determine methodological quality of studies. The search strategy used six databases: Pubmed, Embase, PsycINFO, CINAHL, OTseeker, and Scopus, alongside a hand-search. Three researchers were involved in article selection and two in critical appraisal.

RESULTS

Twelve articles met inclusion criteria from 589 identified. A number of study methodologies were used to assess services, with varying methodological qualities. Studies were located within two major regions in the world. Five main approaches to service provision were identified: telehealth, exercise and education, Comprehensive Cardiac Rehabilitation, one-off visits and care-plan development, and community group programs. The majority of programs focused on secondary prevention and were aimed at an impairment level, with a mix of findings observed.

CONCLUSION

Further development and assessment of services is warranted. Incorporation of the entire transition period, and research that is mild stroke and location-specific is advised. Attention to maximizing participation in daily life, secondary prevention, emotional well-being, and careful reporting is needed.

Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials

BACKGROUND

Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI.

METHODS

We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers.

RESULTS

A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation.

CONCLUSIONS

The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI.

Stroke survivor and informal caregiver perceptions of poststroke depressive symptoms

Poststroke depression is common but remains underdiagnosed and undertreated. One explanation for this is that depressive symptoms go unrecognized by stroke survivors and their family caregivers and thus go unreported to the stroke survivor's healthcare provider. Forty-four stroke survivor-informal caregiver dyads were interviewed using a depression knowledge scale, the Center for Epidemiologic Studies Depression Scale, and an adapted version of the Revised Illness Perception Questionnaire to determine their lay knowledge of depressive symptoms, recognition of poststroke depressive symptoms, and perception of the recognized symptoms. Caregivers and stroke survivors had moderate knowledge of depressive symptoms but had some misconceptions. The most commonly recognized poststroke depressive symptoms by stroke survivors were "feeling like everything was an effort," "restless sleep," "difficulty concentrating," and "talking less than usual." Caregivers identified that the stroke survivor was "feeling like everything was an effort," had "restless sleep," "felt sad," and "felt depressed." Three quarters of stroke survivors with high levels of depressive symptoms identified the cluster of symptoms as potentially being depression. Neuroscience nurses are in the unique position to educate stroke survivors and their caregivers about poststroke depressive symptoms, treatment options, and the importance of discussing depressive symptoms with their healthcare provider.

Subtle problems in activities of daily living after a transient ischemic attack or an apparently fully recovered non-disabling stroke

Little is known about the effects on the performance of activities of daily living (ADL) and quality of life (QoL) of transient ischemic attack (TIA) or a nondisabling stroke (NDS) with a full recovery in 72 hours. The present study evaluated ADL performance and QoL, as well as symptoms of anxiety and depression, in patients at 1 and 6 months after a TIA or an NDS. Consecutive hospitalized TIA/NDS patients not requiring rehabilitation were assessed at 1 and 6 months after discharge from a hospital or emergency department. ADL performance was evaluated using the Assessment of Motor and Process Skills (AMPS), QoL was assessed with the Short Form 36 (SF-36), and depression and anxiety symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS). A total of 45 patients completed the follow-up. At 1 month after TIA/NDS, all patients were independent in ADL performance but had AMPS and SF-36 scores below the norm. In addition, 12 patients (27%) had anxiety symptoms, and 9 patients (20%) had symptoms of depression. Although initially considered fully recovered, 23 patients (51%) required rehabilitation after the first follow-up. After 6 months, their AMPS, SF-36, and HADS scores were lower than those of the patients who did not require rehabilitation after the first screening. Half of the patients with a TIA or an NDS who were initially considered fully recovered exhibited ADL limitations, decreased QoL, and symptoms of anxiety or depression after 6 months.

The transition from hospital to home for individuals with acquired brain injury: a literature review and research recommendations

PURPOSE

To review the literature relating to the transition from hospital to home for individuals with acquired brain injury (ABI) and make recommendations concerning the future direction of transition-specific research.

METHOD

Relevant research articles were identified through searching existing database systems and by reviewing the reference lists of identified articles. Only articles in which the results directly related to individuals with ABI from the time of discharge to 1 year post-discharge were included in the review.

RESULTS/DISCUSSION

A total of 50 articles were identified as meeting the criteria for inclusion in the review. The methodological quality of included articles was evaluated using a set of specific criteria. The articles were classified into the following categories: (i) The perspectives of individuals with ABI and their caregivers; (ii) outcomes for individuals with ABI following transition; (iii) post-discharge services; and (iv) transitional living services/programmes. The majority of articles were based on samples of individuals with stroke, typically aged over 65 years. A common theme identified in the review was that the transition from hospital to home is typically perceived as an exciting yet difficult period for individuals and their families and as such, post-discharge support is critical.

CONCLUSION

Further ABI transition-specific research is necessary in order to: (i) Develop a comprehensive theoretical framework of the transition phase; and (ii) facilitate both the validation of current intervention strategies and the development of innovative/tailored intervention approaches.

To cope with uncertainty: stroke patients' use of temporal models in narratives

Stroke victims have to cope with a disrupted autobiography and anxiety because of an uncertain future. Professionals share this uncertainty. The patients reveal their experiences in narratives, and when they try to regain coherence and confidence in life, they use narratives in the reconstructions. Because they have a temporal problem, time might be an important issue in these narratives. The aim of this study was to elucidate the use of time models in stroke patients' narratives. Nineteen stroke patients, who had recently been discharged to their homes after the stroke, accepted to participate in the study. Their age span was between 56 and 89 years. They had lived active urban lives before the stroke, and poststroke only three had more serious physical impairment, and none was demented. They were asked to talk about their present life and their conceptions of future life. The interviews were audio-taped and transcribed verbatim and narratives that referred to temporal aspects were thematically analysed with reference to narrative time models. The stroke accident had caused an autobiographical disruption and a temporal split because of a new awareness of human temporality and an uncertainty of the future. Confronted with these problems of time, the stroke victims constructed narratives based on the time models: time cycles and dissolution of time limits, exchange of time and exclusion from time. Hence, the time models worked as tools when the stroke victims re-established coherence in their present and future life. Stroke patients handled an uncertain future by using temporal models in their narratives. Professionals can support stroke patients by reinforcing these models.

Regional differences in the use of out-patient services by stroke patients after hospitalisation

BACKGROUND

To improve the quality of life in stroke patients, outreach care programmes are developed and assessed for effectiveness. The generalisability of the trials' results is uncertain since information on the comparability of the conventional out-patient services is lacking. This study intended to assess the use of 11 types of conventional out-patient services by stroke patients in the United States and a predefined set of Western European countries.

METHODS

Review of the literature from 1990 to 2001.

RESULTS

We found 11 studies, which contained data on 1,875 patients of 6 countries. Large differences in the use of out-patient services within and between countries prohibited pooling of the data.

CONCLUSIONS

The paucity of data on the use of conventional out-patient services by stroke patients and the regional differences found do not substantiate generalisability of the results from studies on outreach care for stroke patients.

Therapy-based rehabilitation services for stroke patients at home

BACKGROUND

Stroke Unit care is now accepted as an effective service model for hospital care, but the effectiveness of outpatient care is less certain. This review focuses on therapy-based rehabilitation services targeted at stroke patients living at home.

OBJECTIVES

To assess the effects of therapy-based rehabilitation services targeted towards stroke patient resident in the community within one year of stroke onset/ discharge from hospital following stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched November 2001). In addition we searched the following electronic databases: the Cochrane Controlled Trials Register (Cochrane Library Issue 4, 2001), MEDLINE (1996 - Nov 2001), EMBASE (1980 - Nov 2001), CINAHL (1983 - Nov 2001), PsycINFO (1967 - Nov 2001), AMED (1985 - Nov 2001), Wilson Social Sciences Abstracts (1984-Nov 2001), Science Citation Index and Social Sciences Citation Index (1981-Nov 2001). Other strategies to ensure identification of all potentially relevant trials included scanning reference lists of relevant articles and original papers, personal communication and hand searching journals.

SELECTION CRITERIA

All unconfounded, truly randomised controlled trials of stroke patients resident in the community receiving a therapy service intervention, which was compared to conventional or no care. Therapy services were those provided by physiotherapy, occupational therapy, or multidisciplinary staff working with patients primarily to improve task-orientated behaviour (e.g. walking, dressing) and hence increase activity and participation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials and extracted data on a number of prespecified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow-up.

MAIN RESULTS

We identified a heterogeneous group of 14 trials including 1617 patients. Therapy-based rehabilitation services reduced the odds of a poor outcome (Peto odds ratio 0.72 (95% CI 0.57 to 0.92; P = 0.009) and increased personal activity of daily living scores (standardised mean difference 0.14 (95% CI 0.02 to 0.25; P = 0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, 7 (95% CI 2 to 11) patients would be spared a poor outcome, assuming 37.5% would have had a poor outcome with no treatment.

REVIEWER'S CONCLUSIONS

Therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. However, the evidence is derived from a review of heterogeneous interventions and therefore further exploration of the interventions is justifiable.

Setting priorities for a discharge plan for stroke patients entering nursing home care

OBJECTIVE

To agree priorities for the structure and content of the discharge process for stroke patients entering nursing home care.

DESIGN

A formal priority-setting exercise using the Nominal Group Technique.

PARTICIPANTS

A panel of 12 members of a multidisciplinary team from a hospital and community setting with experience in the management of stroke patients on a daily basis.

RESULTS

Agreement was good and improved during the process (Kendall coefficient of concordance 'W increased from 0.48 to 0.58 for physical care needs, 0.45 to 0.75 for care needs and 0.56 to 0.72 for the discharge process). The priorities for discharge were: 1) Plans need to be co-ordinated by one person 2) Clear written information on medication should be provided 3) Clear written information on nutritional needs should be provided.

CONCLUSION

Agreement was reached by a panel of clinicians on an evidence-based discharge plan for stroke patients entering nursing home care.

Post-stroke depression: an update

Those caring for stroke victims should be aware of new developments in our understanding of depression following stroke, its diagnosis, prevalence, pathophysiology, clinical features, and treatment. Appropriate diagnosis and treatment will improve quality of life, self-care independence, and mortality.