Exploring changing needs following minor stroke

Effect of very early supported discharge versus usual care on activi-ties of daily living ability after mild stroke: a randomized controlled trial

OBJECTIVE

To examine the ability to perform basic and instrumental activities of daily life after very early supported discharge vs usual discharge and referral routine during the first year after mild stroke.

DESIGN

A secondary analysis of data from the Gothenburg Very Early Supported Discharge randomized controlled trial.  Patients: A total of 104 patients (56% men; mean (standard deviation) age 75 (11) years) who had experienced a first stroke classified as mild.

METHODS

The primary outcome was the Activities of Daily Living Taxonomy score. Stroke Impact Scale (activities of daily living, and mobility) scores was a secondary measure. Patients were randomized to either very early supported discharge with 4 weeks of home rehabilitation provided by a multidisciplinary stroke team, or a control group discharged according to usual routine (referral to primary care when needed). Assessments were performed at discharge, 4 weeks post-discharge, and 3 and 12 months post-stroke.

RESULTS

Instrumental activities of the Activities of Daily Living Taxonomy scores (the lower the better) in the very early supported discharge and control groups were median 4 and 6 (p = 0.039) at 4 weeks post-discharge and 3 and 4.5 (p = 0.013 at 3 months post-stroke, respectively. Stroke Impact Scale (Mobility) median scores (the higher the better) in the very early supported discharge and control groups at 3 months were 97 and 86 (p = 0.040), respectively. There were no group differences in the 2 outcomes at 12 months post-stroke.

CONCLUSION

Compared with usual discharge routine, team-based rehabilitation during the first month at home is beneficial for instrumental activity in the subacute phase, in patients with mild stroke. One year post-stroke both groups show equal results.

Lasting impairments following transient ischemic attack and minor stroke: a systematic review protocol

Introduction

The focus on medical management and secondary prevention following Transient Ischemic Attack (TIA) and minor stroke is well-established. Evidence is emerging that people with TIA and minor stroke can experience lasting impairments as fatigue, depression, anxiety, cognitive impairment, and communication difficulties. These impairments are often underrecognized and inconsistently treated. Research in this area is developing rapidly and an updated systematic review is required to evaluate new evidence as it emerges. This living systematic review aims to describe the prevalence of lasting impairments and how they affect the lives of people with TIA and minor stroke. Furthermore, we will explore whether there are differences in impairments experienced by people with TIA compared to minor stroke.

Methods

Systematic searches of PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Libraries will be undertaken. The protocol will follow the Cochrane living systematic review guideline with an update annually. A team of interdisciplinary reviewers will independently screen search results, identify relevant studies based on the defined criteria, conduct quality assessments, and extract data. This systematic review will include quantitative studies on people with TIA and/or minor stroke that report on outcomes in relation to fatigue, cognitive and communication impairments, depression, anxiety, quality of life, return to work/education, or social participation. Where possible, findings will be grouped for TIA and minor stroke and collated according to the time that follow-up occurred (short-term < 3 months, medium-term 3-12 months, and long-term > 12 months). Sub-group analysis on TIA and minor stroke will be performed based on results from the included studies. Data from individual studies will be pooled to perform meta-analysis where possible. Reporting will follow the Preferred Reporting Items for Systematic review and Meta-Analysis Protocol (PRISMA-P) guideline.

Perspectives

This living systematic review will collate the latest knowledge on lasting impairments and how these affect the lives of people with TIA and minor stroke. It will seek to guide and support future research on impairments emphasizing distinctions between TIA and minor stroke. Finally, this evidence will allow healthcare professionals to improve follow-up care for people with TIA and minor stroke by supporting them to identify and address lasting impairments.

Outcomes in Patients with Minor Stroke: Diagnosis and Management in the Post-thrombectomy Era

In the era of mechanical thrombectomy and better preventative strategies, a higher number of patients are being discharged home from the hospital with the so-called minor strokes. This has significantly changed the landscape of stroke recovery. Unfortunately, while symptoms may be categorized as mild compared to individuals with higher NIH Stroke Scale scores, the physical, cognitive, and emotional sequelae can be disabling and result in failure to return to work and poor quality of life in a population with significant potential to recover fully. In this review, we discuss the current state of minor stroke, the most common pattern of resulting deficits, what is known about the underlying pathophysiology that leads to a relatively global pattern of impaired cognition following an infarct in any location, and special considerations for treatment based on this population's unique needs. Raising awareness of the current morbidity associated with minor stroke, the need for a uniform definition that allows for comparisons of individuals across studies, and further research focused on this population to optimize outcomes, has the potential to significantly improve recovery.

The effects of racism and resilience on Black stroke- survivor quality of life: Study protocol and rationale for a mixed-methods approach

Introduction

Stroke, a life-threatening stressor, often negatively impacts stroke-survivor (SS) quality of life (QoL). Annual age-adjusted incidence and death rates for stroke are significantly higher among Black Americans than among White Americans. Racism, a significant stressor, occurs at structural, cultural, and interpersonal levels and contributes to health disparities for Black SS. Resilience, a dynamic process of positive adaptation to significant stress, is impacted by factors or resources both internal and external to the individual. This study aims to examine the effects of experiences of racism and resilience on Black SS QoL during early stroke recovery. This article presents the study protocol.

Methods and analyses

This will be a prospective observational mixed-methods study. Black community-dwelling adults who are within 4 weeks of a stroke will be eligible for inclusion. Baseline measures will include the exposure variables of experiences of racism and resilience. Covariates measured at baseline include sociodemographic variables (age, sex, marital status, education, income, health insurance, employment status, number of people in household, residential address), clinical variables (date and type of stroke, inferred Modified Rankin Scale, anxiety and depression screening), and psychosocial variables (COVID-19 stress, perceived stress, mindfulness). The outcome variable (QoL) will be assessed 6-months post-stroke. Multiple-level linear regression models will be used to test the direct effects of experiences of racism, and the direct and indirect effects of resilience, on QoL. Qualitative data will be collected via focus groups and analyzed for themes of racism, resilience, and QoL.

Discussion

Racism can compound the stress exerted by stroke on Black SS. This study will occur during the COVID-19 pandemic and in the aftermath of calls for social justice for Black Americans. Experiences of racism will be measured with instruments for both “everyday” discrimination and vigilance. Sociodemographic variables will be operationalized to assess specific social determinants of health that intersect with structural racism. Because of the long-standing history of racism in the United States of America (USA), cultural influences and access to resources are central to the consideration of individual-level resilience in Black SS. Study results may inform the development of interventions to support Black SS QoL through enhanced resilience.

Voicing the perspectives of stroke survivors with aphasia: A rapid evidence review of post-stroke mental health, screening practices and lived experiences

A rapid evidence review (RER) of empirical literature was conducted to explore aphasic stroke survivors' mental health outcomes and lived experiences, as well as the screening instruments for this cohort. The RER was informed by a critical disability theory approach and synthesised qualitative and quantitative evidence within and across 29 studies, published between 2000 and 2021, from a systematic search of three databases. Understanding the relationship between post-stroke aphasia and mental health outcomes is essential for developing comprehensive treatment strategies and designing appropriate long-term care. Available screening instruments currently only detect depression and anxiety, which are then used to detect further mental health issues. The RER revealed that the current screening instruments demonstrate reliability; however, research remains limited regarding their validity. Furthermore, limited studies include aphasic patients as participants and decision-makers in stroke research. Methodological limitations across studies include comparators and small sample sizes. Importantly, across the studies, there is a lack of representation of culturally diverse and minority participants. Overall, the RER results found a high prevalence of aphasic stroke survivors experiencing depression and other mental health outcomes, indicating that implementing mood screening in a timely manner is essential. In addition, the results support that psychological care pathways must be developed and evaluated in consultation with aphasic patients' and carers' lived experiences to identify stepped levels of care and establish appropriate screening instruments. Furthermore, the health system requires consistency, which would ideally be achieved by establishing staff roles and responsibilities regarding mood screening and supportive care in these psychological care pathways. Including mental health specialists such as social workers and establishing specialist training in the multidisciplinary team would support this endeavour. There is a need for further research regarding mood screening instruments, a diversity of aphasic stroke survivors' lived experiences and the clinical expertise of those providing psychological support.

What do people with lung cancer and stroke expect from patient navigation? A qualitative study in Germany

OBJECTIVE

This qualitative study investigated patients' needs and wishes in relation to patient navigation.

DESIGN

A qualitative interview study was conducted. Participants were invited to take part in three in-depth interviews over a period of 6-12 months. Thematic analysis was used.

SETTING

Interviewees were sought in the Berlin metropolitan area of Germany in academic university hospitals, in rehabilitation clinics and through self-help organisations.

PARTICIPANTS

The sample consisted of individuals diagnosed with lung cancer (n=20) or stroke (n=20).

RESULTS

From the perspective of interviewees, patient navigators should function as consistent contact persons, present during the whole care trajectory. Their role would be to guide patients through an often confusing healthcare landscape, offering practical, advisory and emotional assistance corresponding to patients' needs. The study shows that-independent of the disease-participants had similar expectations and needs regarding support from navigators.

CONCLUSION

For chronic and complex diseases-as is the case with lung cancer and stroke-it appears less important for navigators to fulfil disease-specific tasks. Rather, they should ensure that patients' more general needs, in relation to social, practical and emotional support, are met in a way that suits their individual wishes. Following these results, patient navigation programmes might be designed to include generic elements, which should then be adapted to the infrastructure in a particular healthcare region and to the particularities of a specific healthcare system.

Disrupted biographies: making sense of minor stroke after hospital discharge

PURPOSE

To explore how people with minor stroke make sense of the stroke in the first weeks following hospital discharge to home.

MATERIALS AND METHODS

A qualitative descriptive approach using semi-structured interviews with 17 participants with minor stroke at approximately 2 weeks post-hospital discharge was used to explore their experiences of the early stage of recovery. Interview transcripts were analysed using qualitative content analysis.

RESULTS

Three main themes were derived from the analysis 1) Reconciling personal reactions, 2) Emotional introspection after the stroke, and 3) Navigating the social side of stroke.

CONCLUSIONS

Although participants had different experiences of minor stroke, there were common elements. The first weeks post-hospital discharge were a time of questioning and reconciling the stroke for many participants. Adjusting to post-stroke impairments and the impact of these on social participation was also prominent. There is a critical need for education about what to expect prior to discharge from hospital with minor stroke and a designated discharge pathway to avoid the development of secondary post-stroke issues in the community.IMPLICATIONS FOR REHABILITATIONPeople with minor stroke may experience ongoing post-stroke disabilities following discharge home.The transition period is characterised by questioning and reconciling what has happened by people with minor stroke.Information about what to expect prior to discharge from hospital for people with minor stroke and their families is essential.There is a critical need for a designated discharge pathway with follow up for people with minor stroke and their families.

Meeting unmet needs following minor stroke: the SUN randomised controlled trial protocol

Background

Whilst there are comprehensive guidelines for the rehabilitation of people with severe impairments from stroke, there has been less attention on the health and rehabilitation needs of people with minor stroke. Our study will assess whether a new multi-component service pathway using an integrated model based around primary care will reduce unmet need following minor stroke compared with usual care 1 and 3 months post-hospital discharge.

Methods

One hundred ten patients with minor stroke will be recruited within a parallel, randomised controlled trial design comparing a new service pathway and usual care.

The new service pathway will comprise a self-management kit, customised General Practitioner checklist, and a series of minor stroke educational topics. Participants will complete assessments pre-hospital discharge and 1 and 3 months later. The primary outcome measure will be the Survey of Unmet Needs and Service Usage. Secondary outcome measures will include assessments of ability, adjustment and participation; social group connectedness; return to work; health-related quality of life; and perceptions of the new service pathway (intervention group only). Mixed model repeated measures will be used to analyse within and between group differences at each time point. Return to work will be analysed using Chi square tests. Perceptions of the new service pathway will be analysed qualitatively.

Dissemination of results

The project will produce an evidence-based, multicomponent service pathway for minor stroke patients, applicable to other health services nationally and internationally. Dissemination will include publications and presentations.

Trial registration

Prospectively registered - Australian New Zealand Clinical Trials Registry (ACTRN12619000133134p) 30 January 2019.