Steroids to reduce the impact on delirium (STRIDE): a double-blind, randomised, placebo-controlled feasibility trial of pre-operative dexamethasone in people with hip fracture

Neuro-inflammation may be important in the pathogenesis of postoperative delirium following hip fracture surgery. Studies have suggested a potential role for steroids in reducing postoperative delirium; however, the potential efficacy and safety of pre-operative high-dose dexamethasone in this specific population is largely unknown. Conducting such a study could be challenging, considering the multidisciplinary team involvement and the emergency nature of the surgery. The aim of this study was to assess feasibility and effectiveness of dexamethasone given as early as possible following hospital admission for hip fracture, to inform whether a full-scale trial is warranted. This single-centre, randomised, double-blind, placebo-controlled study randomly allocated 79 participants undergoing hip fracture surgery to dexamethasone 20 mg or placebo pre-operatively. Eligibility and recruitment rates, timing of the intervention and adverse events were recorded. Incidence and severity of postoperative delirium were assessed using the 4AT delirium screening tool and the Memorial Delirium Assessment Scale. Postoperative pain, length of stay and mortality were also assessed. The eligibility rate for inclusion was 178/527 (34%), and 57/178 (32%) of eligible patients presented to hospital when no researcher was available (e.g. after-hours, weekends, public holidays). Recruitment was limited mainly by ethical limitations (not including patients with impaired cognition) and lack of weekend staffing. Median (IQR [range]) time from emergency department admission to drug administration was 13.3 (5.9-17.6 [1.8-139.6]) hours. There was a significant difference in delirium severity scores, favouring the dexamethasone group: median (IQR [range]) 5 (3-6 [3-7]) vs. 9 (6-13 [5-14]) in the placebo group, with the probability of superiority effect size being 0.89, p = 0.010. Delirium incidence did not differ between groups: 6/40 (15%) in the dexamethasone group vs. 9/39 (23%) in the placebo group, relative risk (95%CI) 0.65 (0.22-1.65), p = 0.360). A larger randomised controlled trial is feasible and ideally this should include people with existing cognitive impairment, seven days-a-week cover and a multicentre design.

Sedentary behaviour and physical activity of people with stroke in rehabilitation hospitals

Background. Sedentary behaviour is associated with health risks, independent of physical activity. This study aimed to investigate patterns of sedentary behaviour and physical activity among stroke survivors in rehabilitation hospitals. Methods. Stroke survivors admitted to four Swedish hospital-based rehabilitation units were recruited ≥7 days since stroke onset and their activity was measured using behavioural mapping. Sedentary behaviour was defined as lying down or sitting supported. Results. 104 patients were observed (53% men). Participants spent an average of 74% (standard deviation, SD 21%) of the observed day in sedentary activities. Continuous sedentary bouts of ≥1 hour represented 44% (SD 32%) of the observed day. A higher proportion (30%, SD 7%) of participants were physically active between 9:00 AM and 12:30 PM, compared to the rest of the observed day (23%, SD 6%, P < 0.0005). Patients had higher odds of being physically active in the hall (odds ratio, OR 1.7, P = 0.001) than in the therapy area. Conclusions. The time stroke survivors spend in stroke rehabilitation units may not be used in the most efficient way to promote maximal recovery. Interventions to promote reduced sedentary time could help improve outcome and these should be tested in clinical trials.

Does evidence really matter? Professionals' opinions on the practice of early mobilization after stroke

INTRODUCTION

Early mobilization after stroke may be important for a good outcome and it is currently recommended in a range of international guidelines. The evidence base, however, is limited and clear definitions of what constitutes early mobilization are lacking.

AIMS

To explore stroke care professionals' opinions about (1) when after stroke, first mobilization should take place, (2) whether early mobilization may affect patients' final outcome, and (3) what level of evidence they require to be convinced that early mobilization is beneficial.

METHODS

A nine-item questionnaire was used to interview stroke care professionals during a conference in Sydney, Australia.

RESULTS

Among 202 professionals interviewed, 40% were in favor of mobilizing both ischemic and hemorrhagic stroke patients within 24 hours of stroke onset. There was no clear agreement about the optimal time point beyond 24 hours. Most professionals thought that patients' final motor outcome (76%), cognitive outcome (57%), and risk of depression (75%) depends on being mobilized early. Only 19% required a large randomized controlled trial or a systematic review to be convinced of benefit.

CONCLUSION

The spread in opinion reflects the absence of clear guidelines and knowledge in this important area of stroke recovery and rehabilitation, which suggests further research is required.

‘Better Wear Out Sheets than Shoes’: A Survey of 202 Stroke Professionals' Early Mobilisation Practices and Concerns

Background

Stroke unit care improves the outcome for patients. One component responsible for this may be that patients are mobilised earlier and more intensively. An ongoing randomised controlled trial is investigating the potential benefits of early mobilisation, but currently there is limited evidence for the practice. Therefore, current practices may be driven by historical precedent and/or clinical opinion, and varying approaches to mobilisation are likely. This study aims to examine different health professionals' concerns regarding early mobilisation in acute stroke. In this study, early mobilisation was defined as frequent out of bed activities within the first 24 h after stroke onset.

Methods

A nine-item anonymous questionnaire exploring benefits and harms with early mobilisation after stroke was used during interviews of stroke care professionals attending the annual Australasian stroke conference in 2008.

Results

The survey was completed by 202 professionals, representing 38% of all conference attendees. Sixty-five per cent were females, 50% under 40-years old, 46% worked in acute stroke and 31% in rehabilitation. Thirty-five per cent were nurses, 26% medical doctors, 19% physiotherapists and 12% occupational therapists. Two-thirds had <10-years experience with stroke. Sixty per cent of the surveyed professionals had concerns about early mobilisation and there were significantly more professionals concerned about early mobilisation for haemorrhagic (59%) than ischaemic (23%) stroke patients.

Conclusion

Our study shows that most clinicians had concerns in relation to early mobilisation of stroke patients and more clinicians had concerns for haemorrhagic than for ischaemic stroke. The evidence underlying these concerns is shallow.