Elderly person with stroke: integrated care from the acute phase to the return home

9 Dec
marco-inzitari
Marco Inzitari

Stroke has a high incidence, a growing prevalence and is the pathology with the second highest impact in the world in terms of disability among adults. Despite important advances in acute stroke management, which have led to a progressive decrease in acute stroke deaths, in terms of residual disability, stroke continues to have an extremely high impact on survivors, their families, their caregivers and on society in general.

Evidence shows that the approach to patients throughout the process of care in stroke, from the acute phase to the rehabilitation phase, needs to be multidisciplinary since patients have multiple health care and social needs which require a strong coordination between the different levels of healthcare. However, the tendency is still to organise conferences and congresses focused on only one speciality or level of healthcare.

On the other hand, and in self-criticism, even though stroke is one of the main reasons for using intermediate or long-term healthcare services, this sector almost never takes part in the decision making process of stroke care organisation. Neither does it do much research in stroke and in general, tends to put little thought into improving knowledge in treatments or in innovating the organisation of services compared to, for example, other conditions such as thighbone fractures.

This is why the Parc Sanitari Pere Virgili organised a monothematic symposium on 27 October, two days before the World Stroke Day. It focused on the treatment and management of stroke in elderly people from a different perspective: we traced the trajectory from the “needle” of the thrombolysis in the acute phase, passing through rehabilitative care and “reablement” in the post-acute phase, to the transition back to home life, describing the care given to patients especially, but not forgetting the attention caregivers need.

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The presentations reflected and reinforced the need for a multidisciplinary approach in all phases of stroke. As an added value, in all cases the speakers not only combined recommendations derived from literature with their own practical healthcare experience but also provided data from their own research or innovation projects, in many cases with data published recently.

Among the speakers there was a varied representation from very different disciplines which included neurologists, geriatricians, physiotherapists, occupational therapists, speech therapists, social workers, a health economist and the representative of the stroke patients association who chaired a roundtable.

Some of the items that were highlighted most strongly during the symposium were:

  1. The large amount of increasingly more accurate data available on all phases of stroke management. In Catalonia, this data is being provided by the Results Centre, which encourages transparency and allows for benchmarking thereby facilitating a reduction in variability and the sharing of best practices.
  2. Despite improvements in the treatment of acute stroke patients using mechanical thrombectomy together with systemic thrombolysis, 40% of patients are left with a considerable disability as a consequence of stroke. This “glass half-full” should therefore encourage more to be done in terms of acute stroke management, and also in post-acute care which is still vital.
  3. In acute care, age should not be a discriminating factor. This is in line with the concept that chronological age does not correspond necessarily to biological age and that two elderly people of the same age can have a totally different “functional potential” (a concept which in practice in the field of geriatrics is understood as meaning more or less “frail”).
  4. Advances have not only been made in acute care but also in the field of primary and secondary preventive care. Accordingly, the development, the approval of and the use of NOACs (new oral anticoagulants) have been a determining factor since they offer an alternative for those patients where traditional anticoagulants are not a therapeutic option.
  5. The rehabilitation prognosis is multifactorial. A recent proposal stemming from a multi-centre Catalan study led by our hospital and published recently, is based on a simple algorithm which incorporates the social factor (presence of the caregiver) together with the severity of the stroke (using the NIHSS score), functional status (according to the Barthel index) and cognitive function (a result of the Rancho Los Amigos scale). This allows patients to be classified in three levels of rehabilitation complexity, but who might evolve differently, with different needs for intervention, both in the rehabilitation process and regarding their return home.
  6. Integrated interventions in geriatric rehabilitation can be home-based for certain patients as an alternative to a hospital admission. This model, deeply rooted in England and which has proven to be beneficial, is producing good results in our context in different pathologies including stroke. Innovative formulas such as “Comprehensive Home-based Hospitalisation” have, in our context, come about from the alliance between home-based geriatric care teams (doctor, nurse and social worker) and those of home-based rehabilitation (rehabilitation doctor, physiotherapist, occupational therapist and speech therapist).
  7. In terms of physiotherapy, treatments should be more standardised and their efficacy demonstrated. During the symposium, interesting evidence was presented on the control of the trunk and its importance throughout the rehabilitation process in stroke.
  8. Dysphagia is a very prevalent risk condition in patients who have suffered a stroke. Different proposals of scales for assessment at the bedside were shown which can be applied by nurses, reserving the speech therapist’s intervention for the most complex cases which require a more specialised assessment.
  9. In rehabilitation, the support from the ICT (“telerehabilitation” which patients can receive following the instructions and programme configuration of the physiotherapist) allows treatments to be extended in time and intensity along with face-to-face treatment.
  10. Working with caregivers is important. Apart from guiding them within the system, the availability of support groups for exchanging personal experiences, for a social worker, for example, could have an impact on the adaptation of the caregiver to the new situation. To this effect, an innovative experience was developed in our centre with a high degree of acceptance by patients and their families.
  11. Continuity in the recovery process is key and the integration of health and social services guarantees an added value. The pilot “Return Programme” in the city of Barcelona, the result of the alliance between the Catalan Health Service and the City Council of Barcelona was presented. It allows for the direct activation of social services, from acute care and long-term care hospitals so that patients can receive the necessary aid when they return home and thus avoid unnecessary and dangerous delays.

In summary, much progress has been made in the treatment of stroke, especially in the acute phase, but innovation is also being carried out in the successive phases and the symposium showcased different experiences which have been implemented in our context. Drawing conclusions from the symposium, the take home messages are that a comprehensive view of the entire process is key, as well as an integrated and coordinated approach between the different levels of healthcare and social services. On the other hand, more research needs to be carried out especially in the post-acute and chronic phases resulting from the disease and this poses a challenge because of the difficulty in designing and implementing complex interventions where designs such as standard clinical trials are not the solution.

Post written by Marco Inzitari (@marcoinzi) and Laura Mónica Pérez, Parc Sanitari Pere Virgili, Barcelona.

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