Hanger Hc

What do patients and their carers want to know about stroke? A two-year follow-up study

Objective: To clarify what issues are important to stroke patients and their carers. To determine whether these issues change over time. Design: Prospective study of consecutive patients admitted to hospital with a diagnosis of an acute stroke. Each participant had interviews at six and 24 months. In addition, a subgroup of these patients (consecutive discharges over a two-month period) were also seen at two weeks post discharge. Setting and subjects: Hospital-based cohort of stroke survivors. Interviewed in their own homes. Main outcome measures: Documentation of the questions asked. Results: At two weeks, six and 24 months, a median of three, two and three questions were asked by each patient respectively. Enquiries about basic aspects of stroke were common but diminished over time. Fear of recurrence was apparent at all three interview periods. Enquiries about the psychological sequelae of stroke became more prevalent at six and 24 months. At two years, 32% of respondents asked about concentration/memory difficulties with smaller numbers commenting on tiredness, depression and frustration. At two years, 18% of the sample were still uncertain of their chances of further recovery. Conclusions: Patients with stroke continue to have unanswered questions even two years after their stroke. The types of questions asked changed over time.

The risk of recurrent stroke after intracerebral haemorrhage

Background and aim: The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0–24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed. Patients and methods: All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronial post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke. Results: Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were “lobar–lobar” type. Conclusion: The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Effect of aspirin and warfarin on early survival after intracerebral haemorrhage

BackgroundTo determine whether taking aspirin or warfarin at the time of an intracerebral haemorrhage (ICH) has an independent effect on early survival.MethodsAll people with ICH presenting in Christchurch, New Zealand over a three-year period were identified. Independent predictors of mortality at 7, 14 and 28 days were calculated using binary logistic regression.ResultsTwo hundred and fifty three cases were identified. Unadjusted 28-day mortality was 43% overall, but 53 % for warfarin associated ICH and 43% for patients taking aspirin. Haemorrhage volume, haemorrhage location, intraventricular spread and the use of warfarin were all independently and significantly associated with mortality at all three time intervals (7, 14 and 28 days). The effect of warfarin was apparent despite similar volumes of bleed in each group. Aspirin was not associated with increased early mortality. Increasing age was also an independent predictor associated with death at 28 days.InterpretationUse of warfarin (but not aspirin) immediately prior to ICH was independently associated with increased mortality, after controlling for comorbidities. Thus therapeutic efforts to rapidly reverse the warfarin induced coagulopathy may be justified to lower mortality.

Secondary prevention of fractures in older people: evaluation of a protocol for the investigation and treatment of osteoporosis.

Abstract

Warfarin-related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates.

Warfarin‐related intracerebral haemorrhage (WRICH) has high mortality. Haematoma expansion is prolonged in WRICH and independently predicts worse outcomes. Guidelines recommend prompt reversal of the warfarin coagulopathy, but evidence of benefit is lacking.

Stroke patients' views on stroke outcomes: death versus disability

Aims: To determine how elderly stroke patients perceive different stroke outcomes, including death, relative to each other and how these views compare with those of age/sex-matched controls. Participants and setting: Twenty-eight elderly patients discharged from hospital with an acute stroke causing hemiplegia. Twenty-eight age/sexmatched control patients from the same hospital who had never had a stroke or transient ischaemic attack. Methods: Patients and controls were asked to rank 11 clinical scenarios of potential stroke outcomes, from the most to the least desirable outcome. Results: There was a striking bimodal distribution for sudden painless death in both groups. Painless death was preferred to even a minor stroke disability in over one-third of elderly individuals, whilst 20% would prefer severe disability rather than painless death. Sixty-nine per cent of stroke patients and 82% of controls ranked death as preferable to severe disability. Stroke patients may be more tolerant of disability (compared to death) than their controls (39% patients and 61% controls preferred death to any disability, p = 0.11). Conclusions: Our results suggest that many elderly individuals would rather die than be alive and severely disabled. This may have important implications for acute stroke treatments such as thrombolysis.

Predictors of discharge stability in the first year following hospital admission for a frail elderly population

The frail elderly are a group of patients who are at high risk of institutionalization and death. Specialist older person’s health care aims to maximize function and independence. However, there is little published work on the long‐term outcomes following hospitalization in a frail elderly population. This study examines the outcomes in the first year after hospitalization for this group. We find that 62% are able to remain in their own homes and that functional status is the strongest predictor of outcome, with age and living arrangements also significant.

Stroke discharges from a rehabilitation unit: 1-year and 5-year domicile outcomes. Function is important

Background: Stroke units save lives, reduce disability and increase the chances of the person returning to their own home. Following the introduction of a stroke rehabilitation unit, we assessed the durability of stroke discharges over a 1‐year period and predictors of early ‘failed’ home discharges. Stability of discharge domicile and survival over 5u2003years was also reviewed.

Fall and fracture rates following a change from carpet to vinyl floor coverings in a geriatric rehabilitation hospital. A longitudinal, observational study:

Objective: To investigate whether changing from 5 mm thick carpet tiles to vinyl on a concrete subfloor would alter fall or fracture rates. Design: Longitudinal, observational study. Setting: Six wards (129 beds) of a geriatric rehabilitation hospital. Subjects: All inpatients during this time. Interventions: The floor covering was changed from 5 mm carpet tiles to vinyl on these wards when they were closed for other maintenance. This occurred in stages from November 2007 to December 2009. Measures: Falls are routinely reported using a quality improvement event reporting form. Fall and fracture rates were calculated in the 12 months prior to and following the change in floor covering on each ward. Results: There were 854 falls on the carpet tiles in the 12 months prior to the flooring change and 878 falls on the vinyl in the 12 months after (19.5 and 19.6 falls/1000 bed days, respectively, [P = 0.95] NS. Fifteen fractures occurred on carpet and 11 fractures on vinyl, [P = 0.39] NS. Using run charts there were no detectable trends in either the fall or fracture rates following the change in flooring surface. Conclusion: There may be no difference in fall rates or fractures on carpet or vinyl floor covering of similar thickness and subfloor type.

Telephone discharge support for frail, vulnerable older people discharged from hospital: Impact on readmission rates – Participant and general practitioner feedback

To assess the use and acceptability to older participants and general practitioners (GPs) of telephone support postdischarge to reduce readmissions.