Lalit Kalra

Determinants of Caregiving Burden and Quality of Life in Caregivers of Stroke Patients

Background and Purpose— A large proportion of disabled stroke survivors live at home and are supported by informal caregivers. Identification of determinants of caregiver burden will help to target caregiver interventions. Methods— Data on patient, caregiver, and health and social support characteristics were collected prospectively over 1 year in 232 stroke survivors in a randomized trial of caregiver training. The contribution of these variables to caregiver burden score (CBS) and quality of life (QOL) measures at 3 months and 1 year was analyzed using regression models. Results— Stroke patients had a mean age of 74±11 years, and 120 (52%) were men. The mean age of caregivers was 65.7±12.5 years, 149 (64%) were females, and 116 (50%) had received caregiver training. The mean CBS was 48±13 and 38±11 (score range of bad to good 88 to 22) and QOL score was 75±16 and 75±15 (score range of bad to good 0 to 100) at 3 months and 1 year, respectively. CBS and QOL correlated with each other and with patient (age, dependency, and mood), caregiver (age, gender, mood, and training), and support (social services and family networks) variables. Of these, only patient and caregiver emotional status, caregiver age and gender, and participation in caregiver training were independent predictors of either outcome at 3 months. Patient dependency and family support were additional independent predictors at 1 year. Social services support predicted institutionalization but not caregiver outcomes. Conclusion— Advancing age and anxiety in patients and caregivers, high dependency, and poor family support identify caregivers at risk of adverse outcomes, which may be reduced by caregiver training.

Early Assessments of Dysphagia and Aspiration Risk in Acute Stroke Patients

Background and Purpose— Dysphagia is common after stroke and is a marker of poor prognosis. Early identification is important. This article reviews the merits and limitations of various assessment methods available to clinicians. Methods— An electronic database search was performed of MEDLINE, EMBASE, and the Cochrane database using such terms as stroke, aspiration, dysphagia, and assessment; extensive manual searching of articles was also conducted. Results— Bedside tests are safe, relatively straightforward, and easily repeated but have variable sensitivity (42% to 92%), specificity (59% to 91%), and interrater reliability (&kgr;=0 to 1.0). They are also poor at detecting silent aspiration. Videofluoroscopy gives anatomic and functional information and allows testing of therapeutic techniques. However, swallowing is assessed under ideal conditions that are different from clinical settings, and reliability is often poor (&kgr;=0 to 0.75) in the absence of assessor training. Fiberoptic endoscopy allows swallow assessment and sensory testing but requires specialized staff and equipment. Oxygen desaturation during swallowing may be predictive of aspiration (sensitivity, 73% to 87%; specificity, 39% to 87%) but is more useful in combination with bedside testing than in isolation. Other methods of swallow testing are invasive and require specialized staff and equipment. Conclusions— Although bedside tests remain an important early screening tool for dysphagia and aspiration risk, further refinements are needed to improve their accuracy.

Improving stroke rehabilitation. A controlled study.

Background and Purpose Assessment of stroke rehabilitation is complicated by the heterogeneity of patients and settings and by difficulties in disentangling effects of organization from effects of types and amounts of treatment input. Methods A prospective controlled study was undertaken in 245 stroke patients stratified into three groups according to prognosis and managed on a stroke rehabilitation unit (n=124) or general medical wards (n=121). Patients were randomly allocated to either setting 2 weeks after stroke and were comparable for baseline characteristics. Results Patients on general medical wards received more physiotherapy on average (16.2 ± 7.2 versus 14.3 ± 3.2 hours; P < .05) but similar amounts of occupational therapy (9.3 ± 2.8 versus 9.5 ± 3.2 hours) compared with stroke unit patients. More time was spent on individual rehabilitation on the stroke unit compared with general wards (P < .001). Functional abilities at discharge, destination of discharge, and length of hospital stay in patients with good prognosis were comparable in both settings. Patients with poor prognosis managed on general wards showed higher mortality (P < .05) and longer hospital stay (123.2 ± 48.2 versus 52.3 ± 19.8 days; P < .001), but functional abilities at discharge in survivors were comparable with those of stroke unit patients. Patients with intermediate prognosis had significantly better outcome on the stroke unit, with more patients being discharged home (75% versus 52%; P < .001), shorter average length of hospital stay (48.7 ± 17.2 versus 104.6 ± 28.6 days; P < .001), and better functional abilities at discharge (P < .05). Conclusions Stroke units improve outcome and reduce hospital stay without increasing therapy time. Their effectiveness may be enhanced by patient selection.

The Influence of Visual Neglect on Stroke Rehabilitation

BACKGROUND AND PURPOSE The poor outcome observed in stroke patients with visual neglect may be due to greater stroke severity or nonspecialist management. METHODS The effects of visual neglect were studied prospectively in 150 consecutive stroke patients with comparable stroke pathology and motor severity managed on a stroke unit. A randomized study was subsequently undertaken in 50 stroke patients with visual neglect to evaluate the effectiveness of spatial cueing during motor activity on functional outcome and resource use in these patients. RESULTS Visual neglect was present in 47 (32%) of a selected group of 146 patients (mean age, 77.0 +/- 8.2 years; 42% men) with moderate stroke severity. There were no differences in demography, prestroke function, or motor power in the arm (2.6 +/- 1.7 versus 2.3 +/- 2.1) or the leg (3.2 +/- 1.4 versus 3.0 +/- 1.6) on the affected side compared with 99 patients with no visual neglect. Although patients with visual neglect had lower median initial (4 versus 5, P < .01) and discharge (14 versus 16, P < .01) Barthel Index scores, equal proportions of patients were discharged home (60% versus 65%) or to institutions (34% versus 33%) in both groups. The durations of hospitalization (64 versus 36 days, P < .001) and therapy input (47.7 versus 27.8 hours; P < .01), however, were significantly greater in patients with visual neglect. The randomized controlled study showed a trend toward higher Barthel scores at 12 weeks (14 versus 12.5, P = NS) and significant reduction in median length of hospital stay (42 versus 66 days) in patients receiving spatiomotor cueing and early emphasis on functional rehabilitation. CONCLUSIONS Patients with visual neglect managed on a stroke unit have similar destination of discharge despite lower Barthel Index scores compared with patients of equal stroke severity who do not have this deficit. Spatiomotor cueing and early emphasis on function can improve outcome and reduce resource use in these patients.

Alternative strategies for stroke care: a prospective randomised controlled trial

BACKGROUND Organised specialist care for stroke improves outcome, but the merits of different methods of organisation are in doubt. This study compares the efficacy of stroke unit with stroke team or domiciliary care. METHODS A single-blind, randomised, controlled trial was undertaken in 457 acute-stroke patients (average age 76 years, 48% women) randomly assigned to stroke unit, general wards with stroke team support, or domiciliary stroke care, within 72 h of stroke onset. Outcome was assessed at 3, 6, and 12 months. The primary outcome measure was death or institutionalisation at 12 months. Analyses were by intention to treat. FINDINGS 152 patients were allocated to the stroke unit, 152 to stroke team, and 153 to domiciliary stroke care. 51 (34%) patients in the domiciliary group were admitted to hospital after randomisation. Mortality or institutionalisation at 1 year were lower in patients on a stroke unit than for those receiving care from a stroke team (21/152 [14%] vs 45/149 [30%]; p<0.001) or domiciliary care (21/152 [14%] vs 34/144 [24%]; p=0.03), mainly as a result of reduction in mortality. The proportion of patients alive without severe disability at 1 year was also significantly higher on the stroke unit compared with stroke team (129/152 [85%] vs 99/149 [66%]; p<0.001) or domiciliary care (129/152 [85%] vs 102/144 [71%]; p=0.002). These differences were present at 3 and 6 months after stroke. INTERPRETATION Stroke units are more effective than a specialist stroke team or specialist domiciliary care in reducing mortality, institutionalisation, and dependence after stroke.

A Randomized Controlled Trial of an Enhanced Balance Training Program to Improve Mobility and Reduce Falls in Elderly Patients

OBJECTIVES: To evaluate the effectiveness of an enhanced balance training program in improving mobility and well‐being of elderly people with balance problems.

A multicentre observational study of presentation and early assessment of acute stroke

Abstract Objective:To investigate delays in the presentation to hospital and evaluation of patients with suspected stroke. Design: Multicentre prospective observational study. Setting: 22 hospitals in the United Kingdom and Dublin. Participants: 739 patients with suspected stroke presenting to hospital. Main outcome measures: Time from onset of stroke symptoms to arrival at hospital, and time from arrival to evaluation by a senior doctor. Results: The median age of patients was 75 years, and 400 were women. The median delay between onset of symptoms and arrival at hospital was 6 hours (interquartile range 1 hour 48minutes to 19 hours 12 minutes). 37% of patients arrived within 3 hours, 50% within 6 hours. The median delay for patients using the emergency service was 2 hours 3 minutes (47 minutes to 7 hours 12 minutes) compared with 7 hours 12 minutes (2 hours 5 minutes to 20 hours 37 minutes) for referrals from general practitioners (P<0.0001). Use of emergency services reduced delays to hospital (odds ratio 0.45, 95% confidence interval 0.23 to 0.61). The median time to evaluation by a senior doctor was 1 hour 9 minutes (interquartile range 33 minutes to 1 hour 50 minutes) but was undertaken in only 477 (65%) patients within 3 hours of arrival. This was not influenced by age, sex, time of presentation, mode of referral, hospital type, or the presence of a stroke unit. Computed tomography was requested within 3 hours of arrival in 166 (22%) patients but undertaken in only 60 (8%). Conclusion: Delays in patients arriving at hospital with suspected stroke can be reduced by the increased use of emergency services. Over a third of patients arrive at hospital within three hours of stroke; their management can be improved by expediting medical evaluation and performing computed tomography early.

Medical Complications During Stroke Rehabilitation

BACKGROUND AND PURPOSE We sought to evaluate the effect of setting on the rate of medical complications during stroke rehabilitation. METHODS A study of the frequency and nature of medical complications in stroke rehabilitation was undertaken in 245 patients managed either on a stroke rehabilitation unit (n = 124) or on general medical wards (n = 121). The stroke unit setting was characterized by established protocols for prevention, early diagnosis, and management of complications (eg, aspiration, infections, thromboembolism, pressure sores, depression, stroke progression). Similar protocols did not exist on general medical wards except for thromboembolism, pressure sores, and secondary stroke prevention. RESULTS Medical complications were documented in 147 patients (60%) and were more common in patients with severe strokes (97%). The frequency of reported complications was similar in both settings. Aspiration (33% versus 20%; P < .01) and musculoskeletal pain (38% versus 23%; P < .05) were more commonly documented on the stroke unit, whereas urinary problems (18% versus 7%; P < .01) and infections (49% versus 25%; P < .01) were more commonly seen on general medical wards. The reported frequency of deep vein thrombi, pressure sores, and stroke progression was similar in both settings. Although depression was reported equally in both settings (34% on the stroke unit versus 27% on general wards), patients on the stroke unit were more likely to be treated compared with general wards (67% versus 36%; P < .05). CONCLUSIONS The study shows that inpatient stroke rehabilitation is a medically active service. Management on specialist units is associated with earlier detection and management of stroke-related problems and prevention of potentially life-threatening complications.

Can differences in management processes explain different outcomes between stroke unit and stroke-team care?

BACKGROUND Stroke units reduce mortality and dependence, but the reasons are unclear. We have compared differences in management and complications of patients with acute stroke who were admitted to a stroke unit or to a general ward as part of a previously reported randomised trial. METHODS 304 patients had been randomly assigned to stroke units (n=152) or to general wards supported by a specialist stroke team (152). We used a structured format to gather prospective data on the frequency of prespecified interventions in each of the major aspects of stroke care. Observations were undertaken daily for the first week and every week for the next 3 months by independent observers. The effect of differences in management on outcome at 3 months was assessed with the modified Rankin score, dichotomised to good (0-3) and poor (4-6) outcome. FINDINGS Patients in the stroke unit were monitored more frequently (odds ratio 2.1 [1.3-3.4]) and more patients received oxygen (2.0 [1.3-3.2]), antipyretics (6.4 [1.5-27.5]), measures to reduce aspiration (6.0 [2.3-15.5]), and early nutrition (14.4 [5.1-40.9]) than those in general wards. Complications were less frequent in patients in the stroke unit than those in general wards (0.6 [0.2-0.7]), with fewer patients having progression of stroke, chest infection, or dehydration. Measures to prevent aspiration, early feeding, stroke unit management, and frequency of complications independently affected outcome. INTERPRETATION Differences in management and complications between the stroke unit and general wards differ substantially, even when specialist support is provided. Such differences could be responsible for the more favourable outcome seen in patients on stroke units than those on general wards.

Prospective cohort study to determine if trial efficacy of anticoagulation for stroke prevention in atrial fibrillation translates into clinical effectiveness

Abstract Objective: To determine whether trial efficacy of prophylaxis with warfarin for patients with atrial fibrillation at high risk of stroke translates into effectiveness in clinical practice. Design: Two year prospective cohort study. Setting: District general hospital. Participants: 167 patients with atrial fibrillation and at high stroke risk who were eligible for anticoagulation Interventions: Long term anticoagulation with warfarin at adjusted doses to maintain an international normalised ratio of 2.0-3.0 Main outcome measures: Comparison of patient characteristics, comorbidity, anticoagulation control, stroke rate, and haemorrhagic complications with pooled data from five randomised controlled trials. Results: Patients in the study group were seven years older (95% confidence interval 4 to 10) and comprised 33% more women than patients in the pooled trials. The international normalised ratio was in the target range for 61% of the time (range 37%-85%), below for 26% of the time (range 8%-32%), and above for 13% of the time (range 6%-26%). The time that patients in the study group spent in the target range was significantly less than in the pooled analysis. The incidence of stroke in the study group (2.0% per year, 0.7% to 4.4%) was comparable to that of patients receiving warfarin in pooled studies (1.4%, 0.8% to 2.3%). Per year the incidence of major (1.7% v 1.6%) and minor (5.4% v 9.2%) bleeding complications was also similar. Conclusion: Rates of stroke and major haemorrhage after anticoagulation in clinical practice were comparable to those obtained from pooled data from randomised controlled studies for patients with atrial fibrillation at high risk of stroke