Sleuthing Out Strokes

LTC practitioners must work to differentiate stroke from other co-morbidities, as well as develop prevention & management guidelines

by Jacqueline Vance, RNC, CDONA/LTC

To assess the burden of stroke among U.S. residents age 65 years and older, the Centers for Disease Control and Prevention analyzed Medicare hospital claims for all 50 states and the District of Columbia (D.C.), for persons with stroke during the year 2000. The report summarized that reducing the burden of stroke in the United States will require primary prevention and control of risk factors, education, early recognition, and evaluation and treatment of persons with acute stroke, and effective secondary prevention among persons living with stroke.¹

"Long-term care providers must be able not only to reduce the risk of stroke by identifying and treating modifiable stroke risk factors, but also to coordinate rehabilitation after a stoke has occurred," observed William Smucker, MD, CMD, chair of the American Medical Directors Association (AMDA) Stroke Prevention and Management in the Long Term Care Setting clinical practice guideline (CPG) workgroup and member of AMDA's clinical practice and Multidisciplinary Medication Management Project committees.

Also in This Issue

Stroke: Causes & Types

Risk Factors: Prevention & Control

In long-term care (LTC) a lack of knowledge commonly exists regarding the presentation of stroke and transient ischemic attacks (TIAs) because multiple medical and neuropsychiatric co-morbidities often present in older persons.

The risk of stroke increases in someone with a history of hypertension, atherosclerosis, diabetes, peripheral vascular disease, smoking, or a family history of stroke. "While it makes sense to manage the risk factors in these patients," explained Dr. Smucker, "there are few scientific studies that include frail, elderly long-term care patients. So the benefits and burdens of treating stoke risk factors must be extrapolated from studies done in younger or healthier patients.

"In general, patients at greatest risk of stroke, like those patients seen in long-term care, are the most likely to benefit from risk factor reduction," he said. "For instance, for those with diastolic blood above the target of 85 mmHg, lowering diastolic blood pressure 6 mmHg can reduce stroke risk up to 40%."

Similarly, using a statin drug to lower cholesterol can reduce stroke risk 25% to 30%.² According to Dr. Smucker, many elderly patients have atrial fibrillation, and maintaining their international normalized ratio (INR) of 2.0 to 3.0 can reduce their risk of stroke by more than 60%. Smoking cessation can reduce stroke risk 50% within the first two years after stopping.

"Each of the medications used to reduce risk involves cost, ongoing monitoring, and the risk of adverse effects," explained Dr. Smucker. "For these reasons, the interdisciplinary team and the patient or family should share the decision of whether to use certain preventive therapies. Each patient's care plan should reflect the patient's preferences as well as their functional abilities, prognosis, co-morbid conditions, and goals of treatment, and should consider both the benefits and burdens of each therapy. The importance of patients having advanced directives in place cannot be stressed enough."

The Role of Anticoagulants

Atrial fibrillation alone leads to nearly 90,000 strokes or TIAs annually. Those who've had a TIA remain at very high risk of having a full stroke. Therefore, atrial fibrillation must be managed as a part of stroke prevention. The use of anticoagulants in elderly patients with atrial fibrillation may provide stroke prevention benefits previously found only in younger people, according to a recent report published in Stroke.^3-4

Anticoagulant drugs, such as warfarin, must be used cautiously in those over 80 because of the associated risk of increased internal bleeding. Paradoxically, because of their higher risk of stroke, the net benefit of blood-thinning therapy may be greater in the elderly. Prior studies have only shown the usefulness of anticoagulants in middle-aged people with atrial fibrillation. Evidence-based data of warfarin's usefulness in elderly adults was difficult to show because the elderly aren't usually included in clinical trials. The Stroke study's lead author, Brian F. Gage, MD, assistant professor of medicine at Washington University, St. Louis, Mo., and director of Barnes-Jewish Hospital Blood Thinner Clinic, St. Louis, Mo., said, "This is the first study to find a statistically significant benefit of using warfarin in the elderly."

The study researchers examined 597 Medicare beneficiaries who had atrial fibrillation and found that those receiving warfarin had a 24% reduced risk of death and hospitalizations from stroke or TIA, compared with a 5% relative risk reduction in those who received aspirin alone. The study showed that only about half of the ideal candidates for the drug received it.

"It shouldn't be that confusing," stated Steven Levenson, MD, CMD, a multi-facility medical director, chair of AMDA's clinical practice committee, and Caring's editorial board chair. "Anticoagulation studies repeatedly conclude that if atrial fibrillation is present, you treat it with anticoagulants--unless the patient converts to sinus rhythm."

Another recent study shows that a heart attack is an indicator that a stroke could follow shortly. According to research conducted at Yale University, 20% of older patients who've had a heart attack have a one-in-25 chance of being hospitalized for a stroke within six months of discharge from the hospital.⁵

That study, published in Circulation (March 2003), provides what is believed to be the most accurate estimates of stroke after heart attack among elderly patients. Among patients hospitalized with a stroke, 77% are 65 or older and half are older than 75 years of age.

Conditions associated with higher stroke admission rates included prior stroke, hypertension, diabetes, atrial fibrillation, heart failure, and peripheral vascular disease. The risk of stroke among the 20% of patients who have at least four of eight identified factors is four times higher than patients with none of these factors. This data can be used to identify high-risk patients in need of more aggressive therapies.

Vigilance: Early Recognition & Evaluation

"While it is important to identify a new stroke in a timely fashion, it may be difficult to recognize the presentation of an acute stroke. This is most likely because stroke and stroke risk present in diverse ways," said Dr. Levenson.

Recognizing stroke in the elderly population often proves problematic because other diseases cause neurologic symptoms that mimic stroke and also because these patients have increased cognitive impairments overall. "Knowing a patient's baseline functional and cognitive abilities and being vigilant for changes in behavior can aid in identification of multiple problems," explained Dr. Smucker.

However, system barriers, such as decreased staffing and use of agency personnel, reduce the staff's knowledge of resident baseline functions, which is important in recognizing minor changes that could be key in identifying a stroke. Plus, the way a stroke manifests itself depends on the affected side of the brain, the part of the brain, and how severely the brain is injured. Therefore, each person may have different stroke warning signs. Example: A stroke may be associated with a headache or it may be completely painless.

Diagnostic Dilemmas

The primary goal of diagnosing a stroke remains to determine whether or not the symptoms are due to another condition with similar symptoms, such as delirium or severe hypoglycemia. If a stroke has occurred, then discovering the location of the brain injury is important.

"You must examine the patient and look for localized neurological deficits, for example, not being able to move the right arm or having a left-sided facial droop," instructed Dr. Levenson. "And then you must compare those findings to existing previous deficits. Baseline motor and sensory functions should be documented for each patient soon after admission.

"Describe the patient's level of consciousness must be described accurately (i.e., lethargy, stupor, or coma). Also, consider fluid and electrolyte imbalance and review the patient's existing medications as a possible cause of changes in level of consciousness--especially in the absence of focal neurological changes," he concluded.

Undoubtable Signs

The clear sign of most acute strokes is the sudden onset of symptoms. While a small number of patients have warning signs, most will experience an acute stroke with no warning at all. A stepwise worsening of symptoms can occur, but usually within a limited time frame. Also, while it's not unheard of for a patient to worsen over a few days, this rarely occurs.

The most important issue you face is differentiating a hemorrhagic stroke from an ischemic stroke, and if it's a hemorrhagic stroke, determining the location of the bleed site. According to Dr. Levenson, making the early differential diagnosis of ischemic stroke or hemorrhagic stroke is extremely important because it influences acute treatment and care.

The features that distinguish between hemorrhagic and ischemic stroke are as follows.

Hemorrhagic stroke:

• Signs of early and prolonged loss of consciousness;
• Prominent headache;
• Nausea and vomiting; and
• Focal signs that do not fit the pattern of a single blood vessel involvement, (the person is unconscious or has weakness in all limbs).

Ischemic stroke:

• Sudden or stepwise progressive worsening of symptoms;
• Focal signs fitting the pattern of a single blood vessel involvement (sudden onset of one-sided muscle weakness in the face, arms, or legs; trouble speaking clearly; sudden loss of vision in one eye); and
• Symptoms waxing and waning, indicating a focal cortical or subcortical lesion.

Although ischemic stroke patients could complain of headache, an explosively and/or suddenly severe headache may signal intracranial hemorrhage. While patients with ischemic strokes may be stunned or slow to respond, early depression of consciousness is uncommon with cerebral hemorrhage. A rapid onset of a coma is suggestive of an intracranial hemorrhage; however, patients with a subarachnoid hemorrhage can have syncope, seizures, or a transient loss of consciousness at the onset of the hemorrhage, but may regain consciousness by the time they are evaluated. Some diagnostic signs can help determine what area of the brain is affected by the stroke. (See "Diagnostic Signs for Locating Affected Hemisphere in Ischemic Stroke," below. Also see "New Evidence: The Benefits of Carotid Endarterectomy,")

The Brain Attack Plan

Most experts advise treating stroke symptoms as a "brain attack" that must be evaluated and treated with the same urgency as a heart attack. This means rapid evaluation by an emergency department, a consult with a physician stroke expert, and admittance to a stroke care unit.

Most frail LTC patients who have strokes won't be eligible for clot-busting thrombolytic drugs to treat acute stroke. Urgent evaluation may benefit the patient and their family by providing early and accurate diagnosis and prognosis. Hospital care in a stroke unit may also provide close monitoring for clinical deterioration during the first 48 hours following acute stroke and preventive measures to reduce the risk of early complications of acute stroke.

"However," added Dr. Levenson, "it is important to identify [those] whose condition and prognosis may benefit from monitoring in a stroke unit."

Which LTC Patients Should Be Transferred?

For LTC patients, it may be appropriate to adopt a less emergent and aggressive approach to evaluation and treatment. Caregivers and patients may base their decisions about hospital transfer on such issues as the benefits and burdens of aggressive evaluation and treatment, prior wishes stated in advance care plans, the presence of advanced comorbid conditions, and cognitive or physical impairments.

"The Stroke [CPG] committee hopes to create a document that presents some of the evidence about urgent evaluation and care in a stroke unit so that caregivers and families can make an informed decision about the best care for each patient," offered Dr. Smucker.

Once stroke is recognized among your patients, which do you send to the hospital? According to Dr. Smucker, send those who came to LTC with expectations of significant functional recovery, those who have only moderate dementia and moderate dependence in activities of daily living, those in whom the diagnosis is in doubt, or those whom the facility can't adequately manage.

For either hemorrhagic or ischemic strokes, clinically assess for the presence of acute medical and neurologic complications, such as airway compromise, cardiac arrhythmias, hypertension, and seizures. If you send a patient to the hospital, the following diagnostic tests will likely be immediately obtained: basic serum chemistries, a complete blood count, cardiac enzymes, pulse oximetry, and urinalysis. These tests are designed to search for conditions that mimic stroke. In addition, the patient will receive an electrocardiogram (ECG) and a chest X-ray for diagnostic purposes.

Secondary Prevention

For optimum secondary prevention post-stroke, you must determine whether the patient's stroke was hemorrhagic or ischemic. If ischemic, find out whether it was caused by carotid atherosclerosis, atrial fibrillation, or cardiac embolus. Because stroke closely relates to heart disease, obtain a computerized tomography scan of the brain, echocardiogram, carotid ultrasound, and electrocardiogram. Brain imaging is crucial in differentiating hemorrhagic stroke from ischemic stroke because clinical presentations of the two have overlapping symptoms. Also obtain a platelet count, prothrombin time with INR, an activated partial thromboplastin time, and a blood glucose test because they can help rule out serious co-morbid conditions, define acute complications of the stroke, and diagnose underlying hematologic (coagulation) disorders. If your patient is unresponsive and trauma is suspected, order a cervical spine X-ray. If you suspect hypoxia, order arterial blood gases.

Should They Stay or Go?

If appropriate, send patients with a suspected hemorrhagic stroke to the emergency room as soon as possible. The acute onset of stroke signs and symptoms is a potential emergency and, ideally, the facility will have a plan for such emergencies. The facility should also have general guidelines or standards for acute assessment and treatment, including parameters for transfer and for treatment in the nursing home.

However, patients with ischemic stroke can sometimes be managed in the nursing home. Your first step is to examine the patient carefully, reverting to the care process. Recognition, the first step, would establish the differential diagnoses. "Physicians and nurses need strong assessment skills to differentiate a stroke from something else with similar symptoms," said Dr. Levenson. "Once that is accomplished you can move on to treatment and monitoring."

If your patient is to remain in the nursing home, order a multidisciplinary plan of care: communication and cognition assessment, assessment for functional status.⁶ Activity orders, such as bed rest, ambulation with assistance, etc., based on the patient's function, neurological deficits, overall function, and preexisting deficits should be determined. Nursing care should include vital sign and neurologic assessments every four hours for the first 24 to 48 hours, pulse oximetry (without over-interpreting low results) with orders for oxygen if hypoxia should occur, compression stockings or heparin for deep vein thrombosis, prophylaxis for bedridden patients, and bowel and bladder care. Give orders for hydration and nutrition, according to the patient's current status. Also order diagnostic tests to ascertain the cause of the stroke.

If you suspect dysphagia, you may need to set up temporary measures. In that case, order a bedside or fluoroscopic swallowing evaluation as well. Medication should be ordered to manage the symptoms, co-morbid diseases, and the stroke itself. You may request consultations, such as speech, physical, or occupational therapy. Provide the patient and/or their family with information about the stroke, its complications, the treatment plans, the expectations, and plans for future care.

"The point is to individualize the scope and aggressiveness of interventions," said Dr. Levenson.

Prevent Post-Stroke Complications

Intervene early to prevent patients from experiencing post-stroke complications. Debates abound as to what defines appropriate medication management among post-stroke patients.

The aforementioned Stroke article showed that two-thirds of elderly stroke survivors in nursing homes don't receive medication to prevent further strokes. Another recent study (supported in part by the Agency for Healthcare Research and Quality [AHRQ]⁷ (HS11256)]), demonstrated that two-thirds (67%) of stroke survivors in nursing homes don't receive anticoagulant or antiplatelet drug therapy to prevent further strokes. In fact, the study reveals that those over 85 are 14% less likely to be treated than those 65 to 74 years old. Black residents were 20% less likely to be treated than whites (even though blacks have a greater risk of stroke). On top of that, residents with severe cognitive or physical impairment were about one-third less likely to receive treatment than those without impairments.

This study pointed out that contraindications to blood-thinning drugs, such as gastrointestinal bleeding and peptic ulcer disease, contributed to some physicians' decisions not to treat with them. However, they didn't fully account for the large gap between recommended and observed levels of treatment.

Among those patients treated, most received aspirin alone (16%) or warfarin alone (10%). The prevalence of atrial fibrillation, which markedly elevates stroke risk, increased with age in these patients--but the use of warfarin decreased with age. The researchers noted reasons as to why this may occur: 1) Perhaps doctors fear the increased risk of bleeding from warfarin among the elderly, or 2) the doctors feel they can't adequately monitor high-risk patients.

The researchers suggest that pharmacist-run anticoagulant clinics might alleviate some of these concerns. Dr. Levenson points out that these clinics are uncommon and often require significant charges for these services.

Post-Stroke Management

The severity and types of neurological impairments remain good predictors of the extent of the brain injury and help predict a patient's prognosis; however, there is evidence that organized stroke care results in lower mortality and better functional outcomes.^8-9 "This means that you don't just treat the primary diagnosis. You need to support co-morbid conditions and adjust medications--especially when you have new deficits," explained Dr. Levenson. (See "Evidence for the Effectiveness of Stroke Rehabilitation Programs," right).

On the other hand, treatment may be either excessively or inappropriately administered. A great deal of confusion exists regarding the benefits of rehabilitative services following a stroke. Perhaps this is due to the lack of knowledge about the medical necessity of rehabilitative services, the lack of ready access to rehabilitation interventions in some areas, the lack of appropriate resident/family expectations, and appropriate rehabilitation goal-setting for post-stroke patients.

We need to better identify the risk/benefit ratio of the various stroke interventions. For this reason, physicians should consider three factors when deciding whether to authorize rehabilitative care for an individual as medically necessary:¹⁰

1. How will the service help assess, manage, or monitor an individual's health care?
2. Is the service appropriate? (Does the individual wish to receive the service and is the service likely to benefit their quality of life?) and
3. Can the individual safely tolerate the service and its consequences?

When considering impaired function, it is helpful to differentiate among the terms disease, impairment, disability, and handicap. Rehabilitation therapies are usually intended to prevent impairments from becoming disabilities or disabilities from becoming handicaps. They play a relatively insignificant role in preventing diseases from progressing to impairments. Thus, the appropriateness of rehabilitation therapy depends primarily on the degree to which it is likely to minimize the extent of impairment while a person is recovering from illness or to prevent an existing impairment from becoming a disability.

In frail elderly and chronically ill individuals, treatable underlying causes and other physical risk factors must also be addressed--even when rehabilitation therapies are relevant. Therefore, identifying and addressing significant risks is also key to stabilizing and improving function.¹¹ Guidance for this issue can be found in the AMDA's information toolkit, Determination of Medical Necessity of Rehabilitation Therapy Services. The kit shows the important risk factors and patient characteristics that influence functional recovery from stroke: These include prior functional status, level of independence in the community prior to the stroke, and availability of a willing and able caregiver.

Risk factors that may impede a patient's functional recovery from a stroke include new visual or sensory neglect, bilateral deficits, blindness, visuospatial deficits, bowel and bladder incontinence, severe cognitive deficits, depression, motivation, and prior stroke.¹²

The toolkit also covers the approach and scope of stroke rehabilitation, as well as patient eligibility criteria. In general, stroke rehabilitation consists of preventing and treating medical complications, minimizing decline in function, facilitating psychological coping, and helping the patient/family adapt and enhance quality of life. The eligibility criteria for stroke rehabilitation include a patient's reasonable medical stability, functional disability, and capability to integrate new learning. The choice of rehabilitation setting for a patient who meets these criteria depends on the level of assistance required to perform daily activities, the intensity of medical supervision needed, the ability to tolerate intense and frequent therapies, and the availability of caregiver support.¹³

A 2001 study tested three hypotheses utilizing rehabilitation therapy post-stroke.¹⁴ One was that the severity of the initial motor impairment after stroke predicts discharge motor impairment and discharge mobility scores. The second is that with the identification of those unlikely to show improvement in motor impairment, rehab efforts can focus on the use of compensatory techniques and assistive devices. The third hypothesis is that improvement in self-care mobility scores--without change in motor impairment, balance, or cognition--is a quantitative estimate of the value of teaching compensation techniques and use of assistive devices.

The study concluded that admission motor-impairment scores predict discharge impairment and activities of daily living (mobility) functional outcome and help guide treatment goals toward improving motor impairment versus the use of compensatory techniques and assistive devices.

New Program for Those with Aphasia

Aphasia, a common problem following stroke, responds well to therapy. Aphasia can be caused by right- or left-brain damage. Left hemisphere involvement affects the patient's ability to understand and use language, while right hemisphere involvement impacts their ability to understand the emotional content of the language. The University of Michigan is finding positive outcomes from its innovative residential aphasia program, the only program of its kind in the country. This is an intensive six-week program that includes individual therapy, group therapy, and computer-assisted training each week.

Michigan's program utilizes two schools of thought: intensive therapy to assist the brain in reorganizing itself and training the individual to compensate for language problems. This therapy has reported successful results among more than 95% of those suffering with post-stroke aphasia. According to the report, program participants can change their communicative abilities within one week. And patients show measurable gains on communication--even if they have been brain-injured for many years prior to entering the program.¹⁵

Summary

A strong need still exists for stroke prevention and management guidelines in LTC. In August 2003, AMDA held a conference in Baltimore to develop a CPG for stroke prevention and management in this setting. We'll report on its progress in future issues of Caring. Hopefully, the CPG will provide us with the guidance we need regarding the prevention and control of risk factors related to stroke, early recognition of stroke, evaluation and treatment of persons experiencing acute stroke, effective secondary prevention among persons living with stroke, and the management of post-stroke patients.

This article originally appeared in Caring for the Ages, September 2003; Vol. 4, No. 9, p. 34-41. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission. The opinions expressed by the authors are their own and not necessarily those of AMDA or of Elsevier.

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