Stroke Update · 2017. 6. 19. · • Sudden physical disability leads to emotional and adjustment...

Stroke Update 9th June 2017

University Hospital Aintree

@NWCStrokeEd #NWCStrokeupdate

Time Title Presenter(s)

9.00 am Registration

9.30 am Stroke Anatomy & Physiology Dr Nik Sharma Consultant Stroke Physician Royal Liverpool and Broadgreen NHS Trust

10.10 am Acute Stroke Treatments Dr Simon Whittingham-Jones Consultant Stroke Physician Wirral University Teaching Hospital NHS FT

10.50 am Tea & Coffee Break

11.05 am Cognitive Problems following Stroke Rosin Cunningham Clinical Psychologist Aintree University Hospitals NHS Trust

11.35 am Visual problems following Stroke Dr Fiona Rowe Reader in Orthoptics & Health Services Research University of Liverpool

12.05 pm Stroke Patient’s Journey: A case study from an OT perspective Felicity Hale Occupational Therapist Wirral University Teaching Hospital NHS FT

12.35 pm Lunch

1.30 pm End of Life Care in Stroke Dr Catherine Hayle Consultant in Palliative Medicine Wirral University Teaching Hospital NHS FT

2.10 pm Stroke Complications Sheeba Philip Consultant Stroke Nurse East Lancashire Hospitals Trust

2.50pm Tea & Coffee Break

3.05 pm Stroke Association

Kate Charles Deputy Head of Operations - North West Charlotte Covey Stroke Association Ambassador

3.45 pm Patient and Carer Panel

4.30 pm Close

Participants

Stroke AssociationWirralNWASBlackpoolPrestonAintreeLancasterCommunityRoyal LiverpoolWarringtonChester

Participants Background

Stroke AssociationSALTParamedicPhysiotherapistDoctorOTStudent ParamedicEMTTherapy AssistantManagerOther

STROKE ANATOMY AND PHYSIOLOGY

Dr Nikhil Sharma

Stroke Lead Royal Liverpool Hospital

WHY IS IT IMPORTANT?

To diagnose stroke

To diagnose stroke mimics

Clue to the aetiology

Predict the behaviour of the stroke

Predict long term outcome

CAUSES OF STROKE

ATHEROSCLEROSIS

LICA STENOSIS

Main Functional Areas of Cerebral Cortex

LOCALISING THE STROKE ACCORDING TO

VASCULAR SUPPLY

Anterior v Posterior

Right v Left

Unilateral with few exceptions

All symptoms should be from area of same supply

So …should be aware of

Blood supply to each lobe of brain

Function of each lobe of brain

VASCULAR SUPPLY

Anterior V Posterior system

4 arteries

All arteries connected to each other by circle of

Willis in the base of the brain

Circle of WillisComplete in only 25% of humansACA, MCA, AComm, Pcomm, PCA, superior cerebellar artery, anterior inferior cerebellar artery, posterior inferior cerebellar artery

Anatomy and Vascular Territories of the 3 Main Cerebral Arteries:Middle cerebral artery, anterior cerebral artery, posterior cerebral artery

Middle Cerebral Artery – Superior and Inferior Divisions

Anterior Cerebral Artery and Posterior Cerebral Artery

Cortical Areas Supplied by theMCA, ACA and PCA

Lenticulostriate Arteries Supply the Basal Ganglia and Internal Capsule

TYPES OF

STROKE

TYPES OF STROKES

Oxford/Bamford Classification

HEMIPARESIS

HEMIANOPIA

HIGHER CORTICAL DYSFUNCTION

Hemiparesis or hemisensory loss

Homonymous hemianopia

Cortical dysfunction (dysphasia /

perceptual problem)

Hemiparesis and hemisensory loss

Homonymous hemianopia

Cortical dysfunction (aphasia / perceptual

problem)

2 of the three or cortical dysfunction alone

Hemiparesis

OR Hemisensory loss

OR Hemisensorymotor loss

OR Ataxic hemiparesis

(no cortical dysfunction)

Double-vision, vertigo, ataxia, incoordination,

vomiting, hemianopia, crossed signs, cortical

blindness.

PROGNOSIS

Stroke Dead – 30

Dead – 1 year Independent

TACS 30-40% 60% 4%

PACS 4% 15% 55%

LACS 2% 10% 60%

POCS 7% 20% 62%

LEFT MCA INFARCT

RIGHT MCA INFARCT

Anterior Cerebral Artery

➢Contralateral leg weakness/sensory loss➢Frontal lobe dysfunction: behavior changes, incontinence,

semiautomatic movements of contralateral arm

Posterior Cerebral Artery

➢Contralateral homonymous hemianopia➢Contralateral sensory loss/weakness (ICap infarct)

Cerebellar Arteries➢Cerebellar signs

RISK FACTORS

Smoking- Atherosclerosis/A-A

embolism…….

Hyperlipidemia- Atheroscleorsis/ A-A emb

Hypertension – small vessel disease

Diabetes mellitus – small vessel D,

atherosclerosis

Cardiac disease (esp AF)

Thrombophilic factors

WHEN A STROKE STRIKES

Cerebral Blood Flow ml/100g/min

Pathophysiological Changes

Normal

Impaired protein synthesis, selective

neuronal death

Lactate release, glutamate release, Oedema

Loss of electrical activity (Electrical

Failure)

Na+/K+ ATPase pump failure(Membrane

failure)

Infarction and cell death

(Siesjo 1992)

CBF<10

The Ischaemic Penumbra

CBF 10 - 30

CBF 30-50

Donnan & Davis, 2002

CLINICAL DEDUCTIONS

Is it a stroke?

Right or Left sided?

Anterior or Posterior?

Type of stroke – prognostic classification

INTRACEREBRAL BLEED

Acute extravasation of

blood into brain

parenchyma

10-25% of stroke

30-50%, 6 months

mortality

20%, functional

independence at 6/12

PRIMARY V SECONDARY ICH

Primary- spontaneous rupture of small artery/arteriole

SecondarytraumaAV malformation/aneurysmcoagulopathyvenous sinus infarctsneoplasmdrugs like cocaineCNS VasculitisHemorrhagic transformation of infarcts

RISK FACTORS

Hypertension- 60-70% cases

Cerebral amyloid angiopathy-15-20%

High alcohol consumption

Abnormal Coagulation

?Hypocholesterolemia

No clear association with smoking

HEMORRHAGE AND VOLUME

Expect good recovery for small volume <10 mL*

Mortality 90% for comatose patients with large volume >60 mL*

3 hours 9 hoursHEMATOMA GROWTH

2.0 hours after onset

6.5 hours after onset

ADVERSE PROGNOSTIC FACTORS

ICH volume

ICH growth

Low GCS

Intraventricular blood

Infratentorial site

SUMMARY

Knowing about stroke anatomy and physiology

helps us to better diagnose strokes.

Improves estimates of prognosis

Guides management

Acute Stroke Treatments

Dr Simon Whittingham-Jones Consultant Geriatrician and Stroke Physician

Wirral University Teaching Hospital 9th June 2017

• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!

Stroke – WHO definition

• Focal (occ. global) disturbance of cerebral function

• Rapid onset

• Lasts >24 hours

• Vascular origin

Stroke in the U.K.

• 100 000 strokes per year • Leading cause of disability

• 4th largest cause of death

Types of Stroke 85% ischaemic 15% haemorrhagic

The ischaemic core and penumbra

‘Time is Brain’

• On average, major stroke is 10 hours in evolution

• 1.9 million neurons lost per minute

• Brain ages 3.6 years each hour without treatment

NICE Guidelines (2017)

‘thrombolsysis with alteplase should be started as early as possible within

4.5 hours of onset of stroke symptoms’

• 15% stroke emergencies eligible

• Haemorrhagic excluded by urgent CT brain

• Rapid restoration of blood supply to the brain

Thrombolysis

• Thrombus = clot • Lysis = destruction of cells • Thrombolysis is achieved by using rt-PA

(alteplase) • rt-PA reverses underperfusion ischaemic

penumbra recovers

Thrombolysis

• rt-PA = recombinant tissue plasminogen activator

• activates the release of plasmin as plasminogen

• Plasmin is enzyme that degrades fibrin, the protein which is the main constituent of blood clots

Thrombolysis

• First evidence 1995 – NINDS trial – Treatment with iv tPA within 3 hours of onset

improved outcome at 90 days

• 2008 – ECASS 3 Trial – Extended time window to 4.5 hours

‘Time is Brain’

Thrombolysis…

• 5-7% chance of harm • Symptomatic haemorrhage

Thrombolysis…

• For every 100 acute stroke patients thrombolysed, 13 regain independence rather than die or be dependent in the long term.

Mechanical Thrombectomy

• ‘clot retrieval’

• manual extraction of clot from brain

• specialised neurological centres

• 5 large RCTs in 2015 STRONGLY POSITIVE

• MR CLEAN • EXTEND-IA • ESCAPE • SWIFT PRIME • REVASCAT

• IV tPA thrombectomy

• Evidence of large proximal vessel occlusion (by CT or MR angiogram)

• Often excluded pt.s with large ischaemic core (CT perfusion)

• Time window of 6 hours

• When compared to standard treatment (i.e. thrombolysis):

– Improved chance of functional independence at

90 days (OR 1.56) – No difference in symptomatic ICH or death – NNT 3.2-7.1

• Challenges: – 1-2% of all stroke patients eligible – 9000 per year in England

• Reorganisation of health systems • Rapid delivery regardless of geography or time

of day • 400 patients received this in 2016

Primary Intracerebral Haemorrhage

• 11% of acute stroke patients

• Can deteriorate quickly

• Require admission to Hyper-Acute Stroke Unit (HASU)

• Reversal of anticoagulants

• Managing high blood pressure

• Close observation on HASU

• Warfarin – Pro-thrombin complex

concentrate – IV Vitamin K

• NOAC – Pro-thrombin complex

concentrate

• Dabigatran – Idarucizumab

• Aim is to reduce volume of bleed

• Therefore improve outcome

• Previously unclear evidence

• INTERACT2 • ATACH-2

• Urgent control of SBP >150mmHg

• Within 6 hours of onset

• Safe • Improved outcome

of mild-moderate cases

• No reduction in death or major disability

Aspirin

• All ischaemic strokes are eligible

• NNT=79 to avoid death or dependency

• Cheap!

Stroke Units

• All stroke patients eligible • NNT=18

Stroke Units

• For every 100 patients receiving organised (Stroke Unit) care: 3 more patients will survive

6 more patients will return home physically

independent

Summary

Time is Brain!

COGNITIVE PROBLEMS AFTER STROKE D E P A R T M E N T O F C L I N I C A L H E A L T H P S Y C H O L O G Y

A I N T R E E U N I V E R S I T Y H O S P I T A L

C O N S U L T A N T L E A D C L I N I C A L P S Y C H O L O G I S T – D R M A R K G R I F F I T H S

S E N I O R C L I N I C A L P S Y C H O L O G I S T – D R R Ó I S Í N C U N N I N G H A M

INTRODUCTION A stroke can lead to:

• Physical disability • Cognitive problems (‘thinking skills’) • Behavioural and personality change • Problems with emotional experience and management of

these symptoms

Acute care Rehabilitation or discharge

Long-term adjustment

EMOTIONAL ADJUSTMENT

• Acute confusion • Acute cognitive

problems • Shock – numbness • Anxiety & fear • How will I cope?

• Loss of identity • Loss of confidence • Of stroke

recurrence (increased sense of personal mortality)

• Relationship problems

• Worry about the future

• Challenges in learning to cope

• Grief, mourning • Depression • Anger/frustration –

Why me? • Poor emotional

control • Personality change

MOOD PROBLEMS FOLLOWING STROKE A stroke can be a profoundly unsettling event for anyone to experience

Almost everyone who experiences a stroke will face difficult emotional changes, which will challenge their self-confidence, self esteem and relationships with others

Experiencing a stroke challenges the person’s ability to live as they would like to; to work, do things they enjoy; or be the father/ mother/ partner they want to be

Almost 70% of stroke survivors experience psychological difficulties such as depression and anxiety; 50% experience interpersonal problems (Stroke Association, 2013)

MOOD PROBLEMS FOLLOWING STROKE • Sudden physical disability leads to emotional and adjustment

difficulties for many • In the absence of assistance to help them learn how to best

manage the difficulties faced, many people struggle to cope with the changes they face in the days, weeks, months and years following a stroke

• Almost 70% of stroke survivors experience psychological difficulties such as depression and anxiety and a further 50% experience interpersonal difficulties post-stroke (Stroke Association audit, 2013)

• Post-stroke fatigue (mental and physical) is common (38 to 73 %; Lerdal et al., 2009), often leading to higher dependency/disability and poorer rehabilitation outcomes

COGNITIVE PROBLEMS FOLLOWING STROKE >75% of stroke survivors are likely to have a degree of cognitive impairment impacting negatively on their quality of life (Lesniak et al, 2008; RCP, 2008). Varies from person to person depending on the site of the stroke and type of stroke Do not mean that a person has become ‘stupid’ or ‘slow’; however impairments can be very disabling Are a direct result of damage to the brain Can be frightening, and are often not well-understood Can be worse when fatigued or stressed.

THE BRAIN

Attention / concentration / information processing changes •Attention is our ability to concentrate on the information around us.

•If we are having trouble with our attention we are also likely to have some memory problems. •A stroke can affect someone’s ability to attend to information, concentrate on things around them, and be able to process that information. •Information processing is our ability to attend to information long enough that we can process it, make sense of it in our brains, and respond to it. •You may need more time to be able to take something in and make sense of it.

MEMORY CHANGES Memory is our ability to keep a record of where we are in our lives, and in our environment. It is the ability to bring to mind relevant information from the past, and to incorporate this with what has to be done currently, and in the future. Though it sounds simple, memory is a complex system in our brains, and involves a number of different skills and stages.

FACTORS CONTRIBUTING TO MEMORY PROBLEMS •Low mood and depression

•Significant pain (especially chronic pain)

•Fatigue and sleep problems

•Effects of some medication

DIFFERENT TYPES OF MEMORY 1)Working memory – it is essentially a notepad where all information passes.

2)Prospective – this is the process of remembering to do things in the future.

3)Episodic Memory – remembering facts and things you have been doing.

4)Short term memory – Our short term memory only holds information for a limited period.

5)Procedural memory – this is the part of our long term memory which is responsible for knowing how to do things.

6)Long term memory – This is our memory for events which happened a long time ago.

DIFFERENT TYPES OF ATTENTION

HOW OUR MEMORY WORKS

Attention (information enters the

brain)

Encoding (how 'deep' we process

the information)

Storage (information is stored in our long term memory)

Consolidation (rehearsing and practicing

information)

Retrieval (accessing the information

at a later date)

COGNITIVE PROBLEMS FOLLOWING STROKE Executive impairment - relating to damage to the frontal lobe of the brain - is a very common pattern following stroke Can be caused by impeded blood loss to the frontal lobe area of the brain after ischemic stroke or by hemorrhagic stroke in this area

Consequences: • Changes in - emotional experience; emotional management;

‘personality’ • Challenged empathy; unsympathetic or anti-social behaviour;

emotional/ behavioural impulsivity; emotionalism • Problems with planning, problem solving, decision making,

rigid thinking, self-monitoring/awareness, initiation/inhibition • Wider cognitive changes (e.g. memory, attention)

Self-awareness Having an idea of personal strengths and weaknesses

Goal-setting Ability to set realistic and achievable goals based on our strengths and weaknesses.

Self-initiation This is to be able to start and carry out steps all the way through without planning or prompting.

Self-Inhibition The ability to inhibit or stop behaviour or thoughts that are inappropriate; the ability to manage emotions (e.g. getting angry or upset) This can lead people to feel that personality has changed – ‘he/she is a different person’.

Planning and Organisation Being able to establish steps involved in carrying out a task such as prioritising

Self-Monitoring and Self-Evaluating The ability to assess whether something is appropriate and effective

Flexible problem solving Ability to recognise a problem and anticipate them before they occur. Also being able to work out an alternative solution.

DISENTANGLING COGNITIVE AND EMOTIONAL PROBLEMS

Cognitive problems can be frightening, and are often not fully understood by the individual, families/carers or professionals - Can be made worse when fatigued or stressed - Understanding strengths and weaknesses, while supporting emotional

wellbeing, is key in facilitating rehabilitation and adjustment

E.g. ‘Personality Change’ - Frequently reported by families. • Emotional burden faced following stroke and the increase of this burden

over what can feel a slow recovery phase; • Cognitive effects relating to executive impairment – changing an

individuals ability to plan; to look ahead with hope or motivation; to recognise mistakes being made, or ‘to be’ who they were before (or to recognise themselves now)

• Reduced emotional management abilities • Changes in relationships / roles / identity • All of the above?

PSYCHOLOGICAL IMPLICATIONS FOLLOWING STROKE

Patterns of psychological disturbance (and physical disability), neuropsychological deficits, and emotional burden. Raising inter-related and dynamic patterns of emotional and cognitive deficit symptoms being common (and very disabling if unrecognised or untackled)

Indeed, if left unrecognised and untreated, these have been found to be linked to increased rates of re-admission, higher rates of unplanned follow-ups, longer-term disability and greater mortality (Williams, 2005; Pohjasvaara et al, 2001).

Higher risks of ongoing burden to community and social care services are also indicated.

VICIOUS CYCLES

Low mood

Poor attention

Avoid activities

Stress & anxiety

Poor memory

Relationship problems

Poor self-care

Poor engagement with rehab

Adjustment problems

Executive impairments

CLINICAL PSYCHOLOGY Specific to stroke, the role of clinical psychology is to: Provide specialist assessment to help make sense of the patient’s complex difficulties Disentangle the often-overlapping cognitive, emotional, inter-personal and physical factors (within a biopsychosocial and in-depth psychological and neuropsychological understanding of health and wellbeing) Integrate these assessment findings into a (neuro)psycho-social and medical clinical formulation of all of the clients’ needs and difficulties Use this clinical formulation to plan neuropsychological rehabilitation and inform MDT holistic rehabilitation (optimising recovery prognosis) Signpost any broader mental health or risk management needs that may need addressing (to optimise recovery)

CLINICAL PSYCHOLOGY Clarifying what is causing the difficulties faced i.e. how much of the symptoms faced are related to cognitive effects vs. reactive emotional effects? Once the level of ‘thinking’, ‘behavioural’ and ‘mood’ effects has been clarified (and how these relate to each other):

• ‘Compensatory systems’ can be developed and taught, seeking to reduce the problems faced; then reducing the emotional burden carried

• Behavioural strategies • Cognitive rehabilitation

• Strategies can also be taught to help mood management and associated cognitive impairment, in the moment

• Anxiety management – e.g. mindfulness skills • Frustration tolerance • Family intervention

• Skills also taught to help planning to restore enjoyment and balance in life, helping to support improved adjustment and wellbeing

• Value-driven Goal Planning (to help get life back on track, in a desirable direction)

SUMMARY Suffering a stroke can be a highly distressing and disabling event in someone’s life, affecting what someone can do; how they think; how they feel; how they cope; how they interact with others - affecting individuals and their partners, families, friends and carers

The interplay between cognitive and emotional problems can be complex to disentangle and understand

But they are things we can do to help – to improve the person’s understanding of their problems; advising ways of how to manage and reduce the symptoms and problems faced; helping them to get their life back on track, on a desired path and direction to support ongoing adjustment and positive coping

A Stroke Patient’s Journey: A case study from an OT perspective

Felicity Hale – Clinical Lead OT Sam Campbell – Band 6 OT

Aims To explore role of OT Describe journey through acute, rehab

and ESD services Advise on DVLA guidelines and

importance of assessing return to driving. Look at what is assessed and how it is

assessed when looking at return to driving. Vocational Rehab

Social History High functioning / Intelligent individual Highly paid job with significant levels of

responsibility Lives alone Children outside of local area Independent ADL’s Driver – car needed for work and hobbies Friends were of working age and so not

available during the day

Background Assessment Paramedic attendance at property: Collapse R sided weakness Expressive dysphasia

Ambulance arrival to A & E Stroke co-ordinator bleeped Following CT transferred to ASU

Acute stroke unit – OT assessment

Vision

Sensation

Cognition

Function

Motor skills

Goal Setting Immediate therapy goals identified: - Increase attention to R side - Consistently mobilise with assistance of x2

Transferred to Clatterbridge Rehabilitation Centre for further assessment and to work towards goals.

CRC OT intervention Assessment of personal care skills Assessment of basic Kitchen tasks R UL intervention – sensory and motor Transfer / mobility practice Fatigue management Patient demonstrating signs of anxiety Uncompliant with recommendations made

Discharge Planning Need for contextually appropriate

environment ESD goals identified: Return to work / driving Complex ADL assessment Family agreeable to support for specific

period of time Discharge home achieved Immediate ESD transfer of care on 12 week

pathway

ESD OT Symptoms on referral to ESD were right sided

weakness, loss of sensation to right side, some right sided visual and sensory inattention, expressive language impairment and significant attentional, processing and memory problems.

Right sided inattention improved fairly quickly and when completing tasks from the behavioural inattention test and tasks in function it was no longer evident. Upper and lower limb function and sensation improved fairly quickly also.

Driving Stroke is the largest single cause of disability in the

UK. A stroke can impact on a person's ability to drive and the National Clinical Guidelines for stroke highlight driving a key area for consideration for healthcare professionals.

The DVLA are responsible for maintaining the registration and licensing of drivers in Great Britain. The DVLA have strict guidelines about who may and who may not drive.

The guidance differs slightly for TIA and for stroke and for the different categories of license holders.

DVLA Guidelines

What do OT’s assess? Large part of OT’s role is assessing the impact of

cognitive, perceptual, and visual deficits on function.

There is conflicting evidence and no universal way to assess cognitive fitness to drive (Frith et al 2014).

Vision – visual fields, occular motor skills, visual cognitive components such as visual inattention.

Cognitive – attention, speed of processing, problem solving, praxis

Physical – limb movement and sensation.

How do we assess? Functional tasks, specific cognitive work

sheets or tasks during their rehab sessions. Standardised assessments to evaluate

cognitive functioning and guide treatment. Standardised assessment – Rookwood Driving

Battery and trail making B All return to driving decisions need to be

made in conjunction with looking at overall functional performance and any doubts patient's should be referred for on road driving assessment.

Vocational Rehab Individual dependent. Activity analysis of the work they complete. Design activities that work on some of the

core components of the patients job. Advise on things like fatigue and grading tasks.

Referral onto Acquired Brain Injury team who are commissioned for vocational rehab.

OT intervention with Case Study Regular cognitive sessions working on sustained attention,

progressing to selective attention, alternating attention and finally divided attention.

Intervention around executive function, planning, organisation and problem solving

As a result of working on attention, visual memory improved greatly however auditory memory didn't show as sizeable improvements

Completed Rookwood Driving Assessment and passed all subsections

Felt that as had returned to pre stroke level of functioning in all other ADLs, and had attained sufficient scores on Rookwood and trail making that there was a sufficiently high level cognitive functioning for task such as driving.

Any questions?

End of Life Care in Stroke

Dr Catherine Hayle Consultant in Palliative Medicine

Wirral University Teaching Hospital

• Why am I here? • Definitions • Planning ahead • What matters to dying patients? • National guidelines • Symptom control • Nutrition & hydration • Local solutions & partnerships

RCP National Clinical Guideline 2016

• Impressive improvements in stoke outcomes, but…..

• 1/20 patients presenting with acute stroke receive EOL care within 72 hours

• 1/7 patients with acute stroke die in hospital

‘Providing high quality

end of life care is a core activity for any multi-disciplinary stroke team’

‘Specialist Palliative Care

Support should be available.’

End of Life Care

‘Care that helps all those with advanced,

progressive, incurable illness to live as well as possible until they die’.

Generally relates to the last year of life…..

BUT……

Risk of further events:

• First stroke: 26% risk at 5 years 39% risk at 10 years • Additional risks of similar magnitude for other

vascular events • Significant illness discussion + advance care

planning (if wished for) should be offered

Advance Care Planning

‘A process that gives people the chance to think about and write down what is important

to them.’

• For those with capacity • http://www.nwcscnsenate.nhs.uk

/strategic-clinical-network/our-networks/palliative-and-end-life-care/advance-care-planning/

Remember this?

‘Most of the submissions

to the Review from relatives and carers that were critical of the LCP made reference to hydration and nutrition.’

NICE: Key Changes in Practice

• Daily assessment & discussion of hydration status

• If CAH commenced, 12 hourly review of benefits/harm

• Individualised approach to anticipatory prescribing

• Named lead HCP, responsible for shared decision-making and daily feedback re. any anticipatory medications administered

Key symptoms & challenges

• Pain (step-wise approach) • Agitation • Delirium • Continence care • Skin care • Nutrition & hydration

Use local guidance

Dying of Thirst? Hydration in the Last Days of

Definitions

• Clinically assisted hydration: - iv fluids - sc fluids - fluid via PEG/RIG - TPN • Drinking (with or without support)

‘You should be satisfied

that nutrition and hydration are being provided in a way that meets your patients’ needs, and that if necessary patients are being given adequate help to enable them to eat and drink.’

COCHRANE REVIEW 2014 Medically assisted hydration for adult palliative care patients Good P, Richard R, Syrmis W, Jenkins-Marsh S, Stephens J.

COCHRANE REVIEW 2014

• Original review 2008 • Updated 2011 • Further update 2014 Objective: ‘To determine the effect of medically assisted hydration in palliative care patients on their quality and length of life’

Inclusion

Palliative care patients where

prognosis limited and focus was QoL

Any life limiting illness

Adults in any setting

Not limited to terminal phase

Exclusion

Medically assisted hydration due to

-pre-surgery -chemotherapy -radiotherapy

Cochrane Review 2014

• 6 relevant studies

• 3 RCTs (222 participants) • 3 Prospective controlled trials (360

participants) • Small number of studies therefore quantitative

analysis not possible

Very different outcomes measured in each study – State of consciousness – Overall benefit (as determined by physician and

participant) – Change in sum of 4 dehydration symptoms (fatigue,

myoclonus, sedation, hallucinations) – Thirst, nausea, delirium, MMSE – Dehydration, fluid retention, delirium, myoclonus,

bedsores, agitation, communication – Multiple physical symptoms and cognition

RANDOMISED CONTROLLED TRIALS Bruera 2005 Bruera 2013 Cerchietti 2000

Methods Double-blind Truly random 2 days duration

Double-blind Multi-centre

Method of randomisation and blinding status unclear. 48 hours duration

Participants 51 patients

129 patients 42 patients

Interventions 1000ml (28) or 100ml (23) 0.9% saline over 4h IV (12) or SC (37)

1000ml or 100ml 0.9% saline over 4h – all SC

1000ml 5% dextrose at 42ml/hr SC or no fluids

Outcomes No significant difference in overall benefit or adverse effects. More improvement in sedation and myoclonus in intervention group.

Night-time delirium deteriorated more in placebo group.

Chronic nausea significantly better in hydration group. 1 adverse event.

PROSPECTIVE CONTROLLED TRIALS Morita 2005 Viola 1997 Waller 1994

Methods Observational. Multi-centre. 3 weeks’ duration.

Multi-centre. Pts included until death, discharge or resolution of fluid deficit.

Single centre. Duration admission to hospice until death.

Participants 226 patients 66 patients 68 patients

Interventions 59 pts in Hydration group – form of fluid unclear; >1000ml per day

SC fluids titrated to needs (median 1000ml per day) or no fluids

Oral hydration (55 pts) or IV 1-2 litres per day (13 pts)

Outcomes Dehydration significantly higher in non-hydration group. Effusion, oedema and ascites significantly higher in hydration group.

No statistical analysis to determine if any significant differences

No significant difference in state of consciousness

• No significant benefit in use of medically assisted hydration

• However insufficient good-quality studies to inform definitive recommendations for practice – low participant numbers and methodological

difficulties

COCHRANE REVIEW-CONCLUSIONS

NICE Guidance on Care of the Dying Adult

December 2015

• Focus on the importance of regular mouth care and providing oral hydration where possible

• Review need for clinically assisted hydration daily with patients and their families/carers

• The risks and benefits must be discussed • Concerns are addressed before starting CAH • No evidence that CAH will prolong life or the

dying phase

NICE CARE OF THE DYING ADULT

• Consider a trial if distressing symptoms of delirium or thirst

• Monitor daily for changes in signs or symptoms

• Monitor daily for evidence of benefit or harm • Stop if evidence of harm • Continue if evidence of benefit

THERAPEUTIC TRIAL OF CAH

Considerations before starting

Wishes and preferences of the patient

Level of consciousness

Swallowing difficulties

Level of thirst

Risks of fluid

overload

Whether recovery from

dying is possible

CONSIDERATIONS BEFORE STARTING CAH

‘The need for CAH in dying patients should be reviewed daily.’ [Grade D]

STANDARD 1

‘Decisions surrounding the use of CAH in dying patients should involve the patient, family and multi-professional team and should be clearly documented.’ [Grade D]

STANDARD 2

‘If CAH is used in the dying phase, a rate of at least 1 litre of fluid over 24 hours intravenously, subcutaneously or via PEG/PEJ is the recommended regimen.’ [Grade D]

STANDARD 3

‘Units caring for dying patients should ensure that all staff are competent in the assessment and delivery of CAH.’ [Grade D]

STANDARD 4

What matters most to dying patients?

• Freedom from pain & distress • Privacy and dignity • Presence of loved ones • Minimising the ‘burden’ on family members

Location not a high priority

‘Shouldn’t we be supporting most people to die at home?’

• Approx 70% wish to die at home • Wide variation in estimates • Flawed research methodology • Patients frequently change their preference as

death approaches (esp. those with non-malignant disease)

• The most elderly are more likely to wish for a death in hospice or hospital

BMJ Oct 2015

Care of dying patients: key messages

• Individualised care • 5 priorities • Hydration & nutrition • Support for those close to the patient • Spiritual care • Experience more important than location • BUT…. crucial to understand local procedures

for rapid discharge to die

In Summary….

• EOL care is part of your core business • Get to know your local specialist palliative

care services - partnership working is key • Stroke is a life-changing event – always

consider advance care planning • Care of dying patients must be individualised • Daily review of hydration/nutrition • Please use local frameworks/guidelines

Stroke Complications

Sheeba Philip Consultant Stroke Nurse

East Lancashire Hospitals Trust

Early Complications First 72 hrs mostly • Seizures • Haemorrhagic Transformations • Malignant MCA syndromes • Stroke Associated Pneumonia/

Chest infections

Late Complications • Urinary tract infections • DVT • PE • Tonal changes • Emotional Disturbances

Seizures • Very early seizures (often mis-diagnosed)

Usually within the first hours from onset of stroke (10-15%) - Suggestive of Post Circulation stroke – Top of the Basilar Thrombus. May be partial or focal initially but more often becomes generalised or bilateral convulsive

seizures .

• Early onset Seizures (day 2 to two weeks) Can be subtle and non-convulsive Noted in Haemorrhagic stroke and Total anterior circulation stroke Frequency – Haemorrhagic strokes- 10.6% and 8.6% in ischaemic stroke

• Late onset Seizures / Post Stroke Seizures (after 6 months from onset ) 3 times more common than early onset seizures. 40% of stroke patients in 2-3 years Common in Large artery atherosclerosis and cardio embolic strokes

Merkler, et al. , 2016; Stefanidou, et al. , 2017

Seizures • Management: Dependent on type • Early onset seizures-

– 16% recurrence rate – Has high mortality rate. – IV benzodiazepines (lorazepam preferred) are the first choice, eventually followed by

phenytoin sodium or valproate sodium. – anti-epileptic drugs (AEDs) not considered as long term

• Late- onset seizures- – 50% recurrence rate. – If onset between 6 months to two years – 62% recurrence rate . After that – 47% – In very-late-onset seizures , guidelines suggest- wait to start AEDs until after a second

seizure on treatment of epilepsy.

Reuck, 2007;

Haemorrhagic Transformation Bleeding within an infracted tissue and is a frequent complication of

thrombolysis Incidence 5-20% - symptomatic 13-40% asymptomatic

40-70% noted on autopsies.

Predictors Large infarcts Cardio embolic strokes Severe stroke / high NIHSS Hyperglycaemia Xing et al, 2011; Tan et al , 2014;Castellanos et al, 2003

Haemorrhagic Transformation

• Management • Observe for neurological deterioration (GCS/pupils) Close monitoring of vital signs :- NIHSS (thrombolysis protocol) & non thrombolysis once daily

NIHSS for at least 3 days. Blood pressure – aim to maintain > 180 in ischaemic strokes BM- 4 hrly for diabetics and 12 hrly for non diabetics (at least

for 72 hrs). CT brain in case of clinical deterioration.

Malignant MCA syndrome/ Space occupying Infarcts

Caused due to the shift of the brain tissue or herniation following vasogenic oedema.

Incidence : 2-10% More common in younger patients Noted in TACS Mortality – 80%

Deterioration – mostly within 72 hrs, but can happen up to 5 days Signs-

Headache/ Vomiting (due to rise in ICP) Sudden drop in GCS Changes in pupillary response

Malignant MCA syndrome/ Space occupying Infarcts

• Management Close continuous monitoring and management of physiology Maintain airway Ensure fluid therapy (osmotherapy – debatable) Stabilise vital signs

• Surgical Management (only proven management ). • Decompressive carniectomy

Better outcome if treated within 48 hrs . Can save life if treated within 60 hrs (but left with severe disability).

Dasenbrock et al, 2017. Hofmeijer ESOC, 2017

Stroke Associated Pneumonia

• Incidence 10-20% of patients

• Predictors • Failed dysphagia screen (unable to clear secretions) • Vomiting at onset of stroke • Immobile patients (poor positioning) • Higher NIHSS

Stroke Associated Pneumonia

Bray et al ,2016

Stroke Associated Pneumonia- management

• Prevention Early dysphagia screening Referral to SLT Good oral hygiene Positioning (early seating) Maintain Fluid balance Regular vital signs to identify

early signs of infection (fever/ tachypnea )

Sputum culture/ CXR (if suspicious )

• Treatment • NBM (NG tube) • Antibiotics • Chest Physiotherapy • Hydration/ Nutrition • Drugs – GI motility ? (MAPS –

oncoming trial)

Early Complications First 72 hrs mostly • Seizures • Haemorrhagic Transformations • Malignant MCA syndromes • Stroke Associated Pneumonia/

Chest infections

Late Complications • Urinary tract infections • DVT • PE • Tonal Changes • Emotional Disturbances

Urinary Tract Infections • Incidence

– 10-20% of stroke patients • Causes

– Catherterisation – Dehydration – Diabetic patients – Immobility

• Management • Avoid catheterisation • Ensure adequate hydration

Venous Thromboembolism

• DVT Incidence 2-5% diagnosed in clinical setting 10% noted in Doppler scans

Pulmonary Embolism

Only 1 % diagnosed in clinical setting Upto 50% noted following autopsies

Anticoagulation reduces DVT & PE but increases risk of ICH Dennis, M. (2017) ESOC.

Management • ESO recommendation- • Consider IPC and anticoagulation in patients with ischaemic stroke at high risk

of VTE and do not have features of increase risk or either intervention. (heart failure, severe peripheral vascular disease, confused patients)

• Prophylactic anticogulation (LMWH or UFH) should be considered in immobile patients with acute ischaemic stroke.

• Benefits may be better in patients with PMH of VTE

• NICE recommendation- • Patients with immobility after acute stroke should be offered IPC within 3

days of admission to hospital for the prevention of DVT. Treatment should be continuous for 30 days or until mobile/discharge.

• Do not give Heparin (in any dose).

Tonal changes following CVA

What is tone? Tone is the resistance of resting muscle to

passive movements. Hypotonicity Hypertonicity/spasticity (low tone) (high tone) 60%

High Tone Complications • Muscle shortening • Joint pain • Spasms • Altered patterns of movement • Clonus • Associated reactions • Pressure ulcers

Spasticity can be worsened by external factors such as constipation, urinary tract infections or pressure ulcers.

Taken from Khedar and Nair (2012)

Low Tone Complications • Shoulder Pain – subluxation leading to

impingement. Varies 17-81% • Altered patterns of movement • Oedema • Hip Instability – leading to joint pain and

muscle shortening

Normal humeral head alignment Subluxed shoulder

Management

• Identification and elimination of triggers • Careful handling • Effective positioning • Physiotherapy • Medication • Splinting • Orthotics • FES

Effective positioning

Emotional disturbances

• Depression 25-79% (Kneebone and Dunmore, 2000)

• Anxiety 1/3rd (Astrom, 1996)

• Post stroke fatigue 23% to 75%. (Kim, 2016)

Management • Anti depressants • Psychologist.

Stroke Association Supporting Stroke Survivors & Carers Kate Charles– Deputy Head of Operations NW

Stroke Association Our vision is for a world where there are fewer strokes and all those touched by stroke get the help they need. Our mission is to prevent strokes and achieve life after stroke through providing services, campaigning, education and research.

We offer a range of support services

Stroke Helpline 0303 3033 100 stroke.org.uk

Stroke Association Services Series of service elements built on the Core service

Core Stroke Recovery Service Communication Support

Emotional Support Carer Support

Exercise Based Stroke Rehabilitation 6 month reviews

https://www.youtube.com/watch?v=cAiw9_oHmbc

Intensive support

to prevent hospital readmission

Holistic assessment

Identification of needs and desired

outcomes

Support to self manage

Coordination and navigation activity

Supported conversation to express needs

Addressing social isolation through

community integration

Representation and advocacy

Peer and social support

Reassurance, regular review and

follow-up

Active listening and problem

solving

Secondary prevention

Our Core

Stroke Pathway

We enable peer support

Staying connected

People affected by stroke who stay connected: • Live longer • Remain healthier • Are happier • Maintain their memory and thinking better As effective, and better than, controlling blood pressure, taking exercise, and loosing weight.

Source: Reg Morris, Cardiff University 2016

Our volunteers

The Importance Of Peer Support

Adapted Cycling & Bell Boat Sailing

Challenge For Change 30ft

Aerial Assault Course

Art Therapy

Awareness Raising

2015 Life After Stroke Award Winners

Fundraisers

Friendship

Life After Stroke Charlotte Covey

Before my stroke at the age of 18: >2004

I used to love wearing very high heels (to keep up with my then-6”5-boyfriend!) and skirts – this was the very last time when I did so in June 2004, attending the Sixth Form prom.

Age 17

Age 18

Hospitalised at Salford Royal for 9 weeks: July – September 2004

My parents and I after several weeks where I could finally sit up in a chair.

One year later: 2005

Hiding my right hand at my brother’s graduation in July 2005.

My Dad and I in December 2005. Clothes

always had to have pockets.

Anorexia as a direct result of the stroke: 2005 – 2010, 2014 - 2015

Sectioned in the Eating Disorder Unit at Macclesfield Hospital for 3 months in May 2006.

New start at age 30: 2015 onwards

My super consultant who

treated me at the time, Prof.

Tyrrell, my then-boyfriend, Rich Lewis, and

I in October 2016 at Salford Royal Hospital.

Know Your Blood Pressure event at my work in February 2017.

At the Macclesfield

Knit and Natter group in December

My good friend Jon Burrow (r) – he has supported me all the way from the start

- and his brother Simon (l), who rode 972 miles in 9 days, raising over £3k in

September 2016.

Together we can conquer stroke

For more information

Helpline: 0303 3033 100

Website: stroke.org.uk

Stroke Update · 2017. 6. 19. · • Sudden physical disability leads to emotional and adjustment...

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