Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
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
MRA
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
TACS
HEMIPARESIS
HEMIANOPIA
HIGHER CORTICAL DYSFUNCTION
HIGHER CORTICAL DYSFUNCTION
TACS
Hemiparesis or hemisensory loss
AND
Homonymous hemianopia
AND
Cortical dysfunction (dysphasia /
perceptual problem)
PACS
Hemiparesis and hemisensory loss
Homonymous hemianopia
Cortical dysfunction (aphasia / perceptual
problem)
2 of the three or cortical dysfunction alone
PACS
LACS
Hemiparesis
OR Hemisensory loss
OR Hemisensorymotor loss
OR Ataxic hemiparesis
(no cortical dysfunction)
LACS
POCS
Double-vision, vertigo, ataxia, incoordination,
vomiting, hemianopia, crossed signs, cortical
blindness.
POCS
PROGNOSIS
Stroke Dead – 30
days
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
>50
30-50
20-30
10-20
<10
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
Age
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
Aims
• 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
Aims
• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!
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
Aims
• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!
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
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.
Aims
• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!
Mechanical Thrombectomy
Mechanical Thrombectomy
• ‘clot retrieval’
• manual extraction of clot from brain
• specialised neurological centres
Mechanical Thrombectomy
• ‘clot retrieval’
• manual extraction of clot from brain
• specialised neurological centres
Mechanical Thrombectomy
• ‘clot retrieval’
• manual extraction of clot from brain
• specialised neurological centres
Mechanical Thrombectomy
• 5 large RCTs in 2015 STRONGLY POSITIVE
• MR CLEAN • EXTEND-IA • ESCAPE • SWIFT PRIME • REVASCAT
Mechanical Thrombectomy
• 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
Mechanical Thrombectomy
• 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
Mechanical Thrombectomy
• 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
Aims
• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!
Primary Intracerebral Haemorrhage
• 11% of acute stroke patients
• Can deteriorate quickly
• Require admission to Hyper-Acute Stroke Unit (HASU)
Primary Intracerebral Haemorrhage
• Reversal of anticoagulants
• Managing high blood pressure
• Close observation on HASU
Primary Intracerebral Haemorrhage
• 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
Primary Intracerebral Haemorrhage
• Reversal of anticoagulants
• Managing high blood pressure
• Close observation on HASU
• Aim is to reduce volume of bleed
• Therefore improve outcome
• Previously unclear evidence
• INTERACT2 • ATACH-2
Primary Intracerebral Haemorrhage
• Reversal of anticoagulants
• Managing high blood pressure
• Close observation on HASU
• Urgent control of SBP >150mmHg
• Within 6 hours of onset
Primary Intracerebral Haemorrhage
• Reversal of anticoagulants
• Managing high blood pressure
• Close observation on HASU
• Safe • Improved outcome
of mild-moderate cases
• No reduction in death or major disability
Aims
• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!
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
• What is a stroke? • Why is it important? • Why time matters • Thrombolysis • Thrombectomy • Primary intracerebral haemorrhage • …and the rest!
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
home
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
Mood
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
Aims
• 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
Life
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
COCHRANE REVIEW 2014
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
COCHRANE REVIEW 2014
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
CAH
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
Stroke Complications
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)
Stroke Complications
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
Stroke Helpline 0303 3033 100 stroke.org.uk
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
Stroke Helpline 0303 3033 100 stroke.org.uk
Adapted Cycling & Bell Boat Sailing
Challenge For Change 30ft
Aerial Assault Course
Art Therapy
Stroke Helpline 0303 3033 100 stroke.org.uk
Awareness Raising
Stroke Helpline 0303 3033 100 stroke.org.uk
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
2016.
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