Authors
- Capriotti, Teri DO, MSN, CRNP
- Murphy, Teresa SN
Abstract
Each year, more than 795,000 people in the United States suffer a stroke and by 2030, it is estimated that 4% of the U.S. population will have had a stroke. Home healthcare clinicians will be increasingly called upon to assist stroke survivors and their caregivers adjust to disability and assist the survivor during their reintegration into the community. Therapeutic modalities are changing with advanced technology. Great strides are being made in the treatment of acute stroke; particularly endovascular interventions. More patients are surviving the acute stroke event and therefore will need to learn how to live with various degrees of disability. It is important for home healthcare clinicians to understand the process from acute event to medical stabilization, and from rehabilitation to long-term adaptation.
Article Content
Stroke is the leading cause of long-term disability in the United States. Each year, more than 795,000 people in the United States suffer a stroke, with 610,000 of these being first strokes. Stroke risk increases with age; 75% occur in adults older than age 65. Risk of having a first stroke is nearly twice as high for Blacks than for Whites, and Blacks are more likely to die following a stroke than are Whites (Centers for Disease Control and Prevention, 2015; Hall et al., 2012). According to Fang et al. (2014), strokes in the Medicare population aged >=65 years decreased by approximately 40% over the last 2 decades. However, stroke fatalities have also declined, and that has caused an increase in the number of persons who are living with poststroke disabilities. According to Sacco and Dong (2014), despite the decline in stroke incidence, the aging of the population will lead to a significant increase in the prevalence of stroke. By 2030, it is estimated that 4% of the U.S. population will have had a stroke. Home healthcare clinicians will increasingly be called upon to care for persons in the community who are living with complications of strokes.
Etiology/Risk Factors
There are two types of stroke-ischemic and hemorrhagic. Approximately 13% of strokes are due to hemorrhage where a blood vessel has ruptured (American Heart Association/American Stroke Association, 2015). The mortality rate is higher for hemorrhagic stroke (68%) than for ischemic stroke (57%) (Koton et al., 2014). About 87% of all strokes are ischemic strokes, most often caused by an obstruction of blood flow to the brain due to atherosclerosis. The middle cerebral artery (MCA) is the dominant source of circulation in the brain and a branch of this artery is commonly occluded in ischemic stroke (Kumar et al., 2015). Carotid stenosis and atrial fibrillation are also common predisposing conditions to ischemic stroke. According to Reiffel (2014), a patient with atrial fibrillation has a 5-fold increase in risk of stroke compared to the general population due to clot formation in the left atrium or left atrial appendage with emboli traveling to the MCA.
Cell death occurs within minutes in the core region of ischemia and a surrounding region of salvageable "at risk" tissue forms the ischemic penumbra. Brain cells in the penumbra can remain viable for several hours. Infarction of the region of the penumbra can be prevented through aggressive, timely treatment (Kumar et al., 2015). The incidence of ischemia is approximately the same in the right and left cerebral hemisphere. The corticospinal motor nerve tract runs downward from the cortex, crosses over at the medulla, and continues into the spinal cord. From the periphery, the spinothalamic sensory nerve tract crosses over to the opposite side of the spinal cord before ascending to the cortex. Therefore, hypoperfusion of the region of the brain supplied by the MCA causes contralateral (opposite side) sensory and motor deficits in the face, upper, and lower extremities.
Ischemic stroke commonly presents with signs and symptoms that reflect dysfunction of the region of the brain perfused by the MCA. A patient typically experiences drooping of one side of the face and weakness or paralysis and sensory deficit of the upper extremity or lower extremity or both. In the majority of individuals, the speech centers are in the left cerebral hemisphere; therefore, aphasia commonly develops in those affected by a stroke of the left hemisphere (Yew & Cheng, 2015).
Diagnosis of Ischemic Stroke
The American Stroke Association (2015) is promoting the F.A.S.T. campaign (Face drooping, Arm weakness, Speech difficulty, Time to call 9-1-1) to improve awareness of stroke and to expedite activation of emergency services for stroke victims. It is critical to establish the time of onset of symptoms because this determines whether a patient meets the 4.5-hour eligibility window for thrombolytic treatment (Yew & Cheng, 2015). Noncontrast computed tomography scans immediately determine whether the stroke is ischemic or hemorrhagic, which is critical because treatments are different. Stroke severity is determined by performing a complete neurologic exam and assessing the patient using the National Institutes of Health Stroke Scale (NIHSS). The NIHSS is a 15-item scale that can be performed in about 5 minutes (National Stroke Association, 2015). A score of greater than 16 predicts a high probability of death or severe disability, whereas a score of less than 6 predicts a good recovery.
Acute Treatment of Ischemic Stroke
The goal of treatment in the acute phase of ischemic stroke is to salvage brain tissue by restoring blood flow as soon as possible. Emergency management for ischemic stroke consists of assessment of the patient's airway, breathing, and circulation; stabilization of the patient; and complete initial evaluation including neurologic exam, imaging, and laboratory studies within 60 minutes of patient arrival (Sauser et al., 2015). Early intravenous administration of the thrombolytic agent, recombinant tissue plasminogen activator (rt-PA) improves outcomes if given up to 4.5 hours after onset of initial symptoms (Gomis & Davalos, 2014).
Another treatment option is an endovascular surgical procedure called mechanical thrombectomy. In this procedure, the blood clot causing the ischemia is extracted by threading a catheter with a wire-caged device called a stent retriever into the blocked arterial vessel in the brain. The procedure should be done within 6 hours of acute stroke symptoms and only after a patient receives rt-PA. Recent studies show success with thrombectomy up to 8 hours after the onset of stroke symptoms (Jovin et al., 2015).
Secondary Prevention After Ischemic Stroke
After ischemic stroke, there is high risk of recurrent stroke. It is estimated 80% of recurrent strokes might be prevented with dietary modification, exercise, weight control, blood pressure lowering, anticoagulation, antiplatelet therapy, and statin therapy (Davis & Donnan, 2012). According to Davis and Donnan, carotid endarterectomy or carotid-artery stenting is indicated for the treatment of patients with a history of transient ischemic attack (TIA) or nondisabling ischemic stroke who have carotid stenosis. Intervention within 2 weeks after the onset of symptoms is recommended. Insertion of a carotid-artery stent is less invasive than endarterectomy and is associated with a more rapid recovery; however, studies have shown that the risks (death and recurrent stroke within 30 days) are significantly higher with carotid-artery stenting than with carotid endarterectomy (Davis & Donnan, 2012).
Poststroke Rehabilitation
The American Heart Association-American Stroke Association recommends screening for admission to a rehabilitation program as soon as the patient's neurological and medical condition permits. Successful relearning of lost motor and speech functions after stroke is due to cortical plasticity. Studies show increased cortical plasticity in the peri-infarct tissue within a 14- to 60-day period immediately after stroke. This plasticity declines over time so rehabilitative interventions are more effective when started early (Nudo, 2013). According to the National Institute of Neurological Disorders and Stroke (2015), successful rehabilitation depends on:
* Amount of damage to the brain
* Skill on the part of the rehabilitation team
* Supportive social network and cooperation of family and friends
* Timing of rehabilitation-the earlier it begins, the more likely survivors are to regain lost abilities and skills
* Comprehensive care from a team of healthcare specialists including primary care physicians; neurologists; physiatrists; physical, occupational, and speech therapists; nutritionists; and social workers.
Implications for Home Healthcare
Each stroke patient has a different presentation and a distinct path to recovery based on what area of the brain has been affected. The full impact of the stroke may not become apparent until the patient has been home a few weeks. Adequate support from family and caregivers is critical at this time. It is important to ensure that all necessary equipment and support services are in place. The need for physical, occupational, and speech therapy should be carefully assessed. It is also wise to make an early referral to the social worker.
The time frame for functional recovery is difficult to predict; recovery from stroke is an ongoing process that can take weeks to years (Hughes, 2011). According to Kwakkel and Kollen (2013), initial severity of disability and extent of improvement observed within the first weeks poststroke are important indicators of outcomes at 6 months. Their study showed that most motor recovery is almost completed within 10 weeks poststroke. Other studies have shown stroke recovery plateaus 3 to 6 months after onset. Scores on scales assessing severity of neurological deficits, such as the NIHSS are strongly correlated with the activities of daily living outcome at 3 months poststroke (Kong & Lee, 2014). However, Sun et al. (2015) claim functional recovery can occur well after that time period.
Investigators assert there is potential for functional improvement in stroke survivors who exercise. Home-based exercise regimens have been shown to significantly improve strength, mobility, and physical and general recovery (Wang et al., 2015). High-intensity upper and lower limb physical therapy also results in greater improvements in motor function in the poststroke period (Wang et al.). Tai Chi exercises are performed slowly with meditation and can improve gait, balance motor strength, flexibility, reaction time, and coordination (Chen et al., 2015).
Fall Risk
The risk of fall-related fractures is of concern in stroke survivors given their impaired mobility and high risk for developing osteoporosis. Poststroke patients at greatest risk of falling exhibit impaired balance, hemi-neglect, and self-care deficits (Campbell & Matthews, 2010). These patients may benefit from the use of aggressive fall prevention interventions. The Stroke Assessment of Fall Risk is a tool that accurately predicts falls risk (Breisinger et al., 2014). An exercise program for stroke survivors "Step Up to Stop Falls" developed by Jung et al. (2015) includes education regarding fall prevention, physical therapy, and training for muscle strengthening, balance, and flexibility. The program, carried out for 30 minutes per day, five times a week, over a 5-week period, has been effective at improving gait, balance, and fear of falling. According to Subramaniam (2014), video gaming technology can be used as a fall prevention strategy. Investigators tested the use of Nintendo Wii Fit for stroke survivors for 2 hours per day for 5 days with significant improvements in balance and reaction time.
Home modifications for the stroke survivor may be necessary. Examples include 32-inch wide doorways for easy passage of wheelchairs, bathroom grab bars, raised toilet seats, and shower chair. A complete list of home adaptations for the stroke survivor can be found at http://www.strokecenter.org/patients/caregiver-and-patient-resources/home-modifi.
Upper-Extremity Rehabilitation
Up to 85% of stroke survivors experience hemiparesis following stroke. The upper extremity (UE) is usually more involved than the lower extremity (LE), and eventual motor recovery in the UE is less than in the LE. Up to 75% of stroke survivors regain leg function but have limitations in upper-extremity functioning in the poststroke period (Langhorne et al., 2009). A commonly used assessment tool is the upper-extremity Fugl-Meyer Assessment. This tool can give the healthcare provider a sense of the potential for recovery of the UE (Lee et al., 2015). The severity of UE weakness at onset and the timing of the return of movement in the hand are important predictors of eventual motor recovery. The prognosis for return of useful hand function is unfavorable when UE paralysis is complete at stroke onset or grasp strength is not measurable by 4 weeks. There are numerous rehabilitation techniques used to enhance upper limb function. Traditional techniques include constraint-induced movement therapy (Box 1), mirror therapy (Box 2), repetitive task activity, biofeedback, electrical stimulation, and strength training. No one therapeutic technique has proved to be superior to the others regarding motor recovery (Pollock et al., 2014).
Lycra garments and volar splints, designed to produce continuous stretch of muscles and functional position of the upper limb, worn for several hours each day, have rapid splinting and antispastic effects on wrist and fingers in patients with hemiplegia (Gracies et al., 2015). Newer therapeutic techniques are focusing on the neuroplasticity of the cortex. These include use of virtual reality, repetitive transcranial magnetic stimulation (Box 3), transcranial direct current stimulation (tDCS) (Box 4), and robot-assisted arm rehabilitation.
Up to 30% of stroke survivors suffer upper limb spasticity 12 months poststroke (Watkins et al., 2002). Spasticity varies from mild muscle stiffness to severe, painful, and uncontrollable muscle spasms. Some patients suffer disabling pain and permanent contractures. Studies have demonstrated intramuscular botulinum toxin (Botox) injections effectively reduce arm spasticity, contracture, and pain within 12 months (Gracies et al., 2015).
Medication Management
Medications to prevent reoccurrence of stroke and enhance cardiovascular health include anticoagulants or antiplatelet drugs, antihypertensives, and lipid-lowering medication. The home healthcare clinician needs to educate the patient and caregiver regarding proper administration of these medications and possible side effects. (Table 1, Supplemental Digital Content 1, Retrieved from http://links.lww.com/HHN/A35). Pharmacists can exchange child-proof caps on medication vials for easy-open caps. Electronic pillboxes are available that sound an alarm when a medication is due and dispense the exact dose. The home care nurse or caregiver can refill the pillbox each week. Medications can be supplied in liquid form if swallowing difficulty is present. Special swallowing cups, Oralflo or Ezy dose, are available for those with dysphagia.
Dysphagia
More than 50% of patients have dysphagia at the onset of stroke (Martino et al., 2005). Most swallowing problems resolve in the first week, but problems persist in up to 19% of patients (Wirth et al., 2013). There is high risk of aspiration if any two of the following are present: 1) dysphonia; 2) dysarthria; 3) abnormal gag; 4) abnormal volitional cough; 5) cough after swallowing; or 6) voice changes after swallow (Smithard et al., 1997). Videofluoroscopy is used to observe, record, and analyze the swallowing process as patients swallow contrast materials of different sizes and consistencies (Gonzalez-Fernandez et al., 2013). The most feared complication of dysphagia is aspiration pneumonia and up to 50% of stroke survivors develop this complication during the first year, with a mortality rate up to 45% (Smithard et al., 2007). Poststroke patients can have silent episodes of aspiration pneumonia, during which food and/or fluid enters the airway and goes unnoticed because the patient does not cough or show signs of distress during swallowing. Stroke patients should be screened for dysphagia before receiving oral intake. Patients may need maneuvers to direct food away from the weak side, a change in posture to reduce the likelihood of aspiration, oropharyngeal exercises to improve strength of swallowing muscles, and/or a change in the consistency and volume of food in order to improve bolus transit and reduce the likelihood of aspiration (Gonzalez-Fernandez et al., 2013).
Nutrition/Hydration
Causes for reduced food intake and subsequently impaired nutritional status range from dysphagia to functional disability, cognitive dysfunction, and depression. It is important to screen poststroke patients for malnutrition, particularly if weight loss occurs. Patients who are able to eat and are at risk of malnutrition should receive oral nutritional supplements. Clinicians should strive to prescribe only the least thickened liquid required for swallowing safety. Stroke patients with a decreased level of consciousness, severe dysphagia, or severe paresis are at high risk for malnutrition and are likely to benefit from tube feeding.
Skin Breakdown
Patients at highest risk for skin breakdown have (1) dependence in mobility; (2) diabetes; (3) peripheral vascular disease; (4) urinary incontinence; (5) lower body mass index; and (6) end-stage disease (Berlowitz et al., 2001). A valid and reliable pressure ulcer risk assessment tool, such as the Braden Scale can help predict the risk of pressure ulcer development and help clinicians prevent skin breakdown. Preventive interventions include: frequent repositioning, mobilization, turning, proper transfer techniques, use of skin care/incontinence products, and surface-pressure-reducing devices.
Aphasia and Speech Recovery
Aphasia is a devastating consequence of stroke, present in up to 37% of patients. According to Szaflarski et al. (2015), improvement of language performance in patients with chronic aphasia after stroke can be achieved by intensive constraint-induced (CI) therapy. Patients with aphasia often use the communication method that is easiest for them; they gesticulate or make drawings instead of using spoken language. In CI therapy, the patient's "easy" communication strategies are suppressed in favor of only verbal communication. For improving speech and avoiding further nonuse of verbal communication, CI therapy induces aphasic patients to use words that they normally tend to neglect.
Poststroke Depression
Depression is a common yet often unrecognized consequence of stroke, affecting up to 70% of survivors. Untreated poststroke depression leads to a poorer prognosis and increased mortality (Ellis et al., 2010). According to Whyte and Mulsant (2002), stroke survivors have more than a 6-fold higher risk of developing depression compared with age-matched controls. It is vital that screening for depressive symptoms begins during the acute phase and continue at regular intervals during follow-up. Social isolation, withdrawal, and reduced energy are common signs of poststroke depression. These symptoms may be misattributed by the stroke survivor or their caregiver as expected poststroke sequela.
A challenge of screening for depression in the poststroke population is the common communication problem present after the event. A number of instruments to assess depressive symptoms in patients with aphasia are available. These include the Stroke Aphasic Depression Questionnaire-10, the Stroke Aphasic Depression Questionnaire-H10, and the Signs of Depression Scale (van Dijk et al., 2015).
Caregiver Burden
Family caregivers are an essential source of support for stroke survivors transitioning home but their needs for support are often poorly addressed and, as a result, they can experience poor mental and physical health (Tsai et al., 2015). Caregiver burden can contribute to poor rehabilitation outcomes for stroke survivors or threaten the sustainability of patient care at home and is a leading cause of stroke survivor institutionalization (Camak, 2015). Studies have shown that 25% to 46% of caregivers perceive a substantial burden during the first 6 months of caregiving (Tooth et al., 2005) and the average level of the burden decreases by 5 years poststroke (Hung et al., 2012). Depression is especially prevalent in family caregivers of stroke patients with some studies reporting higher depression rates in the caregivers than in the survivors for whom they provide care (Tooth et al.). Family caregivers often ignore their own healthcare needs and can be neglected by healthcare professionals during the stroke recovery process.
The Caregiver Burden Scale is a useful tool to assess subjective burden of persons caring for a stroke survivor (Onega, 2008). Providing assistance and advice about coping strategies and time management, including respite care, may be helpful in reducing the risk of caregiver role strain. A free booklet is available from the Agency for Healthcare Research and Quality entitled "Recovering After a Stroke." It is designed to help stroke survivors and their families get the most out of poststroke rehabilitation. It includes resources for help and information. It is available in English and Spanish and can be found at: http://www.ahrq.gov/. Also fact sheets from the Family Caregiver Alliance are free, easy to download, and provide practical guidance to caregivers on topics. These can be found at: (http://www.caregiver.org/caregiver/jsp/publications.jsp?nodeid=345).
Conclusion
The aging of the population will lead to a significant increase in the prevalence of stroke in the United States. Home healthcare clinicians can assist the survivor during their reintegration into the community environment. It is important for home healthcare clinicians to understand the process from acute event to medical stabilization and from rehabilitation to long-term adaptation. Great strides are being made in the treatment of acute stroke; particularly endovascular interventions. Therapeutic modalities are changing with advanced technology and more patients are surviving the acute stroke event. Home care clinicians can be most effective if they are able to assess the poststroke patient for complications of stroke and assist with the current therapeutic options available.
Box 1. What Is Constraint-Induced Movement Therapy (CIMT)?
Constraint-induced movement therapy (CIMT) forces the use of the affected side by restraining the unaffected side. With CIMT, the therapist constrains the survivor's unaffected arm in a sling. The survivor then uses his or her affected arm repetitively and intensively for active exercises (Corbetta et al., 2015).
Box 2. What Is Mirror Therapy?
Mirror therapy is a rehabilitation intervention in which a mirror is placed between the arms or legs so that the image of the nonaffected limb gives the illusion of normal movement in the affected limb. The uninvolved extremity should be placed in front of the mirror so as to make the reflection look like the contra-lateral limb. Before any exercises, the patient should simply look at the limb in the mirror and focus on engaging in the belief that the mirrored image is in fact his or her contra-lateral limb. Mirror feedback is designed to trick the patient's brain by remapping and transforming neural circuits related to the paralyzed limb. The use of the mirror gives the patient the impression of having two functioning limbs. The concept behind this visual input modality is that it helps patients reeducate, or reintroduce to their altered higher processing neural networks, a normal relationship between a physical movement and sensory feedback. Many studies show that at the end of treatment, mirror therapy improves movement of the affected limb and the ability to carry out daily activities (Arya et al., 2015; Park et al., 2015).
Box 3. What Is Transcranial Magnetic Stimulation (TMS)?
Transcranial magnetic stimulation (TMS) is a noninvasive procedure that utilizes magnetic fields to create electric currents in discrete brain regions. TMS involves discharging a current through a coil of copper wire that is held over the subject's scalp. The current pulse flowing through the coil generates a rapidly fluctuating magnetic field that penetrates the scalp and skull unimpeded, and induces a changing electrical field in the cerebral cortex below the coil. The physiologic response appears to be caused by neuronal depolarization exciting or inhibiting the cortex. The participant feels a "light tap" on the scalp, may feel a twitch of the face muscles, and hears a brief, loud click as the current passing through the coil tightens the copper wire. Participants report that this is not unpleasant. The stimulation of the brain itself is painless (Fernandez et al., 2002; Naeser et al., 2012; Rothwell, 1997). Repetitive transcranial magnetic brain stimulation (rTMS) has been studied as a potential treatment for paralysis, hemispatial visual neglect, and aphasia (Lefraucher, 2006).
Box 4. What Is Transcranial Direct Current Stimulation (tDCS)?
Transcranial direct current stimulation (tDCS) is a form of neurostimulation that uses constant, low current delivered to the brain via electrodes on the scalp. It was originally developed to help patients with brain injuries such as strokes. Tests on healthy adults demonstrate that tDCS can increase cognitive performance on a variety of tasks, depending on the area of the brain being stimulated (Utz et al., 2010). It has been utilized to enhance language and mathematical ability, attention span, problem solving, memory, and coordination. One of the aspects of tDCS is its ability to achieve cortical changes even after the stimulation is ended. The duration of this change depends on the length of stimulation as well as the intensity of stimulation (Blesneag et al., 2015).
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