Age-Related Health Care Adelaide and Meath Hospital Dublin

http://indigo.ie/~arhc

Age-Related Health CareAdelaide and Meath Hospital Dublin

incorporating the National Children’s Hospital

Dept of Medical GerontologyTrinity College Dublin


Stroke in Ireland

•Kills more people than breast cancer, lung cancer and bowel cancer combined


Stroke is…...

• a focal or global neurological deficit• of presumed vascular origin• lasting more than 24 hours• or causing death within 24 hours


A TIA is…...

• a focal or global neurological deficit• of presumed vascular origin• lasting less than 24 hours


Stroke burden

• 9,250 acute strokes/year• 25% die in first year• 30,000 with residual disability

– 48% hemiparesis– 22% cannot walk– 24-53% need help in ADLs– 12-18% aphasic


Impact

• Personal: – “..more impact than my wedding, or the

birth of my first child”

• 2nd most expensive illness• Most common cause of acquired

physical disability• Most expensive single DRG medically


Biggest advance in Stroke Care

Not, not, not

Thrombolysis

Stroke Units


Stroke Units• Reduce death, disability,

institutionalization• Reduce death and disability by 25%• NNT

– 33 to save a death– 20 to regain independence– 20 to prevent institutionalize

• Save 2-11 days hospital• If this were a tablet………..

Cochrane 2005


Stroke Units• Direct care of a specialist in stroke care

and interdisciplinary team• Clearly defined continuum of care• Geographical unit preferable• CT/MRI on site• Main base general hospital• Take all patients referred


Vascular surgeon

Radiologist

Public Health

Geriatrician

RehabilitationistNeurologist

GP

PHN

Person with stroke

Carer

Hospital nurses

Physiotherapy

Occupational therapySpeech therapySocial workPsychology

Clinical nutrition


3 tasks•Was it a stroke?•What did the stroke cause?

–Cognitive impairment–Dysphagia–Gait disorder–Sensory–Inattention

•What caused the stroke?



Vulnerable Tissue:

Work Fast!


Brain attack• ABC• Diagnosis• Stabilize

• BP, O2, Temp, glucose

• Swallow• Positioning• Stroke Service


History

• Patient• Collateral/witness


Cincinnati Prehospital Stroke Scale

• Facial droop• Arm drift• Speech


4 level neuro Ax• End of the bed• Alertness (GCS), language, cognition• Classical neuro examination

– Cranial nn– PTCS– Reflexes

• ‘Parietal’ signs– Inattention/neglect– Agnosia– Apraxia


Differential

• Tumour• Meningitis/encephalitis• Seizure• Epilepsy• Migraine• Metabolic causes• MS


TIA’s• 38% 'true' TIA• 10% had migraine• 9% had faints• 9% had possible TIAs, 9% had 'funny turns’• 6% had epilepsy• 6% had vertigo• 0.8% had hypoglycaemia• 0.4% had brain tumours


ABCD of TIA treatment• 10% stroke risk within one week: 30% if high

score• ABCD Score

– Age - >60 = 1– Blood Pressure - Syst > 140 or Diast > 90 = 1– Clinical

• Motor = 2• Speech = 1

– Duration• > 1 hour = 2• 10-59 min = 1

Rothwell, Lancet 2005


Urgent investigations

• Glucose• FBC• U + E• ECG


Urgent CT

• Head injury• Suspicion sub-arachnoid

– Headache– Meningism

• Neurological deterioration• Possibility of thrombolysis


BP

• Ischaemic stroke - dangerous to treat if not > 220/140

• Sub-arachnoid - neurology advice - nimodipine and normal blood pressure


Stabilize

• Keep euglycaemic• Antipyretics for pyrexia

• O2: avoid hypoxia

• NPO until swallow assessed• Early advice on positioning


First 12 hours

• Stroke Service• Book CTB (within 48 hours)• Book other tests as appropriate:

– Carotid dopplers– Holter monitor– ECHO– ……..


Pharmacological

• Anti-platelets– NSA, Asantin R, clopidrogel


Strategies: who can benefit?

• 150-250 strokes yearly in a Dublin hospital– Stroke Unit 100%– Aspirin 80%– Neuroprotective strategies 90%– Thrombolysis 5%


iv Thrombolysis

• 3 Streptokinase: terminated• European r-TPA: no overall change• NINDS r-TPA: modest improvement


NINDS rt-PA regime

• Within 3 hours (mean 90 mins)• 0.9 mg/kg (max 90mg)• 10% bolus• 90% over one hour• Systolic <185, Diastolic <110• BP managed by algorithm


Contra-indications

• PUD• Recent surgery• Recent arterial puncture• Abnormal coagulation• BP not manageable to 185/110• No sign of established stroke on CT - NB

difficult


Cochrane review

• Excess of deaths – 23% thrombolysis– 18% controls

• Reduction death and disability– 45% thrombolysis– 51% controls

• Treat 16 patients to avoid one death/disability


The real world....Chiu, Stroke 1998

• 6% receive rt-PA• Those who don't:

– Time 37%– ICH 22%– Minor/rapidly resolving symptoms 19%– Nonstroke Dx 12%


Acute treatment

• Aspirin• LMW Heparin• Thrombolysis


Neuroprotective

• Nimodipine• Glutamate antagonists• Na channel antagonists/glycine

antagonists• Opioid antagonists• Antoxidants/Free radical scavengers


Management issues

• Reducing delay• Stroke unit approach• CT access and expertise (?

telemedicine)• Neuro-ICU



Unmet needs post-stroke

• 38% no personal contact GP• 46% attended DH• 79% had health concerns• 64% required Rx advice• 18% had resumed smoking

Martin Scot Med 2002


6 Months after discharge

• 58% in the community• 87% had seen GP• 48% reviewed in OPD

Crowe IMJ 2002


Remediable risk factors

• Smoking• Alcohol• Exercise• Obesity, DM• Psychosocial

• BP• Lipids• Homocysteine• Infections• Inflammation,

thrombosis

Sem Vasc Med 2002, 2, 229-445


Fibrinogen

•Adds to likelihood of event•Reduce inflammation?

– Flu vaccine– Reduces stroke hospitalization by 16%

Nichol NEJM 3 April 2003


Healthy lifestyle is anticoagulant and anti-

inflammatory

• Weight loss, exercise• Reduce vascular inflammation and

insulin resistance

• So, stop smoking, keep walking!

Esposito, JAMA, April 9, 2003


• Antithrombotics

• BP reduction

• Cholesterol

• Diet and DM

• Exercise/rehabilitation

• Forget smoking/Flu jabs


Antiplatelets

• 25% reduction in all events• CHD• Stroke• VTE• Revascularization


BP reduction

• Diuretics and ACE-Inhibitor• Primary prevention trials suggest drug

equivalence• Cave postural symptoms!


Statins

• All patients with stroke• Fire and forget• Highest effective dose• Simvastatin 40• Pravastatin 40• Atorvostatin 10



Carotid endarterectomy

• Carotid territory stroke TIA in last 6 months

• >70% stenosis (about 5% of our patients)

• NNT 15 to prevent death or disability over 2-6 years

• Surgically fit patients• Surgeons with <6% complication rates


• Antithrombotics

• BP reduction

• Cholesterol

• Diet and DM

• Exercise/rehabilitation

• Forget smoking/Flu jabs

Documents

Age-Related Health Care Adelaide and Meath Hospital Dublin