Section 4 - Management of diagnosed conditions

1. What is a stroke or TIA? ^1,2

• Stroke:
  • occurs when a vessel supplying blood to the brain suddenly becomes blocked (ischaemic stroke) or ruptures and bleeds (haemorrhagic stroke)
  • results in part of the brain dying. Is often fatal
• TIA:
  • occurs when blood supply to the brain is temporarily blocked, which usually fully resolves < 24 hours
  • requires rapid assessment and management to prevent subsequent stroke, with greatest risk within 48 hours
• The symptoms for a stroke and a TIA are the same, however stroke symptoms last > 24 hours and results in brain tissue death (neurological infarction), including:
  • unilateral weakness, clumsiness or numbness
  • speech disturbance; trouble talking or understanding speech
  • difficulty recognising or naming things
  • double vision or sudden loss of vision in one or both eyes
  • sudden loss of balance
• Isolated sensory symptoms are unlikely to be due to Stroke or TIA

2. Diagnosis of a stroke or TIA ^1–3

• Diagnosis is made within 48 hours of onset of stroke symptoms by:
  • history and clinical presentation of neurological symptoms
  • a CT or MRI scan of the brain to detect ischemic cerebral vascular disease
  • an ECG to exclude AF and other cardiac conditions
  • a carotid doppler to exclude atherosclerotic plaque and vessel occlusion
  • an echocardiogram to assess heart function and exclude micro thrombi
• CT angiogram or MRA imaging of the entire vasculature from aortic arch to cerebral vertex improves diagnosis, recognition of stroke aetiology and assessment of prognosis
• A BGL improves specificity as hypoglycaemia can mimic a stroke
• Severity is assessed and recorded using a validated tool. See Resource 1.

3. Management of people post stroke or TIA ^1–3

• The goals of managing stroke or TIA is to prevent recurrent episodes, support the patient to rehabilitate and to maintain an active productive life by:
  • building a therapeutic partnership with patient and family
  • Lifestyle modifications
  • identifying, addressing and the meeting target values of comorbidities in conjunction with Australian cardiovascular disease risk calculator
    • Hypertension; a primary risk factor for first and subsequent stroke
    • Atrial fibrillation; anticoagulants are commenced immediately
    • Diabetes; a risk factor for subsequent strokes
    • Dyslipidaemia; stroke risk reduces within 12 months of commencing lipid therapy
    • Coronary heart disease
    • Heart failure
    • Overweight and obesity (adult)
    • Chronic kidney disease

1. Support patient self-management ^1,2
   • Discuss with patient and family:
     • what a stroke or TIA is, what it entails and how it progresses. See Resource 2.
     • preventing further strokes and TIAs by way of Lifestyle modifications
     • early warning signs for immediate medical attention (and calling 000) by using the acronym FAST:
       • F–Facial weakness
       • A–Arm and/or leg weakness
       • S–Speech difficulty
       • T–Time to act fast
     • the need to monitor blood pressure and blood glucose
     • risk factors i.e. history or family history of vascular disease, hypertension, obesity, dyslipidaemia, physical inactivity, atrial fibrillation, excessive alcohol and smoking
   • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients
2. Social-emotional support ^1,2
   • Depression and Anxiety disorders are common mood disorders post stroke. Consider trial of psychological therapies, relaxation strategies or medicines
   • Assess and discuss the impact of the patient’s function on employment, finances, routines and emotions
   • Encourage and support the patient to:
     • be as independent as is feasible and safe
     • participate in leisure and productive activities
     • re-engage in family and community roles
     • seek medical approval to return driving (if appropriate)
     • access the wider community
     • maintain quality relationships with family and friends, including sexual relationships
   • The Rural Stroke Outreach Service can provide support as needed. See Resource 3.
   • See Social-emotional wellbeing
3. Carer support ¹
   • Caring for a patient after a stroke is a source of stress and burden
   • Carers may experience isolation and abuse if patient becomes violent or agitated
   • Ensure carer is engaged in service coordination
   • Refer carers to support services, including respite, which allows carers to have a break and enables patients to stay in their home longer. See Resource 4.
4. Smoking cessation ^1–3
   • Smoking increases the risk of stroke by narrowing of blood vessels and changing blood dynamics
   • The risk of stroke from smoking disappears five years after giving up cigarettes
   • See Smoking cessation
5. Diet and nutrition ^1–3
   • Dehydration and malnutrition are common after a stroke due to swallowing impairment, immobility and communication difficulty. Refer to a speech therapist to assess for swallowing impairment
   • Refer to a dietitian to assist with malnourished patients and instigate texture modified diets and fluids or supplements
   • Those with hypertension should reduce their salt (sodium) intake to reduce cardiovascular risk
   • Encourage the carer to make preferred fluids and foods available, supervise patient during meals and monitor and document intake
   • Diet and nutrition, high in fruit, vegetables and oily fish reduces the risk of further strokes
6. Alcohol reduction ^1–3
   • Excessive alcohol consumption increases the risk of subsequent strokes
   • Refer to Mental Health Alcohol and Other Drugs Service (MHAODs) to support Alcohol reduction.
7. Physical activity ^1–3
   • Cardiovascular deconditioning occurs as a result of immobility after a stroke
   • Physical activity and sleep has a protective effect against stroke by improving blood pressure and reducing cardiovascular risk
   • Once strength returns encourage up to 40 minutes of moderate physical activity every day. Structured exercise classes are more beneficial
8. Falls prevention ^1,2
   • The majority of patients experience a fall after a stroke
   • Screen for individual falls risk. See Resource 5.
   • Review medicines and minimise sedatives especially benzodiazepines
   • Refer to a physiotherapist and a balance and strength group
   • Refer to an occupational therapist to assess for home modifications required to minimise slips and falls hazards
9. Rehabilitation^1,2
   • Undertaken to maximise a person’s functionality
   • A plan is developed by the discharging hospital after a comprehensive assessment
   • The goal oriented plan is tailored and documented by the physiotherapist and implemented in consultation with the patient and carer by local clinicians
   • Rehabilitation starts < 48 hours post stroke and involves as much scheduled therapy as tolerated daily
   • Encourage patients and carers to continue rehabilitative interventions while the patient is at home. See Table 2.

10. Oral hygiene ^1,3
    • Physical weakness, dysphasia, lack of coordination and altered cognition can lead to Dental caries and periodontal disease
    • Provide patient and carer with oral hygiene management and education
11. Preventing contracture ^1,3
    • Contracture is the result of impaired and infrequent range of motion movement of a joint and muscle due to severe weakness post stroke
    • Early rehabilitation including active motor training or electrical stimulation (TENS) can prevent contractures. See Table 2.
12. Pain management ^1,3
    • Shoulder pain is common post stroke. Management involves shoulder strapping, TENS, active motor training and education to prevent trauma
    • Central post stroke pain (CPSP) is a burning pricking sensation made worse by touch, water or movement and is managed by medicines or the specialist pain management team. See Persistent pain
13. Oedema ^1,3
    • Weak and immobile patients risk their feet and hands swelling
    • Management includes pressure garments, TENS, continuous passive movement and elevation of limbs when resting. See Table 2.
14. Fatigue ^1,3
    • Fatigue unrelated to exertion and not relieved by rest, occurs in most patients post stroke
    • Patients should avoid sedatives and excessive alcohol
    • Arrange therapy for periods of the day when the patient is most alert
15. Incontinence ^1,3
    • Incontinence is common post stroke due to poor muscle tone and cognitive and perceptual impairment
    • Refer to a continence nurse advisor for assessment and to offer strategies such as:
      • patient and carer support to develop, document, implement and monitor bladder and bowel continence. See Resource 6.
      • avoiding indwelling catheters except with acute urinary retention
      • trialling anticholinergics for urge incontinence
      • trialling a voiding regimen to assist with bladder retraining
      • employing a bowel habit retraining regimen to identify the type and timing of dietary intake to exploit the gastro-colic reflex to defecate after food
      • using continence aids e.g. urinary pads, pants, uridomes
    • If continence is not achieved refer patient and carer to Medical Aids Subsidy Scheme (MASS) and Continence Aids Payment Scheme (CAPS). See Resource 7.
16. Emotional and personality changes ^1–4
    • Irritability, aggression, apathy, disinhibition, impulsivity, lack of insight and rapid mood changes (e.g. crying to laughing) is common after a stroke
    • These changes can contribute to significant carer burden and stress
    • Provide patient and carer with Resource 8. to help manage challenging behaviours
17. Deep vein thrombosis (DVT) and pulmonary embolism (PE) ^1,3
    • Reduced mobility, stroke severity, age, dehydration and delayed rehabilitation interventions is associated with nearly 30% of deaths post stroke from DVT and PE
    • Prevention focuses on:
      • rehabilitative interventions. See Table 2.
      • adequate hydration
      • antiplatelet therapy^. See 4. Medicines in people post stroke or TIA
    • Antithrombotic stockings are not recommended for the prevention of DVT and PE
18. Pressure area care ^1,4
    • Age, stroke severity, immobility, incontinence, nutritional status and diabetes are contributing factors to localised tissue damage due to pressure, shearing or friction
    • Assess patients for pressure ulcer risk using The Waterlow Pressure Ulcer Risk Assessment Tool. See Resource 9.
    • Management of pressure ulcers involves:
      • addressing contributing factors above
      • attentive skin and wound care
      • use of pressure beds, mattresses or cushions
      • regular mobilisation and repositioning
19. Obstructive sleep apnoea (OSA) ³
    • OSA occurs in up to 80% of patients following a stroke
    • Weight reduction and CPAP therapy are the accepted effective treatments for OSA
    • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 10.
20. Palliative care ¹
    • Palliative care should be considered in all patients where risk of significant deterioration is high
    • Anticipate grief and loss from time of diagnosis, and the need for counselling
    • Perform Advance Care Planning so the patient can retain control over their care and future decision making
    • Refer eligible patients to the Commonwealth Home Support Programme (CHSP) and Medical Aid Subsidy Scheme (MASS). See Resources 7. and 11.

4. Medicines for people post stroke or TIA ^1,3

• Continuation or initiation of hormone replacement therapy is not recommended
• Oestrogen-containing contraceptive pill is contraindicated in women who have had a stroke or TIA
• Seek specialist advice for medicine use after haemorrhagic stroke.

1. Prevention of recurrent stroke or other vascular events ^1–3
   • Recommended medicines post stroke or TIA are:
     • antihypertensives regardless of Hypertension history
     • antiplatelets after a non-cardioembolic ischaemic stroke or TIA
     • statins regardless of Dyslipidaemia history
     • anticoagulants if comorbid Atrial fibrillation.

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. The NIH Stroke Scale/Score (NIHSS) for quantifying stroke severity
2. The Stroke Foundation website
3. The Rural Stroke Outreach Service
4. Carers Queensland and MyCare respite information
5. Queensland Stay On Your Feet falls prevention resources
6. Continence Foundation of Australia bladder and bowel diary
7. The Medical Aids Subsidy Scheme (MASS) and Continence Aids Payment Scheme (CAPS) and the Australian Government bladder and bowel resources
8. Stroke Association emotional changes after stroke resources and the Stroke Foundation Emotional and personality changes after stroke factsheet
9. The Waterlow Pressure Ulcer Risk Assessment Tool
10. The Epworth Sleepiness Scale and STOP-Bang questionnaire
11. The Commonwealth Home Support Programme (CHSP)