Rehabilitation Of The Older A... Health Article

Medical Issues During Stroke Rehabilitation

Medical management of the stroke patient goes beyond the acute care period. This is especially true with the recent trend toward earlier discharge from acute care to a rehabilitation facility. The goals during the rehabilitation phase of a stroke patient include (1) ensuring medical stability by implementing secondary stroke prevention measures and controlling risk factors, (2) preventing and treating complications that may increase morbidity and mortality, and (3) promoting neurologic and functional recovery. Ensuring medical stability of a patient demands a thorough review of clinical history, physical examination including a detailed neurologic assessment, laboratory studies, imaging results, and diagnostic testing. Specific treatments should be noted, including use of tissue plasminogen activator or interventional procedures and initiation or discontinuation of medications. Secondary stroke prevention measures, including risk factor modification, pharmacologic management, and surgical management (ie, carotid endarterectomy), should be implemented or confirmed.

Specialized stroke units are associated with better prognosis than general medical units [33]. Effective early management of acute stroke and transient ischemic attack reduces morbidity and mortality and can reduce use of scarce health and social services resources. Stroke-related mortality has decreased in recent years partly because of better risk factor management, the advent of tissue plasminogen activator, and improvement in acute medical management after stroke. Despite this overall reduction in mortality, stroke still remains an important cause of death worldwide. Approximately 20% of first-ever stroke patients die within 30 days. In the first few days, mortality is usually caused by the stroke itself from edema, herniation, or disruption of brainstem centers. Patients who have suffered a stroke remain at an increased risk of recurrent stroke at 30% to 40% within 5 years. An individualized strategy for secondary stroke prevention should be implemented within a maximum of 7 days of acute stroke or transient ischemic attack.

Pneumonia, cardiac disease, and pulmonary embolism are the most frequent causes of death during the first 30 days. Pneumonia may occur in approximately one third of patients, commonly caused by aspiration secondary to dysphagia. All stroke patients should undergo a bedside screening before initiation of oral intake followed by a full bedside swallow study if needed. Cardiac disease after stroke is manifested as myocardial infarction, arrhythmias, or heart failure. Full cardiac work-up should be completed during the acute care of a stroke patient. The incidence of pulmonary embolism after stroke is between 10% and 15%. Its peak is usually during the first week after stroke; initiation of prophylactic measures for deep vein thrombosis should be done as soon as possible. The total duration of prophylaxis is still unknown, because the risk of deep vein thrombosis continues well beyond the first week. Risk factors for deep vein thrombosis should be assessed during the rehabilitation phase and at the time of discharge. It is generally accepted that an ambulation distance of 50 ft per day significantly reduces the risk of deep vein thrombosis after stroke [34]. Contraindications to chemical prophylaxis may warrant mechanical (sequential compression device) or surgical (inferior vena cava filter) interventions.