Prevention and Other Special ManageDlent Issues in the Postacute Care of the Geriatric Stroke Patient Rehabilitation of older stroke patients does not take place isolated from social and medical problems. Nurses and internists are crucial members of the interdisciplinary team, maintaining health and preventing long- and short-term complications in the stroke survivor. This review describes our research interests and clinical approaches to some of the special medical and nursing needs of the population, using prevention as a model for caring for these chronically ill patients and their families.
This article was supported in part by the Andrus Foundation and by a Merck/AFAR Fellowship in Geriatric Clinical Pharmacology (E.L.S.).
Eugenia L. Siegler, MD Divisions of Geriatric Medicine, University of Pennsylvania School of Medicine and Philadelphia VA Medical Center Philadelphia, PA
Fay W. Whitney, RN, PhD, FAAN University of Pennsylvania School of Nursing Philadelphia, PA
To be successful, the rehabilitation of geriatric stroke patients must incorporate the patients' medical and nursing needs into the plans of care. During inpatient rehabilitation, medical care is complex; stroke patients usually have multiple medical comorbidities, and management must be both anticipatory and therapeutic. Nurses, like other professionals, focus on retraining for functional integrity, but in doing so, they monitor total care, prevent further disability, and enable the stroke survivor and family to gain and maintain access to services and resources that will promote optimal recovery and future health. After discharge from inpatient rehabilitation, function is best maintained by continuing the interdisciplinary management that was initiated in the hospital. The complex management of noninstitutionalized stroke survivors is difficult because communication among providers is often fragmented, mechanisms for unifying plans of care are rare, and the reimbursement system often dictates the type and amount of care that is delivered. This article will discuss some of these special topics related to the management of older stroke patients, beginning with medical care and ending with nursing concerns. NeuroRehabil1993; 3(1):1-11
Copyright © 1993 by Andover Medical.
2
NEUROREHABILITATION / WINTER 1993
MEDICAL MANAGEMENT Medical management of the geriatric stroke patient would seem as varied as the complex interplay of comorbidities in the postacute geriatric stroke population. Traditionally, medical management has focused on emergencies and the appropriate interventions. But treatment of emergencies, once they are recognized, does not differ substantially from the acute setting. The internist on a rehabilitation ward must minimize the likelihood that complications will occur and anticipate the future needs of the impaired stroke patient. One way to understand the patients' needs is to view medical care as essentially preventive. Classically, prevention has been divided into three levels that are related to the disease state (see Table 1). A fourth level has been added in this discussion, because of its relevance to management of frail, older individuals. Primary prevention aims to avert disease, fur example, by administering a vaccine to prevent pneumococcal pneumonia. Secondary prevention aims to abort the development of end-organ damage after disease has developed. An example might be treatment of hypertension to prevent end-stage renal disese, or screening for curable cancers. Tertiary prevention refers to the prevention or minimization of subsequent damage once pathology occurs. In the stroke patient, tertiary prevention would involve not only reduction of risk of subsequent stroke, but also prevention of deconditioning and urinary tract infections, fur example. Qy,aternary prevention, as defined in this article, aims to reduce the likelihood of provider-initiated errors-adverse drug reactions, for example. Tertiary and quaternary prevention can be viewed as short-term in perspective;
primary and secondary prevention, on the other hand, take a more long-term view. Why can medical management of the postacute geriatric stroke patient be viewed as one of both long-term and short-term prevention? Clinicians can begin to focus on the long term because the patient who is transferred to inpatient rehabilitation services after a stroke is both "stable" and "captive." The neurologic deficit is no longer evolving, and the brain has begun to heal. The long stays (often 3 weeks) typical of postacute stroke patients allow the provider to work daily with a patient for a length of time that is luxurious by acute care standards. Patients are receptive to counseling, vaccination, and disease screening when they are in a setting that is promoting functional recovery. The clinician must practice short-term prevention, as well. Rehabilitation's physical and emotional stresses have physiologic consequences, and one must never assume that medical problems that have been stable, even for months or years, will remain so during rehabilitation. Add to this the potential for development of new conditionspressure ulcers, thromboembolic disease, or depression, for example-and it becomes clear why physicians' notes in rehabilitation charts often seem to concentrate as much on medical as physiatric issues. Although the need for long-term prevention during inpatient rehabilitation has received scant attention in the literature, short-term preventive needs have been documented. 1•2 Maintaining both short- and long-term perspectives when providing medical care for the elderly postacute stroke patient is a great challenge, however. Caution about the patient must not overwhelm appropriate planning for the future.
Table 1. Levels of Prevention in Rehabilitation of Stroke Patients. Level
Definition
Example
Tertiary
Prevention of disease Early detection and treatment of disease before adverse consequences occur Limitation of damage once illness has occurred
Qy,aternary
Prevention of iatrogenic complications
Pneumococcal and tetanus vaccination Cancer screening Hypertension treatment "Cardiac precautions" Carotid endarterectomy Medication review
Primary Secondary
Prevention and Other Special Management Issues
PREVENTION IN THE ACUTE SETTING While this article concentrates on the postacute setting, prevention should begin the moment the stroke occurs; minimization of central nervous system (CNS) damage is a classic example of tertiary prevention. Unfortunately, few interventions can alter the pathology caused by cerebrovascular accident. Careful supportive management includes prevention of hypotension, hypoxia, and hyperglycemia, as all have been shown to worsen outcome after cerebral insult. 3 Although none is currently routinely given, many agents that minimize ischemia are under investigation, and administration of anti platelet agents such as aspirin or ticlopidine for tertiary prevention is the norm. 3 - 5 Prevention of stroke-induced sequelae also begins in the acute setting. Some authors suggest that patients should be monitored for at least 24 hours acutely poststroke; the literature has documented that stroke patients have increased risk for myocardial infarction and ventricular arrhythmias. 6- 8 Subcutaneous heparin administration (in nonhemorrhagic strokes) has been demonstrated to prevent deep venous thrombosis. 9, 10 In addition, therapies to minimize dehydration, deconditioning, and pressure sore development should all be initiated upon the patient's admission to the hospital.
POSTACUTE PREVENTIONTERTIARY AND QUATERNARY After transfer to the rehabilitation ward, postacute medical assessment begins with a review of the records of the acute stay to determine (1) the extent of neurological damage, (2) the effectiveness of the preventive measures that were instituted prior to transfer to the rehabilitation facility, and (3) comorbidities and the impact that they have had on the patient. As the focus shifts from acute care to rehabilitation, short-term medical management expands to include prevention or minimization of complications due to rehabilitation therapy itsel£ Table 2 lists some of the com-
3
monest of these medical complications encountered in this population. What follows are approaches to some of these problems.
Assessment and Treatment of Heart Disease Stroke patients are usually assessed by history and physical examination, to screen out those who have unstable or severe cardiac disease before admission to inpatient rehabilitation units. Nonetheless, patients can, and do, have cardiac complications during rehabilitation. II - 13 The ability to predict who will become ill might allow clinicians to develop interventions to prevent complications. Screening for cardiac disease in patients who are functionally impaired is difficult. They cannot perform standard stress tests, and specially modified devices may not give accurate information. The vascular surgery literature (whose subjects are similarly unable to do exercise tests, yet are at risk for perioperative complications) can be considered a model for study of this problem. This literature has investigated alternative methods, such as ambulatory monitoring for silent ishchemia or dipyridamole-thallium testing, and it appears that the latter does have utility in stratifYing patients according to risk. 14 While the literature describing peri-operative risk should be studied for its methodology, it is not clear that rehabilitation patients can be managed using formulae derived from these articles. The Table 2.
Acute Medical Problems Commonly Encountered in Older Postacute Stroke Patients.
Adverse drug reactions Cardiac complications Deconditioning Dehydration and electrolyte abnormalities Difficulties with blood pressure or glucose control Falls and orthopedic injuries Neurologic events (especially extension of the original stroke) Pneumonia Pressure sores Psychiatric illnesses (depression, anxiety disorders) Thromboembolic events (DVT, PE) Urinary Tract Infections
4
NEUROREHABILITATION / WINTER 1993
positive predictive value of these tests, that is, the percentage of patients with an abnormal test who are at risk for complications, depends on both the accuracy of the test and the likelihood of complications in the rehabilitation population as a whole. Since the stress of rehabilitation is not comparable to that of major surgery, and the complication rates are relatively low in comparison, the positive predictive value of screening tests is also likely to be low for rehabilitation patients. II How should cardiac disease be managed in these patients? Once again, prevention is the key. Physiatrists must familiarize themselves with cardiac medications and become comfortable making dosage adjustments as a patient's functional status changes. Rehabilitation personnel should talk with the patient's internist or cardiologist before rehabilitation begins and determine (1) baseline data, such as physical examination, weight, electrocardiogram, and other diagnostic studies, such as echocardiogram, (2) the need for cardiac precautions, and how they will be carried out-this must be done in consultation with the physical and occupational therapists, and (3) a therapeutic plan that takes into account which symptoms are chronic and expected, which are serious, and how they should be managed. Ideally, the consultant should continue to observe the patients throughout their rehabilitation. Nursing's involvement is essential; care plans should incorporate appropriate assessment strategies (e.g., daily weights, lung exams for patients with a history of congestive heart failure).
Prevention of Thromboembolic Complications Work by McCarthy 9 and Gelmers lO has documented that subcutaneous "minihep" prophylaxis reduces the risk of deep venous thrombosis (DVT) after stroke. Heparin doses of both 5000 units every 12 hours and 5000 units every 8 hours have reduced the incidence of DVTs. The lower dose, however, was used in a study that screened for DVTs by physical examination. 10 Despite the rapid adoption of heparin prophylaxis, DVTs and pulmonary emboli (PEs) still occur. In the absence of good guidelines, the clinician must use his or her own judgment regarding
length of heparin prophylaxis, use of alternative or additional methods such as pneumatic compression devices, and appropriate means of screening for DVT. A review of thromboembolic disease and stroke was recently published by the American Academy of Physical Medicine and Rehabilitation. 15 Accurate diagnosis ofDVTs is difficult. A recent review by Kelley I6 describes one approach to the patient with clinically suspected thromboembolic disease. The hallmark of DVT, asymmetric leg swelling, can result from any number of pathologies,I7 and DVTs can also be present in the stroke patient without any clinical suspicion. I8 Some have recommended routinely performing noninvasive testing in this population to look for DVTs that remain clinically silent. 18, This recommendation does not take into account the (1) the risk of anticoagulation therapy in patients who may have a history of falls or a vascular dementia, and (2) a reduced baseline prevalence of DVT (and hence a lower positive predictive value for the noninvasive studies) in populations receiving heparin prophylaxis during their acute stay. Further study is needed.
Prevention of Dehydration Elderly stroke patients are at risk for dehydration. Even in patients who are found to have no dysphagia, intake is often restricted during the first few days after a stroke, while aspiration risk is being assessed. Healthy elderly in general have a diminished sense of thirst 19 and a decreased ability to concentrate urine, when compared to younger patients. 20 In addition, stroke patients are at risk for dehydration because of altered mental status, ADL dysfunction,21 multiple chronic diseases, or multiple medications. 22 Dehydration may be difficult to recognize. It is important to remember that hyponatremic and hypernatremic forms of dehydration present differently. Hyponatremic dehydration is usually accompanied by diminution in skin turgor and blood pressure, and a concomitant elevation in pulse; hypernatremic dehydration, because all body compartments share the fluid loss, may not demonstrate perturbations in vital signs. 23 Clinicians can prevent dehydration by (1) providing
Prevention and Other Special Management Issues
adequate access to fluids, (2) ensuring that those fluids are consumed, recording intakes and outputs, if necessary, and (3) anticipating and replacing extra losses that might occur with fever, diarrhea, or large, exudative wounds such as pressure sores.
Prevention of Adverse Drug Reactions Adverse drug reactions are only one of a series of potential drug-related problems that a patient can experience. 24 Although the incidence of adverse drug reactions increases with age, recent studies have shown that the risk of adverse drug reactions is related to the number of drugs taken, rather than to age itsel£25.26 It is likely that reducing the number of medications will reduce a patient's risk of ADR. If less time is needed to dispense and monitor drug interactions, rehabilitation nurses can spend more time working with patients and families to maximize learning strategies that will improve the transition from the rehabilitation setting to home. Clinicians, however, should not be therapeutic nihilists, ignoring medical problems that could be treated. Rather, as in the rest of rehabilitation, selection of drugs should be based on optimization of function. Drugs designed to ameliorate symptoms of major illnesses like coronary artery disease, chronic obstructive pulmonary disease, or depression should not be spared. Only when the risk of adverse reaction exceeds the minimal gain provided by a medication should the drug be withheld. That threshold may be reached more easily in the elderly. When a stroke patient undergoes rehabilitation, both admission and interval team discussions offer excellent opportunities to reevaluate medications. Clinicians should ask: Are the drug doses correct, given the patient's age, weight, and renal and hepatic function? Are all of the drugs that were started when the patient first developed the stroke still necessary? How many drugs are being used to treat side effects of other drugs? Are there substitutions that can be made in favor of drugs that have fewer side effects in
5
general, and that will be less detrimental to continence, cognitive function, or mobility, in particular?27 What functional gains have resulted from the introduction of recent medications?
POSTACUTE PREVENTIONPRIMARY AND SECONDARY Inpatient rehabilitation seeks to prepare the stroke survivor to live with a disability. Primary and secondary prevention should be included in the long-term goals. Table 3 lists the types of l0l!-g-term prevention that can be undertaken in the inpatient rehabilitation setting. The reader is referred to reviews 28.29 regarding timing of primary and secondary preventive strategies. Table 3. Long-Term Preventive Measures Possible in the Postacute Setting. Vaccination Influenza Pneumococcal pneumonia Tetanus Screening Alcohol and other substance abuse Breast cancer (examination w or wio mammography) Cholesterol Dental Hearing loss Opthalmologic Pelvic examination and Pap smears Podiatric Prostate cancer Stool occult blood In appropriate risk groups: HIV PPD VDRL Hepatitis Counseling Chemical Dependency Dietary Obesity Sexuality Smoking Intensive Medical Care Diabetes Hypertension Hypercholesterolemia
6
NEUROREHABILITATION / WINfER 1993
"Preventive Care Guidelines"28 describes in great detail the evidence for effectiveness of these interventions in the general population; no data are available for the geriatric stroke population in particular. In the rehabilitation setting, vaccination, screening physical examination, and counseling are all easily performed. Diagnostic testing such as mammography may be less feasible in some settings because oflimited access to technology or difficulties with reimbursement.
NURSING MANAGEMENT IN THE REHABILITATION SETTING Every stroke survivor, regardless of his or her strengths and deficits, leaves the acute care setting changed. Social roles, family responsibilities, and physical and functional capacity are drastically realigned by the stroke's sudden onset and consequences. As the stroke survivor moves to the rehabilitation phase, nurses take on a subtler, but no less important, role than the active, life-saving one in the immediate time period following the acute admission. As part of an interdisciplinary team that includes the stroke survivor and family, nurses focus on nutrition, drug and symptom monitoring, and bowel and bladder training, while other team members work on mobility, psychological adjustment, speech, use of hands and arms, social problems, and medical complications or conditions. More important, the nurse is often the main manager of care. Rehabilitation nurses have 24hour contact with the stroke survivor and/or family, playa pivotal role in coordinating services, and maintain an orientation toward prevention and recovery. Working with all team members, they reinforce therapies taught and practiced in therapy sessions, monitor medical regimens throughout the length of stay, help families and stroke patients to interpret what plans have been made for discharge, and lay plans for coordinated follow-up. Nursing efforts are aimed at all levels of prevention. For example, primary prevention may take the form of administering vaccines; secondary prevention may lie in giving minidose heparin
to avoid emboli or maintaining a boweVbladder regimen to prevent skin breakdown; tertiary prevention might be treatment of a pressure ulcer to prevent progression and promote healing, and quaternary prevention includes training new staff to assist in transfers in order to prevent accidents. During the rehabilitation stay, nurses help assess family support systems, provide education, and help family members follow through to contact needed community services in collaboration with the social work department. Continuity of the team's efforts during the working day is required on "off hours" when nurses are the most readily available providers. The coordinating nature of the nurse's work provides the continuity needed in an interdisciplinary milieu to ensure that the stroke survivor and family begin the road to recovery as involved, active members. A detailed discussion of nursing techniques for the postacute stroke patient is beyond the scope of this review, but is available in textbooks. 30,34
NURSING MANAGEMENT IN THE COMMUNITY Of the more than 8 million functionally dependent elderly at risk for using long-term care facilities (formal or informal)31,32 one in five are stroke survivors.33 More than 62% return to their homes for care. 30 Home therapies continue in some cases, usually as long as measurable improvement can be documented. Nursing care is provided through visiting nurse services, individual nursing consultants, and case managers. 30 Nursing prevention focuses on problems related to translocation and potential failure to ensure and maintain recovery once patients are home. 34 Nurses serve as the main care managers in the community, and they play multiple roles in maintaining health and preventing functional decline.
Providing Direct, Skilled Nursing Care Activities of daily living (ADL) include major areas of nursing concern: feeding, bathing, dressing and grooming, toileting, and physical ambulation. 35 In community-based care, the instrumental activities of daily living (IADL)35 are equally
Prevention and Other Special Management Issues
important for both the stroke survivor and the caregiver. These higher levels of functioning are harder to assess and do not always present as problems until the home visit is made. For example, intake of adequate amounts of nutrients to hydrate, heal, and maintain organ integrity is a major nursing focus. Nursing management includes (1) monitoring weight, skin integrity, mental status, hematocrit, and hydration; (2) determining who is shopping and cooking, and how safe those activities are made; and (3) helping families arrange for appropriate food services (i.e., Meals on Wheels), and financial and nutritional guidance. One needs to be aware of the role food and eating have in the culture of the home, and the impact of having a disabled person at the dining table. To complicate the picture, eating can be the nidus for a great deal of family disharmony because of its social meaning. Inappropriate food preparation can be the subtlest form of abuse, both psychological and physical, and poor voluntary intake can be the earliest hint of intended suicide in the depressed person. Similar patterns of concerns should be addressed by the nurse in the home for each ADL and IADL.
Monitoring and Assessing Medical Problems Nurses make house calls, and often in lieu of physicians, monitor the chronic medical problems in this population. A synergistic physician/nurse relationship is essential in the community, and here a collaborative, trusting, and respectful relationship must be established if it is to serve the stroke survivor well. The assessment skills of the nurse, coupled with nursing knowledge of the physiologic responses seen in chronically ill people, are the cornerstone of detecting problems and responding appropriately. l
This article was supported in part by the Andrus Foundation and by a Merck/AFAR Fellowship in Geriatric Clinical Pharmacology (E.L.S.).
Eugenia L. Siegler, MD Divisions of Geriatric Medicine, University of Pennsylvania School of Medicine and Philadelphia VA Medical Center Philadelphia, PA
Fay W. Whitney, RN, PhD, FAAN University of Pennsylvania School of Nursing Philadelphia, PA
To be successful, the rehabilitation of geriatric stroke patients must incorporate the patients' medical and nursing needs into the plans of care. During inpatient rehabilitation, medical care is complex; stroke patients usually have multiple medical comorbidities, and management must be both anticipatory and therapeutic. Nurses, like other professionals, focus on retraining for functional integrity, but in doing so, they monitor total care, prevent further disability, and enable the stroke survivor and family to gain and maintain access to services and resources that will promote optimal recovery and future health. After discharge from inpatient rehabilitation, function is best maintained by continuing the interdisciplinary management that was initiated in the hospital. The complex management of noninstitutionalized stroke survivors is difficult because communication among providers is often fragmented, mechanisms for unifying plans of care are rare, and the reimbursement system often dictates the type and amount of care that is delivered. This article will discuss some of these special topics related to the management of older stroke patients, beginning with medical care and ending with nursing concerns. NeuroRehabil1993; 3(1):1-11
Copyright © 1993 by Andover Medical.
2
NEUROREHABILITATION / WINTER 1993
MEDICAL MANAGEMENT Medical management of the geriatric stroke patient would seem as varied as the complex interplay of comorbidities in the postacute geriatric stroke population. Traditionally, medical management has focused on emergencies and the appropriate interventions. But treatment of emergencies, once they are recognized, does not differ substantially from the acute setting. The internist on a rehabilitation ward must minimize the likelihood that complications will occur and anticipate the future needs of the impaired stroke patient. One way to understand the patients' needs is to view medical care as essentially preventive. Classically, prevention has been divided into three levels that are related to the disease state (see Table 1). A fourth level has been added in this discussion, because of its relevance to management of frail, older individuals. Primary prevention aims to avert disease, fur example, by administering a vaccine to prevent pneumococcal pneumonia. Secondary prevention aims to abort the development of end-organ damage after disease has developed. An example might be treatment of hypertension to prevent end-stage renal disese, or screening for curable cancers. Tertiary prevention refers to the prevention or minimization of subsequent damage once pathology occurs. In the stroke patient, tertiary prevention would involve not only reduction of risk of subsequent stroke, but also prevention of deconditioning and urinary tract infections, fur example. Qy,aternary prevention, as defined in this article, aims to reduce the likelihood of provider-initiated errors-adverse drug reactions, for example. Tertiary and quaternary prevention can be viewed as short-term in perspective;
primary and secondary prevention, on the other hand, take a more long-term view. Why can medical management of the postacute geriatric stroke patient be viewed as one of both long-term and short-term prevention? Clinicians can begin to focus on the long term because the patient who is transferred to inpatient rehabilitation services after a stroke is both "stable" and "captive." The neurologic deficit is no longer evolving, and the brain has begun to heal. The long stays (often 3 weeks) typical of postacute stroke patients allow the provider to work daily with a patient for a length of time that is luxurious by acute care standards. Patients are receptive to counseling, vaccination, and disease screening when they are in a setting that is promoting functional recovery. The clinician must practice short-term prevention, as well. Rehabilitation's physical and emotional stresses have physiologic consequences, and one must never assume that medical problems that have been stable, even for months or years, will remain so during rehabilitation. Add to this the potential for development of new conditionspressure ulcers, thromboembolic disease, or depression, for example-and it becomes clear why physicians' notes in rehabilitation charts often seem to concentrate as much on medical as physiatric issues. Although the need for long-term prevention during inpatient rehabilitation has received scant attention in the literature, short-term preventive needs have been documented. 1•2 Maintaining both short- and long-term perspectives when providing medical care for the elderly postacute stroke patient is a great challenge, however. Caution about the patient must not overwhelm appropriate planning for the future.
Table 1. Levels of Prevention in Rehabilitation of Stroke Patients. Level
Definition
Example
Tertiary
Prevention of disease Early detection and treatment of disease before adverse consequences occur Limitation of damage once illness has occurred
Qy,aternary
Prevention of iatrogenic complications
Pneumococcal and tetanus vaccination Cancer screening Hypertension treatment "Cardiac precautions" Carotid endarterectomy Medication review
Primary Secondary
Prevention and Other Special Management Issues
PREVENTION IN THE ACUTE SETTING While this article concentrates on the postacute setting, prevention should begin the moment the stroke occurs; minimization of central nervous system (CNS) damage is a classic example of tertiary prevention. Unfortunately, few interventions can alter the pathology caused by cerebrovascular accident. Careful supportive management includes prevention of hypotension, hypoxia, and hyperglycemia, as all have been shown to worsen outcome after cerebral insult. 3 Although none is currently routinely given, many agents that minimize ischemia are under investigation, and administration of anti platelet agents such as aspirin or ticlopidine for tertiary prevention is the norm. 3 - 5 Prevention of stroke-induced sequelae also begins in the acute setting. Some authors suggest that patients should be monitored for at least 24 hours acutely poststroke; the literature has documented that stroke patients have increased risk for myocardial infarction and ventricular arrhythmias. 6- 8 Subcutaneous heparin administration (in nonhemorrhagic strokes) has been demonstrated to prevent deep venous thrombosis. 9, 10 In addition, therapies to minimize dehydration, deconditioning, and pressure sore development should all be initiated upon the patient's admission to the hospital.
POSTACUTE PREVENTIONTERTIARY AND QUATERNARY After transfer to the rehabilitation ward, postacute medical assessment begins with a review of the records of the acute stay to determine (1) the extent of neurological damage, (2) the effectiveness of the preventive measures that were instituted prior to transfer to the rehabilitation facility, and (3) comorbidities and the impact that they have had on the patient. As the focus shifts from acute care to rehabilitation, short-term medical management expands to include prevention or minimization of complications due to rehabilitation therapy itsel£ Table 2 lists some of the com-
3
monest of these medical complications encountered in this population. What follows are approaches to some of these problems.
Assessment and Treatment of Heart Disease Stroke patients are usually assessed by history and physical examination, to screen out those who have unstable or severe cardiac disease before admission to inpatient rehabilitation units. Nonetheless, patients can, and do, have cardiac complications during rehabilitation. II - 13 The ability to predict who will become ill might allow clinicians to develop interventions to prevent complications. Screening for cardiac disease in patients who are functionally impaired is difficult. They cannot perform standard stress tests, and specially modified devices may not give accurate information. The vascular surgery literature (whose subjects are similarly unable to do exercise tests, yet are at risk for perioperative complications) can be considered a model for study of this problem. This literature has investigated alternative methods, such as ambulatory monitoring for silent ishchemia or dipyridamole-thallium testing, and it appears that the latter does have utility in stratifYing patients according to risk. 14 While the literature describing peri-operative risk should be studied for its methodology, it is not clear that rehabilitation patients can be managed using formulae derived from these articles. The Table 2.
Acute Medical Problems Commonly Encountered in Older Postacute Stroke Patients.
Adverse drug reactions Cardiac complications Deconditioning Dehydration and electrolyte abnormalities Difficulties with blood pressure or glucose control Falls and orthopedic injuries Neurologic events (especially extension of the original stroke) Pneumonia Pressure sores Psychiatric illnesses (depression, anxiety disorders) Thromboembolic events (DVT, PE) Urinary Tract Infections
4
NEUROREHABILITATION / WINTER 1993
positive predictive value of these tests, that is, the percentage of patients with an abnormal test who are at risk for complications, depends on both the accuracy of the test and the likelihood of complications in the rehabilitation population as a whole. Since the stress of rehabilitation is not comparable to that of major surgery, and the complication rates are relatively low in comparison, the positive predictive value of screening tests is also likely to be low for rehabilitation patients. II How should cardiac disease be managed in these patients? Once again, prevention is the key. Physiatrists must familiarize themselves with cardiac medications and become comfortable making dosage adjustments as a patient's functional status changes. Rehabilitation personnel should talk with the patient's internist or cardiologist before rehabilitation begins and determine (1) baseline data, such as physical examination, weight, electrocardiogram, and other diagnostic studies, such as echocardiogram, (2) the need for cardiac precautions, and how they will be carried out-this must be done in consultation with the physical and occupational therapists, and (3) a therapeutic plan that takes into account which symptoms are chronic and expected, which are serious, and how they should be managed. Ideally, the consultant should continue to observe the patients throughout their rehabilitation. Nursing's involvement is essential; care plans should incorporate appropriate assessment strategies (e.g., daily weights, lung exams for patients with a history of congestive heart failure).
Prevention of Thromboembolic Complications Work by McCarthy 9 and Gelmers lO has documented that subcutaneous "minihep" prophylaxis reduces the risk of deep venous thrombosis (DVT) after stroke. Heparin doses of both 5000 units every 12 hours and 5000 units every 8 hours have reduced the incidence of DVTs. The lower dose, however, was used in a study that screened for DVTs by physical examination. 10 Despite the rapid adoption of heparin prophylaxis, DVTs and pulmonary emboli (PEs) still occur. In the absence of good guidelines, the clinician must use his or her own judgment regarding
length of heparin prophylaxis, use of alternative or additional methods such as pneumatic compression devices, and appropriate means of screening for DVT. A review of thromboembolic disease and stroke was recently published by the American Academy of Physical Medicine and Rehabilitation. 15 Accurate diagnosis ofDVTs is difficult. A recent review by Kelley I6 describes one approach to the patient with clinically suspected thromboembolic disease. The hallmark of DVT, asymmetric leg swelling, can result from any number of pathologies,I7 and DVTs can also be present in the stroke patient without any clinical suspicion. I8 Some have recommended routinely performing noninvasive testing in this population to look for DVTs that remain clinically silent. 18, This recommendation does not take into account the (1) the risk of anticoagulation therapy in patients who may have a history of falls or a vascular dementia, and (2) a reduced baseline prevalence of DVT (and hence a lower positive predictive value for the noninvasive studies) in populations receiving heparin prophylaxis during their acute stay. Further study is needed.
Prevention of Dehydration Elderly stroke patients are at risk for dehydration. Even in patients who are found to have no dysphagia, intake is often restricted during the first few days after a stroke, while aspiration risk is being assessed. Healthy elderly in general have a diminished sense of thirst 19 and a decreased ability to concentrate urine, when compared to younger patients. 20 In addition, stroke patients are at risk for dehydration because of altered mental status, ADL dysfunction,21 multiple chronic diseases, or multiple medications. 22 Dehydration may be difficult to recognize. It is important to remember that hyponatremic and hypernatremic forms of dehydration present differently. Hyponatremic dehydration is usually accompanied by diminution in skin turgor and blood pressure, and a concomitant elevation in pulse; hypernatremic dehydration, because all body compartments share the fluid loss, may not demonstrate perturbations in vital signs. 23 Clinicians can prevent dehydration by (1) providing
Prevention and Other Special Management Issues
adequate access to fluids, (2) ensuring that those fluids are consumed, recording intakes and outputs, if necessary, and (3) anticipating and replacing extra losses that might occur with fever, diarrhea, or large, exudative wounds such as pressure sores.
Prevention of Adverse Drug Reactions Adverse drug reactions are only one of a series of potential drug-related problems that a patient can experience. 24 Although the incidence of adverse drug reactions increases with age, recent studies have shown that the risk of adverse drug reactions is related to the number of drugs taken, rather than to age itsel£25.26 It is likely that reducing the number of medications will reduce a patient's risk of ADR. If less time is needed to dispense and monitor drug interactions, rehabilitation nurses can spend more time working with patients and families to maximize learning strategies that will improve the transition from the rehabilitation setting to home. Clinicians, however, should not be therapeutic nihilists, ignoring medical problems that could be treated. Rather, as in the rest of rehabilitation, selection of drugs should be based on optimization of function. Drugs designed to ameliorate symptoms of major illnesses like coronary artery disease, chronic obstructive pulmonary disease, or depression should not be spared. Only when the risk of adverse reaction exceeds the minimal gain provided by a medication should the drug be withheld. That threshold may be reached more easily in the elderly. When a stroke patient undergoes rehabilitation, both admission and interval team discussions offer excellent opportunities to reevaluate medications. Clinicians should ask: Are the drug doses correct, given the patient's age, weight, and renal and hepatic function? Are all of the drugs that were started when the patient first developed the stroke still necessary? How many drugs are being used to treat side effects of other drugs? Are there substitutions that can be made in favor of drugs that have fewer side effects in
5
general, and that will be less detrimental to continence, cognitive function, or mobility, in particular?27 What functional gains have resulted from the introduction of recent medications?
POSTACUTE PREVENTIONPRIMARY AND SECONDARY Inpatient rehabilitation seeks to prepare the stroke survivor to live with a disability. Primary and secondary prevention should be included in the long-term goals. Table 3 lists the types of l0l!-g-term prevention that can be undertaken in the inpatient rehabilitation setting. The reader is referred to reviews 28.29 regarding timing of primary and secondary preventive strategies. Table 3. Long-Term Preventive Measures Possible in the Postacute Setting. Vaccination Influenza Pneumococcal pneumonia Tetanus Screening Alcohol and other substance abuse Breast cancer (examination w or wio mammography) Cholesterol Dental Hearing loss Opthalmologic Pelvic examination and Pap smears Podiatric Prostate cancer Stool occult blood In appropriate risk groups: HIV PPD VDRL Hepatitis Counseling Chemical Dependency Dietary Obesity Sexuality Smoking Intensive Medical Care Diabetes Hypertension Hypercholesterolemia
6
NEUROREHABILITATION / WINfER 1993
"Preventive Care Guidelines"28 describes in great detail the evidence for effectiveness of these interventions in the general population; no data are available for the geriatric stroke population in particular. In the rehabilitation setting, vaccination, screening physical examination, and counseling are all easily performed. Diagnostic testing such as mammography may be less feasible in some settings because oflimited access to technology or difficulties with reimbursement.
NURSING MANAGEMENT IN THE REHABILITATION SETTING Every stroke survivor, regardless of his or her strengths and deficits, leaves the acute care setting changed. Social roles, family responsibilities, and physical and functional capacity are drastically realigned by the stroke's sudden onset and consequences. As the stroke survivor moves to the rehabilitation phase, nurses take on a subtler, but no less important, role than the active, life-saving one in the immediate time period following the acute admission. As part of an interdisciplinary team that includes the stroke survivor and family, nurses focus on nutrition, drug and symptom monitoring, and bowel and bladder training, while other team members work on mobility, psychological adjustment, speech, use of hands and arms, social problems, and medical complications or conditions. More important, the nurse is often the main manager of care. Rehabilitation nurses have 24hour contact with the stroke survivor and/or family, playa pivotal role in coordinating services, and maintain an orientation toward prevention and recovery. Working with all team members, they reinforce therapies taught and practiced in therapy sessions, monitor medical regimens throughout the length of stay, help families and stroke patients to interpret what plans have been made for discharge, and lay plans for coordinated follow-up. Nursing efforts are aimed at all levels of prevention. For example, primary prevention may take the form of administering vaccines; secondary prevention may lie in giving minidose heparin
to avoid emboli or maintaining a boweVbladder regimen to prevent skin breakdown; tertiary prevention might be treatment of a pressure ulcer to prevent progression and promote healing, and quaternary prevention includes training new staff to assist in transfers in order to prevent accidents. During the rehabilitation stay, nurses help assess family support systems, provide education, and help family members follow through to contact needed community services in collaboration with the social work department. Continuity of the team's efforts during the working day is required on "off hours" when nurses are the most readily available providers. The coordinating nature of the nurse's work provides the continuity needed in an interdisciplinary milieu to ensure that the stroke survivor and family begin the road to recovery as involved, active members. A detailed discussion of nursing techniques for the postacute stroke patient is beyond the scope of this review, but is available in textbooks. 30,34
NURSING MANAGEMENT IN THE COMMUNITY Of the more than 8 million functionally dependent elderly at risk for using long-term care facilities (formal or informal)31,32 one in five are stroke survivors.33 More than 62% return to their homes for care. 30 Home therapies continue in some cases, usually as long as measurable improvement can be documented. Nursing care is provided through visiting nurse services, individual nursing consultants, and case managers. 30 Nursing prevention focuses on problems related to translocation and potential failure to ensure and maintain recovery once patients are home. 34 Nurses serve as the main care managers in the community, and they play multiple roles in maintaining health and preventing functional decline.
Providing Direct, Skilled Nursing Care Activities of daily living (ADL) include major areas of nursing concern: feeding, bathing, dressing and grooming, toileting, and physical ambulation. 35 In community-based care, the instrumental activities of daily living (IADL)35 are equally
Prevention and Other Special Management Issues
important for both the stroke survivor and the caregiver. These higher levels of functioning are harder to assess and do not always present as problems until the home visit is made. For example, intake of adequate amounts of nutrients to hydrate, heal, and maintain organ integrity is a major nursing focus. Nursing management includes (1) monitoring weight, skin integrity, mental status, hematocrit, and hydration; (2) determining who is shopping and cooking, and how safe those activities are made; and (3) helping families arrange for appropriate food services (i.e., Meals on Wheels), and financial and nutritional guidance. One needs to be aware of the role food and eating have in the culture of the home, and the impact of having a disabled person at the dining table. To complicate the picture, eating can be the nidus for a great deal of family disharmony because of its social meaning. Inappropriate food preparation can be the subtlest form of abuse, both psychological and physical, and poor voluntary intake can be the earliest hint of intended suicide in the depressed person. Similar patterns of concerns should be addressed by the nurse in the home for each ADL and IADL.
Monitoring and Assessing Medical Problems Nurses make house calls, and often in lieu of physicians, monitor the chronic medical problems in this population. A synergistic physician/nurse relationship is essential in the community, and here a collaborative, trusting, and respectful relationship must be established if it is to serve the stroke survivor well. The assessment skills of the nurse, coupled with nursing knowledge of the physiologic responses seen in chronically ill people, are the cornerstone of detecting problems and responding appropriately. l
