Stroke Follow Up Dr Ali Ali Consultant Geriatrician & Stroke Physician Sheffield Teaching Hospitals

Objectives Why stroke follow up is required. National drivers. What it should consist of. Local practice – what’s changing.

Why we need stroke follow up Stroke patients and their carers experience a diversity of problems that often affect patients for the rest of their lives. Specialist support should be accessible FOR THE REST OF THEIR LIVES.

Why we need stroke follow up Nearly 800 stroke patients 1 – 5 years after their stroke: Half had > 1 unmet needs. 54% needed more information. 38% emotional problems. 52% fatigue. 45% poor concentration. 43% declining memory. 52% unable to work / exercise. 31% expenses increased.

Why we need stroke follow up 137 reviews at 6 months. Total 464 unmet needs.

National Drivers NSF 2001 Standard 5: Stroke – Long term support: –Following a stroke, any patient reporting a significant disability at six months should be re- assessed and offered further targeted rehabilitation if this can help recover further function.

National Drivers QM 14 – assessment & review –People suffering stroke, should be offered a review of health and social care needs typically at 6 weeks and again at 6 months after leaving hospital. –This should be followed by an annual health and social care check, with clear pathway back to specialist review

National Drivers Commissioning in relation to the long-term consequences of stroke: –CCG’s should commission a system that provides routine follow-up of patients 6 months post discharge and annually after a stroke. –Offer reassessment and where appropriate further treatment for patients no longer receiving rehabilitation.

National Drivers

Service provision in Sheffield Stroke Discharge 6 week review 3 months CSS 6 month review pilot Stroke6 month review Discharge 6 week review 3 months CSS Annual review Ongoing CSS Beech Hill

What should be reviewed Secondary vascular risk Medicines management / compliance Physical impairment –Weakness, mobility, falls, spasticity, swallow, pain, continence, vision, communication, fatigue Psychological complications –Depression, anxiety, emotionalism, personality change, cognition Social integration –Employment, benefits, travel / driving Carer support

Secondary vascular risk Smoking cessation, alcohol management, diet Exercise management (30mins x 5 weekly) BP < 130/80(unless DM <120/80) Cholesterol < 4.0(LDL < 2.0) Diabetes(Hba1c < 7.5) Anti-platelets Clopidogrel or Aspirin & Persantin AF then considered for anticoagulation

Blood pressure Reduction of 3/3 results in 15 – 20% RR reduction at 1 year. Reduction of 12/5 results in 42% RR reduction at 1 year. Remains poorly controlled in up to 40% of patients after their stroke. Cholesterol Each reduction in LDL of 1 mmol/L results in RR risk reduction in major vascular events of 22% at one year. More intensive (Atorvastatin 40-80mg) vs less intensive (Simvastatin 40-80mg) assoc. with further 15% RR reduction. Approx. 40% patients do not reach target after stroke. Secondary vascular risk

Atrial fibrillation Anticoagulation reduces stroke risk by 2/3. Only 1/3 of patients with AF admitted with stroke are on OAC. INR sub-therapeutic in the majority (~70%). Diabetes No hard data to support the role of tightly controlled glucose in future stroke prevention. More aggressive BP control is important. Metformin is the only oral hypoglycaemic that has data to suggest protection against macrovascular complications (heart attack / stroke). Secondary vascular risk

Physical impairments/problems Falls – 40% suffer falls within the first year after stroke. Falls clinics, bone health. Spasticity – 30% patients following stroke. Can occur early or late. Often require multi-disciplinary input (meds, botox, splints, analgesia). Pain – nearly 75% all stroke patients suffer some sort of pain after stoke. Hemiplegic shoulder – up to 70% of those with hemiplegia. Central post stroke pain – up to 12% patients. Oedema, headache etc.

Continence – urinary incontinence affects 25% patients at discharge and 15% at 1 year. MDT input – drugs, bowels, function, aids. Faecal incontinence – 10% at 1 year. Fatigue – 10% feel tired all the time. At 1 year 50% of patients report this as their main problem. May require multiple lifestyle / medication modifications. Physical impairments/problems

Psychological complications Depression 20 – 50% Anxiety20 – 30%1 year Emotionalism10% Depression and anxiety screened for at discharge and 6 weeks. Not emotionalism, personality change. Cognitive decline & post stroke dementia New onset dementia after stroke ~ 7% Stroke contributing to worsening dementia ~ 30% Cognitive screens on discharge and at 6 weeks.

Social integration Employment – 25% strokes occur in patients of working age Fatigue, depressions, cognition. Different strokes website Sheffield – re-ablement service – Jane Hammond Driving – only a third of stroke patients who were previously able to drive return to driving at 6 months following a stroke. Generally patients require information. DVLA / direct.gov.uk / stroke association. Finances / benefits – general information required. Stroke association website.

6 week review

6 month review - Pilot September to December 2013 (3 months). 233 strokes discharged 6 months earlier. Telephone consultation using modified GM-SAT from Adult Rehabilitation Centre (ARC) – Nether Edge Hospital. Clahrc-gm.nihr.ac.uk/stroke/GMSAT Performed by nurse practitioners. 6 hrs training on use of tool prior to initiation. Real time data collection for audit purposes.

6 month review - Pilot

112 / 233 were able to complete assessment (48%) 6 month review - Pilot Reasons for non-participation in telephone review ~10% unable to complete due to cognition, aphasia, hearing impairment. - Face to face assessments may be required in these cases.

6 month review - Pilot Total unmet needs – 300: CategoryNumber medicines 7 BP 46 anti-thrombotic therapy 6 Cholesterol 47 diabetes 13 alcohol 3 smoking 13 diet and healthy eating 14 exercise 12 Vision 8 hearing 6 communication 5 swallowing 6 pain 9 continence 14 ADLs 3 falls 7 mood 20 anxiety 12 emotionalism 4 personality 7 memory 19 driving 3 hobbies 1 work 3 money/benefits 6 Sexuality 4 Carer needs 2

Onward referrals – data awaited. Evidence from GM-SAT in Greater Manchester: 6 month review - Pilot

Patient feedback: –‘Great to talk’ –‘Felt supported’ –‘Lifeline, information backup’ –‘Good to talk to someone who knows about stroke’ –‘Repetitive, GP already monitors’ –‘Don’t know who’s coming or going’ 6 month review - Pilot

Staff feedback: I learned a lotIt has made me more confident I felt that the patients were very appreciative of the review It was an interesting project It gave me personal job satisfactionIt was worthwhile It was a bit stressful at first, but then it was fine It was good, it was a positive experience It made me more aware of the need for our patients to have a medical assessment whilst at ARC It was an eye opener, - how many patients had not had either their blood pressure or cholesterol checked since their stroke It was enlighteningI was sceptical about the review being on the phone but it was fine

Longer term support Ideally patients should receive specialised therapy (CSS) for as long as they are exhibit rehab potential. Patients who have been discharged from the stroke service should be able to access services again should the need arise. Develop and enhance maintenance interventions (exercise programmes, peer support)

Summary The needs of stroke patients are varied and can change with time. Evidence to suggest this need is currently unmet. National drivers exist to incorporate routine review of needs into service provision. There exists a big opportunity to improve the lives of patients suffering stroke.

Thank you