Literature review is systematically written presentation on given area of study or topic (Burns and Saunders, 2005), and this paper is a systematic review, investigating the effects of post-stroke rehabilitation with special reference to older adults (?65). The Stroke Association [TSA] (2010b) defined stroke as disturbance to the brain’s blood supply resulting in damage(s) to brain’s cells/tissues (Figure1).
The rationale (see appendix1) is partly because National Audit Office [NAO] (2005p.4) stated that, over 110,000 strokes and 20,000 transient ischaemic attacks [TIA] occurs annually in England. Additionally, over 300,000 people are living with stroke related disabilities and, over 75% of all stroke fatalities occur in older adults aged ?65 (DH, 2007p.13). Various policy documents also informed the choice of topic (appendix2). However, little evidence exists on the effectiveness of post-stroke rehabilitation in relation to this adult-cohort.
Outcome parameters includes mortality rate, level of disabilities, mobility, speed of recovery, and Barthel Index [BI] scores on activities of daily living [ADL]. ADL is colloquially called activity of living [AL] in relation to nursing process however ADL is used in accordance with BI scale used in specialist stroke units [SSU] in England (SNPlacement, 2009).
There was paucity of studies on post-stroke rehabilitation in older adults though there is wealth of information on outcomes of different care structures. However, little evidential research exists that clarifies combination or individual rehabilitation pathways that better suited older adults. However, Stroke Unit Trialist’ Collaborations [SUTC] in 1993, 2001, and 2007 concluded that post-stroke fatality was lowest in Trusts with greater number of SSU care thus, nurses with advanced knowledge on stroke.
This write-up included only studies used in Cochrane collaborative reviews and meta-analysis, and similar collaborations. Consequently, reducing the risks associated with validity, reliability, generalizability, bias, and ethics often encountered when reviewing research studies (PHRU, 2006). Systematic approach, and various search engines were utilised for the literature searches (appendix3). The writer systematically organised the nine chosen research articles/studies (appendix4) into groups of three within three chapters:
Chapter One: Specialist Stroke Units Versus General/Neurological Wards.
Chapter Two: Specialist Stroke Units Versus Specialist Stroke Unit with Early Supported Discharge.
Chapter Three: Efficacy of Specialist Stroke Unit Care on Post-Stroke Rehabilitation: A Way Forward for Older Adults?
Informed consent (NMC, 2008) was, obtained from gatekeepers (appendix4) prior to visiting an SSU in Southern England for empirical fact-finding in March 2011. The term “the writer” refers to the author of this review to avoid ambiguity of terminology (Polit and Beck, 2010).
Figure 1: Damages to Brain Due to Stroke
(Source: NAO, 2010p.6)
SPECIALIST STROKE UNITS VERSUS GENERAL/NEUROLOGICAL WARDS
According to RCN (2007) rehabilitation is a holistic person-centred, action-based process which entails individual’s ability to learn adaptive ways of dealing with changes in life circumstances due to incapacitation resulting from conditions such as stroke. It is the process by which stroke survivors learn new skills and or relearn skills that are lost or rendered dormant due to damages to areas of the brain. For example, hand to mouth co-ordination in order to feed oneself, and relearning mobility with the aid of walking devices. Indeed, paralysis to one-side of the body often leads to survivors needing to learn how to perform ADL with one-side of the body. The primary characteristics of evidence-based rehabilitative regime entails repetitive practice of specific skills in a carefully coordinated, and well-focused manner similar to those utilised when learning a new skill such as swimming or riding so as to achieve mastery or best possible level allowed by ones condition. Post-stroke rehabilitation for most survivors can be a lifetime activity. Moreover, very few cases of rehabilitation are time-limited.
The key political influence on rehabilitation process for older adults is the National Service Framework (DH, 2001) which emphasises the importance of rehabilitation and the availability of rehabilitation services. It has had huge impacts on the rehabilitation service provision and treatment for older people in the UK since 2002. Rehabilitation can be a lifetime activity moreover very few cases of rehabilitation are time-limited.
Over the years, stroke patients were cared for in general/neurological wards (GW). However, during the past two decades, specialist stroke units (SSU) have emerged as a preferred treatment option for stroke patients mainly due to evidence from various meta-analytic studies (SUTC, 1999; 2001; 2007). The results suggest that SSU care has beneficial effects by reducing post-stroke mortality, need for institutionalization, and improving ADL and speed of recovery. Indeed, SUTC (2007) published meta-analysis with 6936 participants from 31 trials were analyzed to assess whether SSU care was consistently associated with improved outcomes. The authors concluded that patients who received SSU care were more likely to survival, remain independent, and living at home 12 months post-stroke accident. Langhorne et al., (2002) proposed that the basic characteristics of SSU are stroke specialist staff including nurses; dedicated units; multidisciplinary team [MDT] care, and systematic diagnostic evaluation; acute monitoring and treatment; early post-stroke mobilization; and early immediate start of rehabilitation (cited in Indredavik, 2008p.1). However, not all SSU have these detailed characteristics thus for the purpose of this analysis, irrespective of structure, all studies with units similar to defined characteristics are given the blanket term of SSU.
Kalra et al., (2000Study1) in their prospective RCT study compared the efficacy of SSU with stroke team or domiciliary care using 457 acute-stroke patients (48% women) with an average age of 76 years (appendix1). During the 12 month follow-up, the data suggests that there was low mortality or institutionalisation for patients treated on SSU compared to patients who were treated by the GW stroke team (21/152 [14%] versus 45/149 [30%]; p<0.001) or domiciliary stroke care (21/152 [14%] 34/144 [24%]; p<0.03) stroke. The results suggest that SSU were more effective than GW with stroke team or domiciliary stroke care in reducing mortality, dependency and, institutionalisation post-stroke. This was similar to the findings in the prospective comparative cohort study by Glader et al., (2001study2) which is a two years follow-up study that investigated rate of stroke-case-fatality, and patients’ level of independent assistance for primary ADL before and post-stroke (appendix4). The authors found that with regard to stroke-case-fatality there was 30.2% of SSU and 34.0% of GW treated patients. There was 25.4% and 29.1% respectively for rate of case fatalities for SSU and GW patients who were independent in primary ADL prior to stroke (OR, 1.18; CI, 1.06 TO 1.30). The 3376 participants that completed the questionnaire had mean age of 74.3 years (SD, 10.6) with 1.4 years in age difference between SSU and GW treated patients. More SSU treated patients were still living in their own homes, and most maintained independence with primary ADL. Indeed, following case adjustment for differences in case mix, SSU treatment remained an independent predictor for patients retaining independence of assistance with ADL two years post-stroke. Conversely, with regards to patients dependence on assistance for primary ADL defined by BI, 354 patients that required assistance with primary ADL had an average age of 78.5 years (SD=9.8). SSU and GW treated patients had average age of 79.0 versus 77.6 years respectively with p-value of p=0.19 which is not statistically significant. Indeed, patients cared for in SSU had statistically significant less pain compared to GW patients, this statistical significant difference remained after adjustment for differences in case mix prior to stroke (OR, 0.75; CI, 0.61 to 0.91).
Kalra et al., (2000study1) in their own study suggested that the reduced mortality or institutionalisation amongst SSU patients was attributed to reduction in post-stroke mortality. Moreover, the benefits of SSU care was further emphasized because, the proportion of survivors without severe disability at 12 months follow-up was statistically significantly higher for SSU patients compared with GW stroke team (129/152 [85%] versus 99/149 [66%]; p<0.001) or domiciliary stroke care (129/152 [85%]) versus (102/144[71%]; p=0.002). These differences were present at both 3 and 6 months follow-ups post-stroke. Therefore, the results further suggest that SSU are more effective than GW with stroke team or domiciliary stroke care in reducing mortality, dependency and, institutionalisation post-stroke. Indeed, the ADL barthel score (15-20) was best for SSU patients at 3 months follow-up (82%) compared to 70% of patients in GW with stroke team and, 74% of patients in the domiciliary stroke care.
Zhu et al., (2009study3) in a recent comparative retrospective cohort study on the impact of SSU on length of hospital stay and case fatality further demonstrated the efficacy of SSU to reduce stroke fatality and speed-up recovery. They found that for all stroke patients, the adjusted odds on length of hospital stay (>7days) was reduced by 22% (p<0.0001) on SSU compared to GW. Congestive heart, dementia, and peptic ulcer disease were the co-morbidities (p<0.05) that predicted duration of hospital stay. Indeed, SSU care significantly reduced overall in-hospital case fatality (adjusted OR, 0.70, p<0.0001). The authors observed that reduction in case fatality for SSU patients was similar to the 5% mortality reduction observed in the follow-up of a similar study by Candelise et al., (2007).
In summary, the studies by Kalra et al., (2000); Glader et al., (2001); and Zhu et al., (2009) supports the efficacy that SSU care characterised by admission to an SSU with stroke-directed nursing care, physio and occupational therapy, and assessment by a stroke neurologist is beneficial and the preferred post-stroke care pathway. These results were similar to those from SUTC (2002; 2007) reviews/ meta-analysis of SSU. Indeed, Jarman et al., (2004) research on whether there was a link between reduced in-hospital mortality rates, and acute SSU and early Computerised Tomography scan suggests that acute-SSU were associated with >10% lower odds of death.
The proposal here is that, nursing process model of care which entails assessment; care-planning; implementation; evaluation with assessment; and evaluation as a continuous process until discharge and beyond (Holland et al., 2004) were beneficial in reducing stroke fatality; institutionalization or faster improvements in patients ability to be more independent in ADL for SSU patients compared to GW patients post-stroke. Results from a National Sentinel Audit (NSA) of stoke for UK except Scotland (Rudd et al., 2005) arrived at similar conclusions. Additionally, the beneficial effects of SSU compared to GW can be conceptualised in terms of specialist stroke, rehabilitation nurses’ expertise thus superior clinical judgement (Tanner, 2006). Indeed, the 24/7 characteristic of clinical nursing allows nurses to get to know the patient as an individual thus creating the unique bond that enable nurses to care, based on empirical knowledge of the patient instead of fitting rehabilitation models to the patient based on written medical judgement alone (McCaffery et al., 2000).
If rehabilitation is a continuous process that could last a life-time, when does rehabilitation commence post-stroke Hypothetically speaking, what happens after patients are discharged from GW or SSU, and does rehabilitative nursing care continue within the community Are patients better off in the community once stable; are the beneficial effects of SSU due to the 24/7 stroke specialist nursing care given to patients within a structured, MDT staffed, purpose-built stroke unit/ward?
From an economic point of view, patients occupying hospital beds post-stroke with each bed costing over ?400 per night is quite expensive (SNPlacement, 2009) especially when such patient is stable and can continue receiving rehabilitative nursing care within the community preferable in their own home. Having established that SSU have better patient outcome compared to GW, in view of the economic implication, the next chapter will investigate SSU with early supported discharge as a possible solution.
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