General Appearance:

Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.

Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow

Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.

General Observations:

Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.

Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even

Cognitive Testing

MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.

Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.

General Appearance:

Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.

Height: 184cms
Weight: 98kg (which has remained constant)

Please move your cursor over Mr Scott as if you were examining him. You must complete the examination before you go on.

General Appearance:

Mrs Scott looks well. She is reactive but has restricted mobility.

Height: 164cms
Weight: 76kg (which has remained constant)

Please move your cursor over Mrs Scott as if you were examining her. You must complete the examination before you go on.

Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.

General Appearance:

No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.

Height: 160cms
Weight: 70kgs
Temperature: 37.1

Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.

General Appearance:

General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.

Height: 178cms
Weight: 65kg (has remained constant)

Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.

General Appearance:

Mrs Browning looks happy and healthy.

Height: 178cms
Weight: 65kg (has remained constant)

Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.

General Appearance:

Mrs Browning appears well. She is well presented, and is in high spirits.

Height: 178cms
Weight: 66kg (an increase of 1 kg)

Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.

General Appearance:

Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.

Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)

Please move your cursor over Mrs Browning as if you were examining her. You must complete the examination before you go on.

References

Campbell M. Communication with Aboriginal patients in the pre-hospital environment. Australian Journal of Emergency Care 1995;2(2):24-27.

McGrath P, Patton MS., Holewa HG and Rayner RD. The importance of the ‘family meeting’ in health care communication with Indigenous people: findings from an Australian study. Australian Journal of Primary Health 2006; 12(1):56-64

Video resources

There are some fantastic materials freely available that can assist your learning:

1. Fiona Stanley Hospital Medical Education Unit Delirium Simulation Training Video

The project (click here) was developed locally using Commonwealth Department of Health monies in 2016. The target group is all WA hospital based health workers, including JMOs and Allied Health. All material was field tested and results were presented in a national postgraduate medical conference. It provides you with a great learning resource (23mins46).

2. University of Dundee – Clinical Skills – Delirium Assessment

This video (click here) provides a great (brief; only 7min03) introduction to assessment of an acutely confused person.

Presentations

Delirium – a guide for nurses – Dr Massarotto

Dementia Delirium in Surgical Patients – Dr Harding

Delirium Module Test

Delirium Module Test Answers

Bent S et al. (2006) Saw palmetto for benign prostatic hypertrophy, New England Journal of Medicine. 2006;354:557-566 URL: https://content.nejm.org/https://content.nejm.o/

Quiz Feedback

Continence Module Test Answers

Presentations

CONTINENCE – Notes modified from Dr Kate Scott 

URINARY INCONTINENCE – Tutorial by M Donaldson

Constipation Teaching for Interns – Dr Massarotto

“First Steps in Management of Urinary Incontinence in Community Dwelling Older People – A clinical practice guideline 2005”

“Second Steps in Management of Urinary Incontinence in Community Dwelling Older People – A clinical practice guideline for secondary level clinicians”

Developed by Queensland Health and downloadable from https://www.health.qld.gov.au/mass/resourcescont.asp

Student Training in Dementia (STriDe) Final Report

Beer, C and Watson, N. Student Training in Dementia (report). WA Centre for Health and Ageing, University of Western Australia, 2009.

Dementia Lecture

Listen to Dementia Lecture

Dementia Lecture Supporting Materials

Dementia Lecture Slides

The Dementia Lecture was supported by the WA Dementia Training Study Centre.

Student Guidelines for Diagnosis of Dementia

Student Guidelines

What if everything causes dementia?

Lecture by Dr Kenneth Rockwood

Dementia Module Test Answers

Dementia Module Test Answers

References

Bridges-Webb C and Wolk J. Care of Patients with Dementia in General Practice: Guidelines. Royal Australian College of General Practitioners; Sydney, 2003

Dysch L. 2003. Using the Clock Drawing Task in primary care. Geriatric Medicine September 2003. Eastly R., Assessment of Dementia, in Dementia. Eds Burns, O’Brien and Ames. London: Hodder Arnold, 2005.

Feinberg T., and Goodman B. 1984. Affective illness, dementia and pseudodementia. Journal of Clinical Psychiatry. 45; 99-103.

Feldman H et al. 2008. Diagnosis and treatment of dementia: 2. Diagnosis. Journal of the Canadian Medical Association. 178; 7: 825-836

Hecker J., Dementia and Alzheimer’s Disease, in A Practical Guide to Geriatric Medicine. Ed Ratnaike R. McGraw-Hill Professional Publishing, 2002

Hogan D et al. 2008. Diagnosis and Treatment of Dementia: 4. Approach to management of mild to moderate dementia. Journal of the Canadian Medical Association. 179: 8: 787-793

Hogan D et al. 2008. Diagnosis and Treatment of Dementia: 5. Nonpharmacologic and pharmacologic therapy for mild to moderate dementia. Journal of the Canadian Medical Association. 179: 10: 1019-1026

Juby A, Tench S, Baker V. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. Canadian Medical Association Journal 2002; 167(8): 859Ð64

Suresh et al. 2008. 10-Minute Consultation: Memory problems in an older person. BMJ. 337: a1170

Watson JD. 2001. Disorders of Memory and Intellect. Medical Journal of Australia. 175; 433-437.

Online resources

https://www.dementiacareaustralia.com/index.php/library/what-is-dementia.html

Home

https://www.agedcareaustralia.gov.au/internet/agedcare/publishing.nsf/Content/What%20is%20dementia

NICE Clinical Guideline 42; Dementia – Supporting people with dementia and their carers in health and social care. Developed by the National Collaborating Centre for Mental Health, UK. www.nice.org.uk

Advance Care Planning

The Mini Mental State Examination

Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.

Click here to see Dr Zheng’s MMSE result

Dr Zheng was disoriented. He was able to repeat three words immediately, but was able to recall only one. He spelled ‘world’ backwards correctly for two letters, but missed the last three. He was unable to read commands correctly but followed verbal commands (by interpreter). He could write a simple sentence with assistance, and incorrectly copied the intersecting pentagons.

Dr Zheng scored 15/30 on his MMSE. This is consistent with progression of his Alzheimer’s disease.

Mrs Cloverdale scores 7/15 on the GDS, indicating that psychological review is recommended. You discuss the result with Mrs Cloverdale and suggest the option of referral to a psychologist. She is happy with this plan and you indicate you will follow this up at review.

Mrs Cloverdale GDS

Geriatric Assessment https://e-ageing.wacha.org.au/Tutorial 

Comprehensive Assessment – Dr_Seymour Presentation to WACHS ACAT and HACC Staff

Quinn T et al. Functional assessment in older people. BMJ 2011;343:d4681

Healthy Ageing Module Test Answers

View Test Answers

Insomnia

https://www.ehealthmd.com/library/insomnia/INS_causes.html

https://www.helpguide.org/life/sleep_aging.htm

https://www.uptodate.com/patients/content/topic.do?topicKey=~ljjjZJvihvvMX6

https://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/ateaf/1979359?open

Cataract surgery

https://nei.nih.gov/health/cataract/cataract_facts

Age related hearing loss

https://www.mayoclinic.org/news2007-mchi/4220.html

Hearing

https://www.nlm.nih.gov/medlineplus/ency/article/001045.htm

Southwestern Eye Center’s Glaucoma Risk Calculator

https://www.sweye.com/glaucoma-risk-calculator

Stroke Module Test Answers

Stroke Module Test Answers

Online Resources

www.strokefoundation.com.au/health-professionals

www.strokecenter.org/prof/index.html

www.sol.co.uk/r/rsmacwalter/sites.html

www.strokecenter.org/trials/scales/modified_rankin.pdf

https://stroke.ahajournals.org/cgi/content/full/26/11/2027

Publications

Saver JL, Goyal MD, Bonafe A. et al. Stent Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. The New England Journal of Medicine 2015; 372 (24): 2285-2295. 

Goyal M, Demchuk AM, Menon BK. et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. The New England Journal of Medicine 2015; 372 (11): 1019-1030. 

Campbell BC, Mitchell PJ, Kleinig TJ. et al. Endo vascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. The New England Journal of Medicine 2015; 372(11): 1009-1018.

Berkhemer OA, Fransen PSS, Beumer D. et al. A Randomised Trial of Intraarterial Treatment for Acute Ischemic Stroke. The New England Journal of Medicine 2015; 372(1): 11-20.

Jovin TG, Chamorro A, Cobo E. et al. Thrombectomy within 8 hours after Symptom Onset in Ischemic Stroke. The New England Journal of Medicine 2015; 372 (24): 2296-2306.

Lindley RI and Levi CR. The spectacular recent trials of urgent neurointervention for acute stroke: fuel for a revolution. The Medical Journal of Australia 2015; 203(2): 1-3.  https://www.mja.com.au/journal/2015/203/2/spectacular-recent-trials-urgent-neurointervention-acute-stroke-fuel-revolution

ESO-Karolinska stroke update in collaboration with ESMINT and ESNR. Stroke Update – Consensus statement on mechanical thrombectomy in acute ischemic stroke. ESO-Karolinska Stroke Update Conference, Stockholm, 2014. https://2014.strokeupdate.org/consensus-statement-mechanical-thrombectomy-acute-ischemic-stroke

1. Keep him informed regarding Mrs Doherty’s health status
2. Encourage friends to visit to support the Doherty’s
3. Make time for Mr Doherty to ask you any questions
4. Ask if he would like to speak to the chaplain
5. Encourage Mr Doherty to maintain some of his social engagements, and nominate a support person to assist him
6. Talk to him about his fears and concerns. Ask if he has any concerns about Mrs Doherty’s care or if he thinks she is experiencing any troubling symptoms

Respite Care is short term care to “give carers a break”. This can be provided, in home for a few hours, or the care recipient may move into a residential facility for a number of weeks

Other Palliative Care Resources

Palliative Care Knowledge Network: an online resource which provides information about palliative care: www.caresearch.com.au

Palliative Care Australia: the national peak body for palliative care in. www.palliativecare.org.au

Advice on how to discuss palliative care with the patient and their family at: https://www.caresearch.com.au

or

Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers https://www.mja.com.au/public/issues/186_12_180607/cla11246_fm.html

1. Discuss residential care available in Australia.
2. Describe the methods of assessment required before older people can access residential care
3. Describe Home Care Packages and the process of tailoring these to meet patient needs.
4. Use a positive approach to old age and illness in older people.
5. Discuss the principles of palliative care.
6. Discuss effective communication skills when dealing with the patient, the patient’s family and other health professionals in a palliative care setting.
7. Discuss the importance of family support.

Physical Measures

Wt=90.4kg

Biochemistry

Urea, Creatinine & Electrolytes – normal

Full Blood Count – normal

BGL measured on ward daily

0600hrs fasting: 5.1-6.5 mmol/L

1230hrs before lunch: 6.0-7.0 mmol/L

1800hrs before dinner: 5.3-6.7 mmol/L

2000hrs: 8.3-9.7 mmol/L

Like many patients Mr. Tanner has quite a number of issues to consider in planning to return to community living. Some of these issues will include;

• Whether his wife is able to manage his care in the home situation.
• Whether their home requires any modifications to enable his care to be undertaken.
• Whether there are any financial and legal considerations that may need to be looked into.

All of these sorts of issues will be discussed with Mr Tanner and with the family in order to make sure that discharge is appropriate.

We also need to check with Mrs Tanner and make sure that she has an understanding of what has occurred so far, and potentially the long term implications are.

Issues such as;

• Will he still be able to drive?
• What it’s going to mean in terms of his ongoing social situation.
• His previous love of bowling.

All of these sorts of issues will need to be looked at.

Multidisciplinary Pain Management Programs have an increasing evidence-base to support their use in reducing suffering and pain perception. The success of these programs is in their adoption of a Cognitive Behavioural approach to management.

Pain Management Programs have the capacity to improve the patient’s quality of life, reduce suffering and distress and provide a more satisfying daily lifestyle. They are not designed to eliminate pain or provide the patient with a cure.

Wt=91kg

Biochemistry

Urea, Creatinine & Electrolytes – normal

Full Blood Count – normal

BGL measured on ward daily

0600hrs fasting: 5.1-6.5 mmol/L

1230hrs before lunch: 6.0-7.0 mmol/L

1800hrs before dinner: 5.3-6.7 mmol/L

2000hrs: 8.3-9.7 mmol/L

Dysphasia is an acquired communication disorder that results from damage to the language areas of the brain. It can affect the expression (expressive dysphasia) and comprehension (receptive dysphasia) of language, including reading and writing skills. Expressive dysphasia can be classified into fluent and non-fluent forms. Individuals with non fluent dysphasia tend to have reduced rate of speech, effortful articulation and word finding difficulties.

A speech pathologist’s role in stroke management can be both in areas of communication and swallowing.

First, starting with swallowing, around 27-50% of all acute stroke patients experience dysphagia or swallowing difficulties. Dysphagia results in decrease in nutrition and hydration, greater risk of aspiration pneumonia, increased length of hospitalization, illness, and in some cases even death.

Speech pathology intervention focuses on assessment, and management of swallowing and eating difficulties following a stroke.

So, when a patient first presents to me, after they’ve had a stroke, I need to establish;

• Are they safe enough to manage oral intake?
• Can the patient actually swallow?
• Can they be deemed safe enough to take their medications orally?
• Do they require, if they do have impaired swallow, modified diet or fluid level?
• Does their diet need to be pureed?
• Do they need thickened fluids?
• If their swallow is so impaired that they cannot manage a diet orally, do they require nutrition and hydration through an alternative means, such as a nasogastric tube?

In those such cases, I need to liaise with the dietician, and refer to their expertise, and collaborate together with them to effectively manage a nasogastric regime.

There is also a role in dysphagia for education of patient, family, and the stroke team in regards to safe swallowing strategies as well as the continuous monitoring and reviewing of the patient, to monitor progress, or also the regression.

A stroke can also affect communication skills, resulting in a disability due to dysphasia, which occurs in a frequency of around 21-38% of all acute strokes, and/or dyspraxia and dysarthria which occur in incidence of 20-30%.

Communication impairment can also be secondary to cognitive problems, such as decreased concentration, attention, increased tiredness, memory, and problem solving deficits. Speech pathology provides specialized assessment, therapy, and advice regarding the best way to help a patient who has a communication problem.

The impact on a patient who does have a communication problem can be a very isolating experience for them. There is a lack of power because they are not able to get their basic needs and wants met because they aren’t able to communicate those. There is anxiety, the patient is also unable to participate fully in the recovery and rehabilitation process. There is also impact upon all allied health nursing and medical staff. There is frustration within staff members because they are unsure in how to engage the patient. There is increased time needed to actually communicate effectively. There’s also the difficulty in building up rapport and developing the whole therapeutic alliance.

So, a speech pathologist works to establish; how is a patient able to express their basic needs and wants? Can the patient actually understand? And then you can establish a basic communication system which allows the patient to participate in recovery, for them to be able to state their wants and needs, be provided with some sort of choice.

Sometimes, if they are unable to speak or express what they want verbally, we can resort to alternative communication systems, such as communication boards.

A speech pathologist’s role also incorporates education again; the provision of information to the patient, the family as well as the stroke team regarding the best suited mode of communication for the patient, as well as ongoing communication therapy for that patient.

The role of occupational therapy in stroke is two-fold. We can treat people as a rehab candidate as an inpatient, and also have a big role in the discharge planning process.

We treat people by looking at their abilities to complete their desired activities, whether that’s self-care, occupation and leisure.

As an inpatient in rehab, OT’s breakdown activities into smaller parts to ensure that a person can perform affectively in their desired tasks.

The sub-components are;

How the patient moves (so that’s their motor area) and we concentrate specifically on the person’s upper limb as this has most to do with their function in every day life.

We also assess sensation, which is their awareness of their body.

We also assess their vision, which is obviously their eyesight and to make sure that they don’t have any visual field deficits.

Also perception, how people make sense of their incoming information.

We also assess and treat cognition, which is how the person plans to react to that incoming information.

We can also look at the person’s mood and behaviour, as potentially, after stroke, people have a lot of adjustment problems.

We assess these components and treat these areas incorporating them in function so to ensure as well that the patient can actually achieve the desired outcome.

The main problem for Mr. Tanner, we would envisage, is first of all positioning. We would need to liaise with the nursing staff and physiotherapists to ensure that Mr Tanner has correct positioning in both bed and chair, as this may compromise his rehab.

We would also expect him to have reduced sensation and movement in his side contra-lateral to his lesion.

We also suspect that he may have an apraxia, which is a motor planning problem or it’s the idea that he has lost the concept of particular activities.

Lastly, we play a major role in discharge planning. So we need to assess whether the patients environment at home is suitable for him to return to. We would need to take him on a home visit and check for rails and equipment, and we would supply those prior to discharge.

The role of the Physiotherapist is to assess and treat

• Mobility,
• Respiratory function and risk of aspiration
• Determine the level of falls risk and to
• Set goals with the team.

The TACS patient will undergo assessment initially by the medical team to reverse the damage; nursing staff will monitor and position the patient.

Points to consider

• This patient may have a decreased conscious state and the Physiotherapist, Nursing staff and Speech pathologist will all liaise to establish the risk of aspiration.
• Chest physiotherapy will commence immediately a problem is identified, should the patient be unable to clear their own secretions or have focal signs of infection.
• The deficits in this type of stroke syndrome may require education just for the patient to roll in bed. Therefore the physiotherapist will assess bed mobility and will determine safe management of transfers.
• Visual and perceptual deficits can impact on this patient’s safety and therefore the patient may be unsafe to mobilize without full assistance
• They may be unable to sit without support and they may be unable to balance to stand.
• Positioning and Seating requirements will require liaison with the Occupational Therapy department.
• The Physiotherapist will use early mobilisation to promote normal movement and function in all these activities.
• The Physiotherapist facilitates limb and trunk movement to enable independence in self care activities. For example arm recovery in dressing.
• Walking may be with or without facilitation and with or without aids.

Usually, a lesion of this size means the rehabilitation process in hospital may take as long as 3 months and will require regular team meetings and goal setting with constant communication between all disciplines and family.

Acute hospital measures
Wt=92kg

Rehab admission measures

Wt=91.6kg
Ht=170cm
BMI=31.7kg/m2 (30.0-34.9 obese class I)
Waist=130cm (>102 greatly increased health risk)
Blood pressure 140/85 (reported by doctor) borderline

Biochemistry

Urea, Creatinine & Electrolytes – normal
Full Blood Count – normal
Lipids – Chol=5.3 (<5.5) LDL=4.0(<3.0) HDL=1.1(>1.0) TG=2.5 (<2.0)mmol/L
HbA1c = 6.9% (6.0-7.0% good control) Fasting BGL=5.8 (3.0-5.4)mmol/L
Urinary Microablumin and microalbumin/creatinine ratio – normal

BGL measured on ward daily

0600hrs fasting: 5.1-6.5mmol/L
1230hrs before lunch: 6.0-7.0mmol/L
1800hrs before dinner: 5.3-6.7mmol/L
2000hrs: 8.3-9.7mmol/L

A depressed individual may require management of their depression before engaging in active rehabilitation. Depression impacts upon how a patient processes information. Negative thinking makes it difficult to find positive memories to use in the process of developing new goals. Depressed patients also have difficulty in developing concepts for a positive future. The practical implications for this in rehabilitation is that goal-setting may be unsuccessful without targetting depression first.

The Functional Independence Measure (FIM) is an outcome measure of the severity of disability for an inpatient rehabilitation setting. It rates 18 activities of daily living on a 7- point scale ranging from fully dependent (1) to independent with no aids (7). Improvements in functional status can easily be reviewed over time including at discharge and follow-up.

The Barthel Index establishes a patient’s degree of independence in activities of daily living. Scoring is done either by direct observation or by asking the patient, nursing staff or family members.

The primary goal of rehabilitation is to restore the individual to their greatest potential and maximise independence.

Rehabilitation is concerned not only with physical recovery but also with reintegration of the person into the community. The central aspect of rehabilitation is provision of a coordinated program by a specialised, interdisciplinary team of health professionals that is developed in consultation with the patient and their family/caregiver. Successful rehabilitation involves adopting a broader perspective that includes physical, social and psychological functioning.

Other factors that influence successful rehabilitation include:

1. a positive attitude and approach
2. individual assessment of the patient and caregiver
3. team work (ie. cooperation of professionals, patient, family members etc)
4. promotion of independence by:
   a. special and general therapeutic techniques
   b. optimising the environment
5. should begin as soon as possible after the incident.The major goal of rehabilitation programs for older people is to assist them to manage person ADL’s without assistance from another person.

1. Understand the importance of multi-disciplinary care in rehabilitation.
2. Discuss the roles of members of the rehabilitation team.
3. Outline how to develop a feasible rehabilitation plan.
4. Outline how to set appropriate goals for rehabilitation and monitor the progress of patients.
5. Understand assessment tools used to assess rehabilitative needs.
6. Describe the needs of the family of a person in rehabilitation.
7. Understand psychological and medical complications that can be important in rehabilitative care.

1. afrm.racp.edu.au/index
2. strokefoundation.com.au/post-acute-health-professional
3. https://www.daa.asn.au/files/Info%20for%20Professionals/Texture_Mod_Appendix.pdf
4. https://www.daa.asn.au/index.asp?pageID=2145858291
5. https://www.helium.com/items/660939-evidence-based-facts-on-meditation
6. www.mgh.harvard.edu/bhi/
7. Brown P and Gerbarg P. 2009. Yoga breathing, meditation and longevity. Annals of the New York Academy of Science, 1172: 54-62.
8. Manocha et al. 2009. Using meditation for less stress and better well-being. Australian Family Physician, 38 (6), 454-458.
9. Praissman, S. 2008. Mindfulness-based stress reduction: a literature review and clinician’s guide/ Journal of the American Academy of Nursing Practice. 20 (4), 212-216.
10. Ospina et al. 2007. Meditation practices for health: state of the research. Evidence Report – Technology Asssessment. 155, 1-263.
11. Chiesa, A. 2010. Vipassana meditation: systematic review of current evidence. Journal of Alternative and Complimentary Medicine. 16 (1), 37-46.
12. Chiesa, A. 2009. Zen meditation: an integration of current evidence. Journal of Alternative and Complimentary Medicine. 15 (5), 585-592.
13. Chiesa, A and Serretti, A. 2009. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. Journal of Alternative and Complimentary Medicine. 15 (5), 593-600.
14. Chiesa, A and Serretti, A. 2009. A systematic review of neurobiological and clinical features of mindfulnessmeditations. Psychological Medicine. 27, 1-14.
15. Olivo E, et al. 2009. Feasibility and effectiveness of a brief meditation-based stress management intervention for patients diagnosed with or at risk for coronary heart disease: a pilot study. Psychology, Health and Medicine. 14 (5), 513-23.
16. Nidich, S et al. 2009. A randomized controlled trial on effects of the Transcendental Meditation program on blood pressure, psychological distress, and coping in young adults. American Jounral of Hypertension. 22 (12), 1326-31.
17. Tacón AM, McComb J. 2009. Mindful exercise, quality of life, and survival: a mindfulness-based exercise program for women with breast cancer. .Journal of Alternative and Complimentary Medicine. 15 (1), 41-6.
18. Ando, M et al. 2009. The efficacy of mindfulness-based meditation therapy on anxiety, depression, and spirituality in Japanese patients with cancer. Journal of Palliative Medicine. 12 (12), 1091-4.
19. Rubia K. 2009. The neurobiology of Meditation and its clinical effectiveness in psychiatric disorders. Biological Psychology. 2 (1), 1-11.
20. Wilson, BA. 2008. Neuropsychological Rehabilitation. Annual Review of Clinical Psychology. 4, 141-162.
21. Barker-Collo, S et al. 2009. Reducing Attention Deficits After Stroke Using Attention Process Training: A Randomised Controlled Trial. Stroke. 40 (10), 3293-3298.
22. Chestnut et al., 1999. Rehabilitation for Traumatic Brain Injury. Rockville, MD: Agency Haleth Care Policy Res. Evi. Rep./Technol. Assess.
23. Cicerone et al. Evidence-based cognitive rehabilitation: updated review of the literature from 1998-2002. Arch Phys Med Rehabil. 2005; 86:1681-1692.
24. Gainotti G. Emotional and psychosocial problems after brain injury. Neuropsychol rehabil. 1993;3:259-277.
25. Hochstenback et al. Cognitive decline following stroke: a comprehensive study of cognitive decline following stroke. J Clin Exp Neuropsych. 1998;20:503-517.
26. Hyndman et al. The influence of attention deficits on functional recovery post stroke during the first 12 months after discharge from hospital. J Neurol Neurosurg Psych. 2009;79:656-663.
27. Patel et al. Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes. 2002;50:700-706.
28. Prigatano GP ed. Principles of neuropsychological rehabilitation. New York: Oxford Univ Press, 1999.
29. Prigatano GP, Pliskin N eds. Clinical neuropsychology and cost-outcome research: an introduction. Hove, UK: Psychol. Press, 2002.
30. Prigatano, GP. and Morrone-Strupinsky, J. Advancing the Profession of Clinical Neuropsychology with Appropriate Outcome Studies and Demonstrated Clinical Skills, The Clinical Neuropsychologist, 2010; 24: 3, 468 — 480.
31. Understanding stroke – A Practical guide for people affected by stroke, their families and carers. Brainlink, Victoria.

It is commonly thought that to maintain physiologic homeostasis may help to minimise the brain damage due to stroke. Thus we generally try to avoid hyperglycaemia.

Many patients with stroke will have hyperglycaemia so it is a common problem. Hyperglycaemia is an independent predictor of poor outcome, but the GIST trial – a randomised controlled trial of glucose/potassium/insulin infusion compared to normal saline, for tight blood glucose control – was negative. Unfortunately, the trial was underpowered so some uncertainly persists.

Prevention of Deep Venous Thrombosis is an important component of care in the stroke unit.

Stroke unit care uses a range of approaches to try and reduce the risk of venous thrombosis including a focus on early mobilisation, and maintenance of adequate hydration.

We use a range of prophylactic therapies including physical compression stockings.

The benefits and risks of these need to be carefully considered, and further data are awaited.

We also use pharmacotherapy, especially unfractionated and low molecular subcutaneous heparin to try and reduce the risk of deep venous thrombosis.

Again, it’s important to weigh the risks and benefits of therapy as stroke patients are often at high risk of bleeding complications.

Hypertension is a significant issue with stroke for two reasons. Firstly, hypertension is the most important cause of stroke in our community and treatment of hypertension prior to stroke can be expected to reduce the patient’s risk of stroke, and as such one should always consider that.

But in the setting of secondary hypertension, that is in post stroke, as in this scenario, treatment of hypertension can be a little tricky at times. Often patients will have a markedly elevated blood pressure following stroke due to the activation of the sympathetic and cortisol based mechanisms such that their blood pressure will often be elevated in the region of 170-200mm systolic.

As you’ll be well aware, the brain has autoregulation and as such during this time, interfering with this autoregulation with aggressive blood pressure lowering may lead to actually increased risk of recurrent infarction and extension of the infarct that has already happened.

As such, when you are called to manage or asked to manage hypertension after stroke, once you consider that the blood pressure is 180 systolic it’s certainly probably safe and certainly don’t need acute management.

Blood pressures from 180 to just over 200 may need some cautious management with gradual blood pressure lowering agents. Whereas blood pressures beyond 220mmH certainly need to be acutely lowered, but again very cautiously, only lowering the blood pressure by perhaps 10-15% in the initial phase and not more than 25% over the next few days.

In terms of choice of medication for those without severe hypertension it has been well shown that ACE inhibitors plus diuretics as well as angiotensin receptor blockers are very safe medications for this indication.

For those with accelerated hypertension, that is blood pressure more than 220mm systolic and/or patients who have complications in their hypertension (such as headache, impaired consciousness or falling renal function), then perhaps a more aggressive strategy is warranted, but cautious lowering of blood pressure with an intravenous agent such as a nitrate or perhaps an intravenous dose of beta blocker may be effective.

It’s important to remember that treating hypertension is a lifelong experience rather than necessarily something that should be done in the first few days

No, the patient can’t just go to a rehab ward. Care on a stroke unit is the most effective way of treating stroke and improves both morbidity and mortality. A stroke unit is usually in a dedicated area of the hospital, where a specialized team looks after stroke patients. A stroke unit aims to promote recovery and independence in activities of daily living.

There is good evidence proving that stroke units reduce death, dependency and institutional care, without having adverse outcomes such as increased length of hospitalization. These benefits have been found to be independent of factors such as age, or the severity of the stroke.

For a more in-depth read of research that has been conducted thus far in regards to stroke units, begin by reading the findings of the stroke unit trials collaboration, who published their findings in the British Medical Journal in 1997, volume 314, page 1151.

There are several models of care, which may be called ‘stroke units’. Some are predominantly acute, or are rehabilitation units. Combined are comprehensive units providing both acute and rehab care. The evidence is clearest from these comprehensive units which follow a patient’s journey, right from the acute phase through to the rehab phase. In a comprehensive stroke unit, a specialized, multidisciplinary team provides a coordinated program that includes individual assessment, treatment, regular reviews, discharge planning, and follow-up.

A stroke may have left a person with a variety of physical complications ranging from problems with swallowing, continence, communication, and mobility. A stroke can also affect someone’s perception and cognitive skills. There are also psychological and emotional changes that can occur which may be quite difficult to cope with. Other changes which can also occur include depression, tiredness, memory problems, loss of concentration, personality changes, irritability and aggression. Therefore, effective rehabilitation provided through a stroke unit relies on a coordinated, multidisciplinary team approach.

There are mobile units which function in some centres. However, these are thought to be a less effective form of specialized stroke care. Now, for further bedtime reading in reference to stroke unit care, you can refer to the National Stroke Guidelines which can be found via the web, www.strokefoundation.com.au or you can also refer to a journal article by Peter Langhorne, which can be found in the Journal of Age and Ageing, published in 2001. This article can be found in volume 31, page 365.

Mr Tanner was offered endovascular thrombectomy and concurrent thrombolysis.

Click on the needle to see how he fared.

Great choice! Mr Tanner has endovascular thrombectomy and concurrent TPA within 2.5 hours of stroke onset. Within 15 minutes he is no longer aphasic, although his speech is still slow with some evidence of expressive dysphasia. His left arm weakness remains, but his left leg is much improved!

Thrombolysis has been used successfully in myocardial infarction for 20 years and has been shown to improve morbidity. In stroke patients it also works by acting as a plasminogen activator, which helps break up the fibrin rich clots which can cause strokes.

More recently, endovascular thrombectomy, in addition to intravenous thrombolysis within 4.5 hours (when eligible), has become the recommended line of treatment for acute stroke patients with large artery occlusions, up to 6 hours after symptom onset.

Neither of the combined therapies should prevent the initiation of the other, provided there are no contraindications to proceed. Intracranial vessel occlusion should be diagnosed with non-invasive imaging wherever possible, before considering treatment with endovascular thrombectomy. Patients with radiological signs of large infarcts (using the ASPECTS score), may be unsuitable for thrombectomy.

There can be an increased risk of cerebral haemorrhage with thrombolysis, so contraindications such as severe uncontrolled hypertension, direct thrombin inhibitors, acute intracranial hemorrhage, thrombocytopenia and coagulopathy, must be considered before proceeding.

Endovascular thrombectomy should be performed by an experienced neurointerventionalist who meets national and/or international requirements.

Urgent CT is mandatory to look for evidence of haemorrhage.

It’s also important to look for signs of stroke mimics (such as other space occupying lesions).

Early subtle signs of ischaemia may also be present on early CT and these include changes such as sulcal effacement.

It’s important to remember that if there are clear signs of ischaemic change, than the time of onset needs to be carefully re-checked, as the stroke may be older than initially thought.

TAC – Total Anterior Circulation
ALL of:

• Higher Dysfunction
• Dysphasia
• Visuospatial (neglect/inattention)
• Homonymous Hemianopia
• Motor/Sensory
• FACE/ARM/LEG – 2/3

*epidemiological data suggest 1 year mortality to be 60%, with 36% of those surviving being functionally dependant.

PAC – Partial Anterior Circulation
Either:

• 2/3rds of a TAC
• Higher Dysfunction
• Hemianopia
• Motor/Sensory >2/3 FACE/ARM/LEG
• Higher Dysfunction Alone
• Pure motor or sensory (LESS extensive than LAC)
• New Higher Dysfunction

*epidemiological data suggest 1 year mortality to be 16%, with 29% of those surviving being functionally dependent.

LAC – Lacunar

• Pure Motor: >2/3 FACE/ARM/LEG (Internal capsule, pons, corona radiata)
• Pure Sensory: >2/3 FACE/ARM/LEG (thalamic)
• Sensory Motor: >2/3 FACE/ARM/LEG
• Ataxic Hemiparesis
• Cerebellar with ipsilateral Long Tract Signs
• (NO dysphasia/visuospatial/vertebrobasilar)

*epidemiological data suggest 1 year mortality to be 11%, with 28% of those surviving being functionally dependent.

POC – Posterior Circulation
Any of:

• Ipsilat CN palsy AND contralateral motor/sensory
• Bilat Motor OR Sensory Deficit
• Conjugate Eye Mov’t Problems
• Cerebellar Dysfunction WITHOUT ipsilateral
• Long Tract Signs
• Isolated Homonymous Hemianopia or cortical blindness

*epidemiological data suggest 1 year mortality to be 19%, with 19% of those surviving being functionally dependant.

Clinical classification systems (like the TACS, PACS, LOCS and LACS system) are useful in enabling us to describe the person’s stroke syndrome accurately.

If anyone telephones me about a patient with a lacunar syndrome for example, I immediately know what they are talking about!

This in turn helps me to estimate prognosis and sometimes is a clue to which aetiology and mechanism of stroke are most likely.

The CHADS score is helpful to estimate the risk of stroke in people with atrial fibrillation.

The CHADS score is based on the presence or absence of a history of congestive heart failure, hypertension, age greater than 75 years, diabetes and prior cerebrovascular disease.

Mr. Tanner’s CHADS2 score comes out to 4. It’s important to remember that Mr Tanner still hasn’t had his Echocardiogram done. We need to make sure he doesn’t have valvular disease or other significant structural heart disease.

The CHADS score only helps us to estimate Mr Tanner’s risk of ischaemic stroke. We also need to consider his risk of a haemorrhage if he should commence warfarin therapy.

Unfortunately as risk of stroke increases, the risk of haemorrhage also increases. This was shown in a study authored by Hylek in the 2007 issue of Circulation. If you are interested, the paper is in Volume 115 on page 2689.

There are some data in older people. For example, you can read the BAFTA trial which was published in the Lancet in 2007. Mant is the lead author. The trial is in Volume 370, page 493.

Although it does appear that the benefits of warfarin therapy extend to older people, unfortunately these results may not be generalisable to the very frail patients that you will sometimes look after.

ATRIAL FIBRILLATION can cause strokes by allowing blood to pool and form clots in the poorly contracting atria and especially in the left atrial appendage. These clots sometimes break off and can lodge in the brain. It is likely that Mr Tanner’s TIA was caused by this mechanism.

Operating on low grade stenosis (even if symptomatic) may lead to more complications than future stroke prevention. Have a look at the following link:

mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001081/frame.html

By the way, thanks for the quick referral. Although carotid endarterectomy is not appropriate in this case, it is important that we see these patients within two weeks of their first symptoms.

Check out the following articles:

Rothwell PM et al. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 2004; 363:915

Fuster V et al. Task force report: ACC/AHA/ESC guidelines for the management of atrial fibrillation. Eur Heart J 2001;22:1852-923

There is a decreasing incidence of stroke (40% over 20 years :OCSP, Oxvasc) related to reduction in traditional vascular risk factors and pharmacotherapy.

However ageing of the population will contribute to doubling of the overall burden of stroke mortality by 2020.

At 6 months after stroke, more than 60% of patients will have died (20%) or be dependent (40%) despite best medical therapy.

Cerebrovascular disease is thought to be the second most common cause of dementia.

Here are some other resources you can refer her to:

Sudlow CLM, Warlow CP, for the International Stroke Incidence Collaboration. Comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. Stroke 1997; 28: 491–99.

Feigin VL, Lawes CMM, Bennett DA, Anderson CA. Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol 2003; 2: 43–53.

The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group. Lancet, 1997. 349(9065): p. 1569-81.

Warolow C, Sudlow C. Dennis M, Wardlaw J, Sandercock P. Stroke. Lancet 2003; 363:1211-1224.

TIA’s can predict future stroke risk.

“We do have tools that allow us to determine the risk of future stroke after a transient ischaemic event. The most commonly used tool is the ABCD squared scale which estimates risk based on the patient’s age, blood pressure, clinical features, duration of symptoms and history of diabetes.”

Mr Tanner’s risk of stroke is around 10% at 90 days, and 4% on day 2.

The best management strategy for these patients is still controversial. Often we are concerned that discharge may not be safe if the risk of recurrence is high.

Many centres have focused care for TIA patients on early assessment and intervention to try and reduce the risk of recurrence. For example, you may like to read the results of the EXPRESS study which was published in the Lancet in 2007. You will find the study in Volume 370 on page 1432. Peter Rothwell is the lead author.”

Yes, if you are concerned about aspiration. This should not delay CT.

Yes this is often the most critical early test, to exclude haemorrhage and look for evidence of stroke mimics.

Pleasingly, Mr Tanner’s CT scan is normal.

Yes, this is an important test, and although often requested urgently, is often not available immediately.

Yes, an ECG should be done early to see if the patient is in AF and to look for other evidence of cardiac pathology.

Yes a BSL is especially important to get done urgently, usually by a finger prick. Other tests often ordered include a full blood count and urea and electrolytes. In Mr Tanner’s case, these are both normal.

This is continuous 24 hour ECG monitoring. Yes this is an important test, and although often requested urgently, is often not available immediately.

Yes this is an important test, and although often requested urgently, is often not available immediately.

We know that adherence with prescribed therapies is often suboptimal and thus it is important to check that Mr Tanner was taking his blood pressure medicines as prescribed. Although hypertension is a very strong risk factor for stroke, it’s important to remember that most strokes do occur in people with high normal blood pressure or mild hypertension.

There is conflicting evidence regarding the association between hypercholesterolaemia and the risk of stroke.

There have been epidemiologic studies suggesting that a higher cholesterol level is associated with a higher risk of ischaemic stroke, but a lower risk of haemorrhagic stroke.

There is good evidence that statins reduce the risk of major vascular events for those with stroke who have a total cholesterol of >3.5 and who may or may not have concurrent coronary heart disease.

In secondary prevention aspirin has a well proven role, with a 0.5% reduction in the risk of stroke. The Antithrombotic Trialists’ Collaboration found that the absolute reduction in the risk of having a serious vascular event was 36 per 1000 patients with previous myocardial infarction treated for two years. This study was published in the British Medical Journal in 2002. You can find the article in Volume 324 on page 71.

However aspirin doesn’t stop recurrent strokes. A recent Cochrane review shows that for every 1000 patients treated with aspirin within 48 hours of an acute ischaemic stroke, only 13 patients will avoid death or dependency. This translates to a number needed to treat to benefit of 79.

The benefits of aspirin therapy in primary prevention are not as clear cut. It may be that it is a reasonable to treat men who are at high risk of vascular events, but the balance of risks and benefits is less clear for people at lower risk, and for women.

• Develop an understanding of the importance of stroke and it’s epidemiology
• Understand the systemic nature of atherosclerosis and the implication of an ischaemic stroke/ transient ischaemic event for a person’s overall cardiovascular risk
• Understand the symptoms of stroke, and in particular that stroke causes focal neurology
• Understand stroke aetiology, and how aetiology influences therapy
• Understand stroke syndromes, and how they are categorised
• Understand that “TIME = BRAIN”, and the usefulness of thrombolysis
• Appreciate that Stroke Units are powerful interventions and change outcome

Mrs Browning is counselled with regard to the findings of her hearing tests and given strategies that she can implement to assist her hearing in difficult situations. These include:

1. Clearly explaining the problem to family and friends
2. Asking others to speak face to face in a clear and unhurried manner. If possible, sit closer to the person who is speaking.
3. Voicing any difficulties with misheard phrases or asking for clarification
4. Assistive listening device – in Mrs Browning’s case, a telephone amplifier may be of assistance.

Mrs Browning is fitted with new glasses and will have bi-yearly vision testing to make sure the macular degeneration does not worsen.

www.mdfoundation.com.au

Insomnia can be a symptom of an underlying medical conditions including asthma, allergy, arthritis, heart disease, hyperthyroidism, or Parkinson’s disease. It can also occur as a result of pain, jet lag, caffeine, trauma, medications, anxiety, depression, or environmental factors such as noise or heat. Take a relevant history and conduct the necessary assessments to determine the most likely cause of Mrs Browning’s insomnia.

In order to take a sleep history, you will need to ask Mrs Browning a series of questions. Please click on the questions below to obtain Mrs Browning’s answer.

1. Understand the normal ageing processes and the physiology of ageing.
2. Explain the concept of successful ageing.
3. Discuss beliefs and values regarding ageing, and how these values might influence practice.
4. Discuss individual and cultural differences in successful ageing.
5. Describe the importance of multidisciplinary care in promoting healthy ageing and maintaining normal activities to promote quality of life.

The Home and Community Care (HACC) Program provides basic support and maintenance services to frail aged people, younger people with disabilities and their carer to assist them to continue living independently at home. The types of support include:

• support to participate in social activity in a group or one-on-one
• assistance with everyday household tasks
• assistance to enhance nutrition, function, strength, independence and safety
• assistance to support independence in personal care activities such as showering and dressing
• assistance to keep up with essential activities such as shopping, banking and maintaining social contacts

Berg Balance Scale

The physiotherapy consult finds Mr Doherty’s Berg balance scale is 46/56. He had difficulty turning to look behind, reaching, retrieving an object from the floor and balancing on one foot. He had a positive Rhomberg test, with persistant sway while standing with eyes closed.

The physiotherapist prescribed specific balance exercises, which can be performed as a home program.

Gait Assessment

Mr Doherty had no trouble transferring or turning in the timed up and go test, completing the assessment in 11.3 seconds. His gait velocity and character were normal. Mr Doherty has some problems with balance, but no significant falls risk as a result of this.

However, in conjunction with his poor eyesight, his risk of having a fall is increased.

Berg Balance Scale

The assessment finds Mrs Doherty’s Berg balance scale is 32/56. She has difficulty transferring, turning, reaching and balancing on one foot. She also had a positive Rhomberg test, with significant irregular sway while standing with eyes closed.

The physiotherapist prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for the leg extensors, which can be performed as a home program.

It is important that Mrs Doherty maintain these exercises, in order to maintain muscle strength and joint range of movement and to improve her balance.

Gait Assessment

Mrs Doherty has a mildly hemiparetic gait related to her residual right sided weakness. There is impaired timing and intensity of muscle action in the right leg, which affects gait velocity and character. She also has mild upper kyphosis. She had trouble with the timed up and go test due to difficulty transferring and gait impairment. Her time for the assessment was 26.7 seconds.

Given this, Mrs Doherty has significant falls risk.

Mrs Doherty gave up her driver’s license 7 months ago. With increasing shortness of breath, tiredness, chest pains and reflux, she has become increasingly unable to shop, prepare food, clean the house, do laundry or adequately administer her medications. She does a good job of managing the household finances

Mrs Doherty is continent and is able to dress, feed and go to the toilet herself. She is having some trouble showering and using her upper extremities due to extreme shortness of breath and fatigue. As a result her personal hygiene and presentation have been affected

Geriatric Assessment Tools

On their own, screening tests are not able to diagnose dementia as they test limited domains of cognition. They can be useful in identifying someone needing further investigation and are also useful if done serially to map any change in cognition over time.

The ideal screening test would be both sensitive (high rate of true positive) and specific (high rate of true negatives results). However this is not as straight forward as it sounds, because positive predictive value of tests is also influenced by the prevalence of the disease condition! Keep in mind too that “cut offs” are based on population norms or empiric studies and thus can not be considered in isolation.

Please click on the tabs below to reveal more information about each of the commonly used screening tools.