1. Canadian Best Practice Recommendations for Stroke Care (Updated 2008) Section # 3 Hyperacute Stroke Management Canadian Best Practice Recommendations for Stroke Care: 2008 Recommendation 6: Selected Topics in Stroke Management

2. Recommendation Section #6 Selected Topics in Stroke Management 6.1 Dysphagia Assessment 6.2 Identification and Management of Post-Stroke Depression 6.3 Vascular Cognitive Impairment and Dementia 6.4 Shoulder Pain Assessment and Treatment

3. 6.1 Dysphagia Assessment  Patients with stroke should have their swallowing screened using a simple, valid, reliable bedside testing protocol as part of their initial assessment and before initiating oral intake of medications, fluids or food.  Patients who are not alert within the first 24 hours should be monitored closely and dysphagia screening performed when clinically appropriate.

4. 6.1 Dysphagia Assessment  Patients presenting with features indicating dysphagia or pulmonary aspiration should receive a full clinical assessment of their swallowing ability by a speech-language pathologist or trained specialist who should advise on safety of swallowing ability and consistency of diet and fluids.  Patients who are at risk of malnutrition, including those with dysphagia, should be referred to a dietitian for assessment and ongoing management.  Assessment of nutritional status should include use of validated nutrition assessment tools or measures.

5. System Implications  Development and delivery of educational programs to train appropriate staff to perform an initial swallowing screening for stroke patients.  Access to appropriately trained health care professionals for in-depth assessments, such as speech-language pathologists, occupational therapists and dietitians.

6. Performance Measures  Proportion of stroke patients with documentation that an initial dysphagia screening was performed during hospital admission.  Proportion of stroke patients with poor results on initial screening who then receive a comprehensive assessment by a speech- language pathologist or other trained health care professional.  Median time from patient arrival in the emergency department to initial screening by a trained clinician (in minutes).

7. 6.2 Identification and Management of Post-Stroke Depression  All patients with stroke should be considered to be at high risk for depression. At time of the first assessment, the team should determine whether the patient has a history of depression or risk factors for depression.  All patients with stroke should be screened for depression using a validated tool.  Screening should take place at all transition points and whenever clinical presentation indicates.

8. 6.2 Identification and Management of Post-Stroke Depression  Transition points may include:  Upon admission to acute care particularly if any evidence of depression or mood changes noted.  Prior to discharge home from acute care or during early rehabilitation if transferred to inpatient rehabilitation setting.  Periodically during inpatient rehabilitation.  Periodically following discharge to community.

9. 6.2 Identification and Management of Post-Stroke Depression  Patients identified as at risk for depression during screening should be referred to a psychiatrist or psychologist for further assessment and diagnosis.  Patients with mild depressive symptoms should be managed by “watchful waiting”, with treatment being started only if depression is persistent.  Patients diagnosed with a depressive disorder should be given a trial of antidepressant medication, if no contraindication exists.

10. 6.2 Identification and Management of Post-Stroke Depression  No recommendation is made for the use of one class of antidepressants over another, however, side effect profiles suggest that serotonin-specific reuptake inhibitors (SSRIs) may be favoured in this patient population.  In adult patients with severe, persistent or troublesome tearfulness, SSRIs are recommended as the antidepressant of choice.  Treatment should be monitored and continue for minimum of 6 months, if a good response is achieved.

11. 6.2 Identification and Management of Post-Stroke Depression  All patients with apparent depressive symptoms should be screened for the presence of hypoactive delirium.  Routine use of prophylactic antidepressants is not recommended in post-stroke patients.

12. 6.2 Identification and Management of Post-Stroke Depression  Patients should be given information and advice about the impact of stroke and the opportunity to talk about the impact of illness upon their lives.  Patients with marked anxiety should be offered psychological therapy.  Patients and caregivers should have their individual psychosocial and support needs reviewed on a regular basis as part of the longer-term recovery and management of stroke.

13. System Implications  Education for health care providers throughout the continuum of stroke care on assessment and recognition of post-stroke depression.  Timely access to appropriate clinicians who are able to evaluate severity of depression.  Timely access to specialized therapies to manage post- stroke depression (medication and counselling as required).  Process for ongoing monitoring of any patient with positive screening for depression during referral process.

14. Performance Measures  Proportion of stroke patients with documentation to indicate assessment or screening for depression performed informally or using a formal assessment tool in acute care or rehabilitation setting following an acute stroke event.  Proportion of stroke patients referred for additional assessment or intervention for a suspected diagnosis of depression following an acute stroke event.  Proportion of stroke patients treated with antidepressants at one month, three months, six months and one year following initial stroke event.

15. 6.3 Vascular Cognitive Impairment and Dementia  All patients with vascular risk factors and those with clinically evident stroke or TIA should be considered at high risk for vascular cognitive impairment.  Vascular risk factors include:  Hypertension  Age >65  Hyperlipidemia, diabetes  Clinical stroke  Neuroimaging findings of covert stroke or white matter disease  Damage to target organs  Patients with cognitive or functional changes that are clinically evident or reported during history taking.

16. Domain ArousalLanguage AlertnessAgnosia AttentionVisual-spatial/perceptual function OrientationPraxis MemoryExecutive functions 6.3a Assessment  All patients with vascular risk factors should be screened for cognitive impairment using a validated screening tool.  Screening to investigate a person’s cognitive status should address the following domains:

17. 6.3a Assessment  The Montreal Cognitive Assessment is considered more sensitive to cognitive impairment than the Mini Mental Status Exam in patients with vascular cognitive impairment. It is recommended when vascular cognitive impairment is suspected.  Additional validation is needed for the Montreal Cognitive Assessment as well as other potential screening instruments such as the Five Minute Protocol from the Vascular Cognitive Impairment Harmonization recommendations. Components of 5-minute protocol for vascular cognitive impairment screening 5-word immediate and delayed memory test 6-item orientation task 1-letter phonemic fluency test ( the letter F) Montreal Cognitive Assessment (www.mocatest.org); National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards(http://stroke.ahajournals.org/cgi/reprint/37/9/2220)www.mocatest.org

18. 6.3a Assessment  Patients should also be screened for depression, since depression has been found to contribute to cognitive impairment in stroke patients. A validated screening tool should be used.  Persons who have cognitive impairment detected on a screening test should receive additional cognitive and/or neuropsychological assessments as appropriate to further guide management.

19. 6.3b Timing  All patients at high risk for cognitive impairment should be assessed periodically as indicated by severity of clinical presentation, history and/or imaging abnormalities to identify cognitive, perceptual deficits, depression, delirium and/or changes in function.  Those who have had a TIA or stroke should have a screening assessment and where indicated a more in-depth assessment of cognitive and perceptual status at various transition points throughout the continuum of care.

20. 6.3b Timing  Transition points include:  During presentation to ER when cognitive, perceptual or functional concerns noted.  Upon admission to acute care especially if evidence of delirium noted.  Upon discharge home from acute care or during early rehabilitation if transferred to inpatient rehabilitation setting.  Periodically during inpatient rehabilitation according to client progress and to assist with discharge planning.  Periodically following discharge to the community by the most appropriate community healthcare provider according to client’s needs, progress and current goals.

21. 6.3c Management  All vascular risk factors should be managed aggressively to achieve optimal control.  Patients who demonstrate cognitive impairment in the screening process should be referred to a health care professional with specific expertise in this area for additional cognitive, perceptual and/or functional assessment to:  Determine the severity of impairment and impact of deficits on function and safety in activities of daily living and instrumental activities of daily living  Implement appropriate remedial, compensatory and/or adaptive intervention strategies.

22. 6.3c Management  A team approach is recommended and may include Occupational Therapist, Neuropsychologist, Psychiatrist, Neurologist, Geriatrician, Speech- Language Pathologist, Social Worker.  An individualized client-centred approach should be considered to facilitate resumption of desired activities such as: Return to work, leisure, driving, volunteer participation, financial management, home management, other instrumental activities of daily living.

23. 6.3c Management  Intervention strategies including rehabilitation should be tailored according to cognitive impairment and functional limitations as well as remaining cognitive abilities, as identified through in-depth assessment and developed in relation to patient and caregivers’ needs and goals.  Strategic or compensatory training appears to be effective in the treatment of apraxia post stroke and should be considered.  The evidence for the effectiveness of specific interventions for cognitive impairment in stroke is limited and requires more research.

24. 6.3c Management  Attention training may have a positive effect on specific, targeted outcomes and should be implemented with appropriate patients.  Compensatory strategies can be used to improve memory outcomes.  Patients with evidence of depression or anxiety on screening should be referred and managed by an appropriate mental health professional.

25. 6.3c Management  Pharmacotherapy  Patients with evidence of VCI should be referred to a physician with expertise for further assessment and recommendations regarding pharmacotherapy.  Cholinesterase inhibitors should be considered for management of VCI diagnosed using National Institute of Neurological Disorders and Stroke (NINDS).  There is fair evidence of small magnitude benefits for galantamine on cognition function and behaviour in mixed Alzheimer and cerebrovascular disease and can be considered a treatment option.  There is fair evidence of small magnitude benefits for donepezil in cognitive and global outcomes with less robust benefits on functional measures and can be considered a treatment option.

26. System Implications  Education of the public by adding cognitive changes to the signs of stroke.  Professional education across specialties to increase awareness that patients with small-vessel disease should be investigated for stroke risk factors and cognitive impairment.  Ongoing professional education to ensure proficiency in assessment administration, interpretation and management of cognitive impairment.  Increased awareness among family physicians that patients with vascular risk factors, if not treated, will be at high risk for cognitive deficits.  Increased public awareness programs focused on untreated hypertension and other vascular risk factors and their relationship to dementia.

27. Performance Measures  Percentage of persons with stroke who have a cognitive screening at each transition point along the continuum of care in the community after inpatient discharge and at any time when there is a suspected change in cognitive status.  Percentage of persons with stroke who are referred for more in-depth cognitive or neuropsychological assessment during inpatient care, inpatient rehab, outpatient and ambulatory clinics (stroke prevention clinics) and/or following inpatient discharge to the community.  Percentage improvement in control of high BP and other vascular risk factors in patients with vascular cognitive impairment.

28. 6.4 Shoulder Pain Assessment and Treatment  All stroke patients should be assessed for shoulder pain and, when symptoms present, have strategies implemented to minimize shoulder joint pain and trauma.  Factors that contribute to, or exacerbate shoulder pain should be identified and managed appropriately.  Educate staff and caregivers about correct handling of the hemiplegic arm.  Consider use of supports for the arm.

29. 6.4 Shoulder Pain Assessment and Treatment  Joint protection strategies should be instituted to minimize joint trauma  The shoulder should not be passively moved beyond 90° of flexion and abduction unless the scapula is upwardly rotated and the humerus is laterally rotated.  Overhead pulleys should not be used.  The upper limb must be handled carefully during functional activities.  Staff should position patients, whether lying or sitting, to minimize risk of complications such as shoulder pain.  Shoulder pain and limitations in range of motion should be treated through gentle stretching and mobilization techniques focusing especially on external rotation and abduction.

30. System Implications  Organized stroke care available, including stroke units with critical mass of trained staff and interdisciplinary team during rehabilitation post stroke.  Initial assessment performed by clinicians experienced in stroke and stroke rehab.  Timely access to specialized, interdisciplinary stroke rehabilitation services.  Timely access to appropriate type and intensity of rehabilitation for stroke survivors.

31. Selected Performance Measures * Length of stay during acute care hospitalization and inpatient rehabilitation for patients with shoulder pain (as compared with patients without shoulder pain).  Proportion of stroke patients who have shoulder pain in acute care hospital, inpatient rehabilitation and after discharge to the community.  Proportion of stroke patients who report shoulder pain at three-month and six-month follow-up.  Pain intensity rating change from baseline to defined measurement periods.

32. Implementation Tips  Form a working group, consider both local and regional stakeholders and include a stroke survivor and family.  Complete a gap analysis to compare current practices using the Canadian Best Practice Recommendations: 2008 Gap Analysis Tool.  Identify strengths, challenges, opportunities.  Identify two to three priorities for action.

33. Implementation Tips  Identify local and regional champions.  Identify professional education needs and develop a professional education learning plan.  Consider local or regional workshops to focus on Selected Topics in Stroke Management.  Access resources such as Canadian Stroke Strategy experts, Heart and Stroke Foundation, provincial contacts, stroke recovery groups.

34. www.canadianstrokestrategy.ca www.cmaj.ca