Age-Related Health Care Adelaide and Meath Hospital Dublin
description
Transcript of Age-Related Health Care Adelaide and Meath Hospital Dublin
http://indigo.ie/~arhc
Age-Related Health CareAdelaide and Meath Hospital Dublin
incorporating the National Children’s Hospital
Dept of Medical GerontologyTrinity College Dublin
http://indigo.ie/~arhc
Stroke in Ireland
•Kills more people than breast cancer, lung cancer and bowel cancer combined
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Stroke is…...
• a focal or global neurological deficit• of presumed vascular origin• lasting more than 24 hours• or causing death within 24 hours
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A TIA is…...
• a focal or global neurological deficit• of presumed vascular origin• lasting less than 24 hours
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Stroke burden
• 9,250 acute strokes/year• 25% die in first year• 30,000 with residual disability
– 48% hemiparesis– 22% cannot walk– 24-53% need help in ADLs– 12-18% aphasic
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Impact
• Personal: – “..more impact than my wedding, or the
birth of my first child”
• 2nd most expensive illness• Most common cause of acquired
physical disability• Most expensive single DRG medically
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Biggest advance in Stroke Care
Not, not, not
Thrombolysis
Stroke Units
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Stroke Units• Reduce death, disability,
institutionalization• Reduce death and disability by 25%• NNT
– 33 to save a death– 20 to regain independence– 20 to prevent institutionalize
• Save 2-11 days hospital• If this were a tablet………..
Cochrane 2005
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Stroke Units• Direct care of a specialist in stroke care
and interdisciplinary team• Clearly defined continuum of care• Geographical unit preferable• CT/MRI on site• Main base general hospital• Take all patients referred
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Vascular surgeon
Radiologist
Public Health
Geriatrician
RehabilitationistNeurologist
GP
PHN
Person with stroke
Carer
Hospital nurses
Physiotherapy
Occupational therapySpeech therapySocial workPsychology
Clinical nutrition
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3 tasks•Was it a stroke?•What did the stroke cause?
–Cognitive impairment–Dysphagia–Gait disorder–Sensory–Inattention
•What caused the stroke?
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http://indigo.ie/~arhc
Vulnerable Tissue:
Work Fast!
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Brain attack• ABC• Diagnosis• Stabilize
• BP, O2, Temp, glucose
• Swallow• Positioning• Stroke Service
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History
• Patient• Collateral/witness
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Cincinnati Prehospital Stroke Scale
• Facial droop• Arm drift• Speech
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4 level neuro Ax• End of the bed• Alertness (GCS), language, cognition• Classical neuro examination
– Cranial nn– PTCS– Reflexes
• ‘Parietal’ signs– Inattention/neglect– Agnosia– Apraxia
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Differential
• Tumour• Meningitis/encephalitis• Seizure• Epilepsy• Migraine• Metabolic causes• MS
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TIA’s• 38% 'true' TIA• 10% had migraine• 9% had faints• 9% had possible TIAs, 9% had 'funny turns’• 6% had epilepsy• 6% had vertigo• 0.8% had hypoglycaemia• 0.4% had brain tumours
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ABCD of TIA treatment• 10% stroke risk within one week: 30% if high
score• ABCD Score
– Age - >60 = 1– Blood Pressure - Syst > 140 or Diast > 90 = 1– Clinical
• Motor = 2• Speech = 1
– Duration• > 1 hour = 2• 10-59 min = 1
Rothwell, Lancet 2005
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Urgent investigations
• Glucose• FBC• U + E• ECG
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Urgent CT
• Head injury• Suspicion sub-arachnoid
– Headache– Meningism
• Neurological deterioration• Possibility of thrombolysis
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BP
• Ischaemic stroke - dangerous to treat if not > 220/140
• Sub-arachnoid - neurology advice - nimodipine and normal blood pressure
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Stabilize
• Keep euglycaemic• Antipyretics for pyrexia
• O2: avoid hypoxia
• NPO until swallow assessed• Early advice on positioning
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First 12 hours
• Stroke Service• Book CTB (within 48 hours)• Book other tests as appropriate:
– Carotid dopplers– Holter monitor– ECHO– ……..
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Pharmacological
• Anti-platelets– NSA, Asantin R, clopidrogel
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Strategies: who can benefit?
• 150-250 strokes yearly in a Dublin hospital– Stroke Unit 100%– Aspirin 80%– Neuroprotective strategies 90%– Thrombolysis 5%
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iv Thrombolysis
• 3 Streptokinase: terminated• European r-TPA: no overall change• NINDS r-TPA: modest improvement
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NINDS rt-PA regime
• Within 3 hours (mean 90 mins)• 0.9 mg/kg (max 90mg)• 10% bolus• 90% over one hour• Systolic <185, Diastolic <110• BP managed by algorithm
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Contra-indications
• PUD• Recent surgery• Recent arterial puncture• Abnormal coagulation• BP not manageable to 185/110• No sign of established stroke on CT - NB
difficult
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Cochrane review
• Excess of deaths – 23% thrombolysis– 18% controls
• Reduction death and disability– 45% thrombolysis– 51% controls
• Treat 16 patients to avoid one death/disability
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The real world....Chiu, Stroke 1998
• 6% receive rt-PA• Those who don't:
– Time 37%– ICH 22%– Minor/rapidly resolving symptoms 19%– Nonstroke Dx 12%
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Acute treatment
• Aspirin• LMW Heparin• Thrombolysis
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Neuroprotective
• Nimodipine• Glutamate antagonists• Na channel antagonists/glycine
antagonists• Opioid antagonists• Antoxidants/Free radical scavengers
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Management issues
• Reducing delay• Stroke unit approach• CT access and expertise (?
telemedicine)• Neuro-ICU
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Unmet needs post-stroke
• 38% no personal contact GP• 46% attended DH• 79% had health concerns• 64% required Rx advice• 18% had resumed smoking
Martin Scot Med 2002
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6 Months after discharge
• 58% in the community• 87% had seen GP• 48% reviewed in OPD
Crowe IMJ 2002
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Remediable risk factors
• Smoking• Alcohol• Exercise• Obesity, DM• Psychosocial
• BP• Lipids• Homocysteine• Infections• Inflammation,
thrombosis
Sem Vasc Med 2002, 2, 229-445
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Fibrinogen
•Adds to likelihood of event•Reduce inflammation?
– Flu vaccine– Reduces stroke hospitalization by 16%
Nichol NEJM 3 April 2003
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Healthy lifestyle is anticoagulant and anti-
inflammatory
• Weight loss, exercise• Reduce vascular inflammation and
insulin resistance
• So, stop smoking, keep walking!
Esposito, JAMA, April 9, 2003
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• Antithrombotics
• BP reduction
• Cholesterol
• Diet and DM
• Exercise/rehabilitation
• Forget smoking/Flu jabs
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Antiplatelets
• 25% reduction in all events• CHD• Stroke• VTE• Revascularization
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BP reduction
• Diuretics and ACE-Inhibitor• Primary prevention trials suggest drug
equivalence• Cave postural symptoms!
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Statins
• All patients with stroke• Fire and forget• Highest effective dose• Simvastatin 40• Pravastatin 40• Atorvostatin 10
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http://indigo.ie/~arhc
Carotid endarterectomy
• Carotid territory stroke TIA in last 6 months
• >70% stenosis (about 5% of our patients)
• NNT 15 to prevent death or disability over 2-6 years
• Surgically fit patients• Surgeons with <6% complication rates
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• Antithrombotics
• BP reduction
• Cholesterol
• Diet and DM
• Exercise/rehabilitation
• Forget smoking/Flu jabs