What are the recommendations for post-stroke care?

Comprehensive Post-Stroke Care Recommendations

Post-stroke care should be organized and comprehensive, utilizing stroke units with multidisciplinary teams to ensure all patients receive appropriate assessment, rehabilitation, and secondary prevention to reduce mortality, maximize recovery, and prevent recurrent stroke. 1

Immediate Post-Acute Care

Organized Stroke Care

• Implement organized approaches such as dedicated stroke units, stroke teams, and standardized protocols 1
• Transfer patients from emergency departments to specialized stroke units as soon as possible, ideally within 6 hours of hospital arrival 1
• Use multidisciplinary teams including physicians, nurses, and rehabilitation specialists who communicate regularly to coordinate care 1

Initial Assessment and Monitoring

• Perform standardized screening evaluations to identify patients with residual impairments 1
• Screen for ongoing physical issues including:
  • Dysphagia
  • Nutrition and hydration status
  • Continence issues
  • Pain management
  • Cognitive impairments
  • Mental health concerns (especially depression)
  • Psychosocial issues 1

Rehabilitation

Early Rehabilitation

• Begin rehabilitation as early as appropriate based on patient stability
• Ensure all stroke survivors receive a standardized screening evaluation during initial hospitalization to determine rehabilitation needs 1
• Tailor rehabilitation intensity to anticipated benefit and patient tolerance 1

Rehabilitation Services

• Provide access to a coordinated multidisciplinary rehabilitation team experienced in stroke care 2
• Include physical therapy, occupational therapy, speech therapy, and recreational therapy as needed 1
• Establish processes for stroke survivors to re-access rehabilitation services if functional decline occurs, even months or years post-stroke 1
• Assess communication capacity and refer to speech and language services as required 1

Physical Activity and Exercise

• Recognize that stroke patients have elevated energy costs of movement (oxygen cost of walking is 2-fold higher than able-bodied subjects) 1
• Screen for and address post-stroke fatigue, which affects 35-92% of patients 1
• Provide a home exercise program or refer to appropriate community exercise programs 2
• Recommend regular strengthening and aerobic exercise designed with consideration of comorbidities and functional limitations 2

Secondary Prevention

Medication Management

• For noncardioembolic ischemic stroke, prescribe one of the following antiplatelet agents:
  • Aspirin 50-325 mg daily
  • Clopidogrel 75 mg daily
  • Combination aspirin 25 mg/dipyridamole 200 mg twice daily 2
• For cardioembolic stroke with atrial fibrillation, prescribe oral anticoagulation unless contraindicated 2
• Prescribe high-intensity statin therapy to reduce LDL-C by ≥50% and target LDL-C <70 mg/dL 2

Risk Factor Management

• Target blood pressure <130/80 mmHg 2
• Optimize glycemic control for patients with diabetes 2
• Counsel patients on Mediterranean-type diet high in vegetables, fruits, whole grains, fish, nuts, and olive oil 2
• Encourage smoking cessation, limited alcohol consumption, and weight management 2

Transitions of Care

Hospital to Home Transition

• Schedule follow-up with primary care provider within 1 month of discharge 2
• Arrange follow-up with rehabilitation professionals 3-6 months after discharge if rehabilitation services were provided 2
• Ensure timely transfer of hospital discharge information to subsequent treating physicians 1
• Provide individualized care plans for patients during transition of care 1

Patient and Family Education

• Educate patients and families about:
  • Stroke risk factors
  • Warning signs of stroke
  • Time-sensitive therapy options
  • Appropriate method for activating emergency medical services 1
  • Self-management of stroke risk factors and lifestyle changes 1

Vocational Considerations

• Assess patients for their potential to return to vocational activities (work, school, volunteering) 1
• Consider cognitive assessments including neuropsychological evaluations to determine ability to meet employment requirements 1
• Work with employers/educators to develop appropriate return-to-work/school plans 1

Common Pitfalls and Challenges

Avoiding Complications

• Screen for and prevent common post-stroke complications:
  • Falls
  • Venous thromboembolism
  • Recurrent stroke or TIA
  • Infections
  • Cardiac complications
  • Dehydration and renal failure 1

Access to Care

• Be aware of geographic variations in access to post-acute services, particularly in underserved areas 1
• Address social determinants of health including:
  • Literacy level
  • Language proficiency
  • Medication affordability
  • Food security
  • Housing and transportation 2

Readmission Prevention

• Focus on reducing mortality, maximizing recovery, and preventing recurrent stroke rather than solely on reducing readmission rates 1
• Recognize that social, functional, and community determinants of health are important factors in later (>7 days after discharge) readmissions 1

Post-stroke care requires a comprehensive, coordinated approach across the continuum of care. By implementing these evidence-based recommendations, healthcare providers can significantly improve outcomes for stroke survivors, reducing mortality and disability while enhancing quality of life.