What are the recommended discharge treatments for a post-stroke patient?

Recommended Discharge Treatments for Post-Stroke Patients

Discharge treatment for post-stroke patients should include a comprehensive rehabilitation plan, secondary stroke prevention medications, and management of complications to optimize mortality, morbidity, and quality of life outcomes. 1

Secondary Stroke Prevention Medications

• Antiplatelet therapy is essential for all patients with ischemic stroke (in absence of atrial fibrillation):

  • Single antiplatelet therapy is recommended for long-term use (aspirin 150-300 mg or clopidogrel 75 mg) 1, 2
  • Dual antiplatelet therapy (aspirin + clopidogrel) has benefit only in the first three weeks after stroke but increases bleeding risk if continued longer 2, 3
  • The highest risk of bleeding with antiplatelet therapy occurs between 3 months and 1 year post-initiation, particularly with aspirin 100 mg or dual therapy 4

• Anticoagulation is indicated only for patients with atrial fibrillation; avoid combining with antiplatelet drugs 2

• Statin therapy should be initiated regardless of baseline cholesterol levels 1, 2

• Antihypertensive medications for patients with systolic BP >140/90 mmHg:

  • ACE inhibitors, calcium channel blockers, and diuretics are first-line options 2
  • Blood pressure control is critical for preventing recurrent stroke 1

Rehabilitation Services

• Determine appropriate rehabilitation setting based on:

  • Residual neurological deficits
  • Cognitive, communication, and psychological status
  • Swallowing ability
  • Previous functional ability and medical comorbidities
  • Level of family/caregiver support 1, 5

• Rehabilitation options include:

  • Inpatient rehabilitation hospital/unit (preferred for qualifying patients) 1
  • Nursing facility rehabilitation
  • Home-based rehabilitation
  • Outpatient rehabilitation 1

Management of Post-Stroke Complications

• Dysphagia management:

  • Ensure formal swallowing assessment is completed before discharge 1
  • Implement dysphagia management plan with compensatory strategies to prevent aspiration 1

• Bladder and bowel management:

  • For urinary retention, implement intermittent catheterization if post-void residual volume >100 mL 1
  • Prescribe prophylactic stool softeners to prevent constipation 1

• Mobility and fall prevention:

  • Implement a formal fall prevention program 1
  • Prescribe early, short, frequent exercise regimens 1
  • Daily stretching of hemiplegic limbs to avoid contracture 1
  • Proper positioning of hemiplegic shoulder in maximum external rotation for 30 minutes daily 1
  • Consider resting ankle splints for prevention of ankle contracture 1

• Neuropsychological management:

  • Screen for post-stroke depression using a structured inventory (e.g., Patient Health Questionnaire-2) 1
  • Treat diagnosed depression with antidepressants if no contraindications exist 1
  • For pseudobulbar affect, consider dextromethorphan/quinidine (FDA approved) 1
  • Implement cognitive rehabilitation to improve attention, memory, visual neglect, and executive functioning 1

Patient and Caregiver Education

• Stroke education about:

  • Signs and symptoms of stroke recurrence
  • Importance of medication adherence
  • Risk factor management (smoking cessation, diet, exercise) 1, 5

• Caregiver training specific to:

  • Proper stretching techniques for hemiplegic limbs
  • Positioning to prevent shoulder subluxation
  • Home exercise program implementation 1, 5

Follow-up Planning

• Schedule follow-up appointments with:
  • Neurologist within 2 weeks of discharge 1
  • Rehabilitation specialists as needed 1
  • Primary care provider for ongoing risk factor management 1

Common Pitfalls to Avoid

• Continuing dual antiplatelet therapy beyond 3 weeks increases bleeding risk without additional benefit 2, 3
• Neglecting depression screening - affects up to one-third of stroke patients and impacts recovery 1
• Inadequate fall prevention - most falls occur during transfers, toileting, or unsupervised activities 1
• Insufficient caregiver preparation - leads to poorer outcomes and increased readmission rates 5
• Overlooking exercise prescription - regular physical activity reduces stroke risk and improves functional recovery 1