Top Things to Know: Primary Care of Adult Patients After Stroke

Published: July 15, 2021

Prepared by Anne Leonard MPH, BSN, RN, FAHA, Sr. Science and Medicine Advisor

Approximately 800,000 US adults will have a new stroke each year and 10% will die within 30 days. At the time of their stroke, approximately 5% of patients below 55 years of age and 40% over 85 years have pre-morbid moderate disability (Modified Rankin Scale Score >2). By 90 days after a stroke, new stroke-related disability of at least moderate severity develops in 10% of younger adults to 30% of adults over age 65 years. There are about 7 million US residents living with stroke.
The risk for recurrence of stroke is about 8% in the first year after and ischemic stroke, after which annual risk levels out at about 2% (still higher than a person without a prior stroke). Because of this risk, it is imperative that a prevention plan be outlined soon as possible when the patient is seen by primary care.
Restoration of ability to engage in physical activities goes beyond 4 months due to brain remodeling, adaptation of compensating strategies, restoration of confidence and use of adaptive equipment. Primary care teams provide the majority of post-stroke care, with targeted teams to provide patient-centered care to prevent recurrent stroke and a goal to maximize function, prevent any late complications from stroke and optimize quality of life.
Patient centered primary care post stroke starts with having a foundation for post-stroke management and engaging caregivers and family members to support the patient. In this care plan, primary care should screen for depression, cognitive impairment, fall risk, and refer patients to appropriate teams for further care.
Laying the foundation for post stroke care in a first step, as outlined in Table 1, at the first visit in planning care for this chronic illness. Shared discussions and shared decision making is a part of laying the foundation of care.
Screening for complications and un-met needs are critical to planning care (defined between patient and clinician). Included in screening: anxiety or depression, bone fracture, cognitive impairment, contractures or spasticity, history of falling, post stroke fatigue, hemiplegic shoulder pain, osteoporosis, any pressure ulcers, post stroke seizures and thromboembolism.
Characterize control of any chronic stroke risk factors. Determining the etiology of the stroke in an important first start and assessing what is being done to prevent recurrent stroke. The most prevalent risks for recurrent stroke include hypertension, atrial fibrillation, carotid stenosis and dyslipidemia.
Screening for complications and un-met needs are critical to planning care (defined between patient and clinician). Included in screening: anxiety or depression, bone fracture, cognitive impairment, contractures or spasticity, history of falling, post stroke fatigue, hemiplegic shoulder pain, osteoporosis, any pressure ulcers, post stroke seizures and thromboembolism. Other important risks to screen for include diabetes and intracranial atherosclerotic stenosis.
Setting the long-term plan for chronic care should be set between the patient and clinician (patient centric). Care plans are based on the list of problems defined during the screening assessment (in an organized fashion).
Specialty and community resources for patients after acute stroke: emotional support, fall prevention resources, functional restoration, medical care include several specialties and social integration as listed in Table 1S in the statement.
The complexity of stroke, its causes, consequences and treatments require that all patients with stroke receive high-quality primary care to manage new needs, prevent recurrence, remediate complications, optimize quality of life and facilitate prompt access to specialists as needed. An organized approach to office-based primary care is center to long-term care of more than 7 million Americans in the US.

View the summary for Primary Care of Adult Patients After Stroke

Citation

Kernan WN, Viera AJ, Billinger SA, Bravata DM, Stark SL, Kasner SE, Kuritzky L, Towfighi A; on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; and Council on Peripheral Vascular Disease. Primary care of adult patients after stroke: a scientific statement from the American Heart Association/American Stroke Association [published online ahead of print July 15, 2021]. Stroke. doi: 10.1161/STR.0000000000000382